><> sfc vM *■& %?§^ &'35§S'' --^ •--"v" mm m± ;mv A NATIONAL LIBRARY OF MEDICINE NLfl DDDfiT?^? D ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. » > THE MEDICAL AM) SURGICAL HISTORY OF THE WAR OF THE REBELLION. (1861-65.) 1TRT? APT NOV?-1914 PEEPAEED, IN ACCOEDANCE WITH ACTS OF CONGEESS, UNDEE THE DIEECTION OF Surgeon General JOSEPH K, BARNES, United States Array. WASHINGTON: GOVERNMENT PRINTING OFFICE. 1870. r ..2. ,t.l X / WAR DEPARTMENT, Suite;eon General's Office, November 12, 1870. In the first year of the War it became evident that the form of Returns of Sick and Wounded, then in use, were insufficient and defective; and, on May 21, 181)2, 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 was 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. Volunteers, then in charge of the Surgical Records, and Curator of the Army Medical Musuem; and on September 8, 1863, 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 ] WAR DEPARTMENT, \ Adjutant General's Office. No. 355. m 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. Surgeon General'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 fl.2.0 0 4-2- IV PREFATORY. future operations of those armies, which may be essential or useful in the accurate compilation of the Medical and Surgical History of the War. Particular attention is called to the following points: The morale and sanitary condition of the troops; condition and amount of medical and hospital supplies, tents, ambulances, 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 officsrs, 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, 1864, with a compact and portable Register of Sick and Wounded, and the following 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, To the 6urgeon-in-charge of ------ Acting Surgeon General. U. S. A. General Hospital. PREFATORY. V In February, 1864, separate Reports were ordered to be made for Sick and Wounded Rebel 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 Return of Wounds and Injuries received in Action, a Report of Wounded, and a Report of Surgical Operations, were adopted in March, 1864, and distributed with the following circulars: [CIRCULAR LETTER.] Surgeon General's Office, Washington, D. G, 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 arc 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.] Suegeon Geneeal's Office, Washington, D. C, March 28, 1864. Sie: 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 Surgical Operations for the same period. A list of wounded remaining under treatment on the 31st December, 1863, in the hospital under your charge, and on furlough, is enclosed;'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 enclosed. 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 PREFATORY. All of the reports above alluded to will, when compiled, be forwarded directly to the Acting Surgeon General. By order of the Acting; Surgeon General: C. H. CRANE, Medical Officer in charge of------ Surgeon U. 8. Army. U. S. A. General Hospital. Contemporaneously with the establishment of a more accurate system of Medical and Surgical reports, a pathological collection wTas 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 Medicine and Surgery of the War, and without which no history could have been com- pletely illustrated. The announcement of this project was 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 specimens, than to stimulate the liberality with which most valuable pathological material was being forwarded : [CIRCULAR LETTER.] Surgeon General's Office, Washington, D. G., 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 haemorrhage. Wounded viscera. Photographic representations of extraordinary injuries, portraying the results of wounds, operations, or peculiar amputations. PREFATORY. 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 super- intendence 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 spiculse 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 following 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 to 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 Surgeon 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 registration of wounds, (October 1, 1863,) which are on file in their offices. By order of the Surgeon General:- C. H. CRANE, Surgeon U. S. Army. VIII PREFATORY. On April (>, 1866, a letter was addressed to each Medical Director, requiring that all Registers of Hospitals, Consolidated Registers of Soldiers treated, and all information in their possession pertaining to the Sick, Wounded, Discharged, and Dead during the war, should be transferred to this Office. Careful revision of the material accumulated up 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, be made available by publication. By authority of the Secretary of War, Hon. Edwin M. Stanton, Circular No. 6, A Report 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 purpose 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 Rebellion, compiled .by the Surgeon General, and on March 3, 1869, by a Joint Resolution 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 Records since June 9, 1862, and Assistant Surgeon George A. Otis, U. S. Army, who was assigned to the charge of the Surgical Records, October :-■>, 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 Russia in 1854, 1855, and 1856, and the Medico-Chirurgical Report 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 the preservation of the great mass of facts 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. PREFATORY. IX The success which has attended this effort 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 General 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 discharged 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, but an enduring monument to the self-sacrificing zeal and professional ability of the Volunteer and Regular 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 publication worthy of the Government and the Nation it represents. JOSEPH K. BARNES, Surgeon General U. 8. Army. 2* THE MEDICAL AND SURGICAL HISTORY OF THE WAR OF THE REBELLION. PART I. VOLUME II. SURGICAL HISTORY. Prepared, under ihe direction of JOSEPH K. BARNES, Surgeon General United States Army, By GEOKGE A. OTIS, Assistant Sukgeon United States Akmy. INTRODUCTION. In the preparation of the 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 in 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 protracted 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 skirmishes, 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 num- ber of wounded received at the Washington 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 History of the Warf 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 directors and others, relating to the field service, should be published as "appended docu- ments" to the Medical and Surgical History. They are bound 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 adverb briefly to some other sources of information of an exclusively surgical nature. Though, from the beginning, it had been customary for *See Circular No. 3, Surgeon Generals Office, June 9th, 1862. t Circular 6, S. G. O., 18(i5. XIV INTRODUCTION. medical 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 Briyade, ........................Division of on the day of Corps, Army of..............., at the Battle , 186 Names. Regiment. 03 P* a o o Injury. Treatment. Result and Date. Remarks 'A Surname. Christian name. •J. 5 Missile or Weapon. Seat of. Nature of (slight or severe.) i Note I.—This List will be made with the strictest accuracy, and will be transmitted by the Medical Directors of Corps to the Medical Director of the Army, within seven days after an engagement. 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 a cavity. Surgeon in Chief........... Division, 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 surgeons, 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 Prescription Booh of Regiment Rank. Reg't. Comp. Disease. In Hospital or Quarters. Preschiption and Remarks. Seei.ENEKAL UKi'EK- No. 355, Wo r Department, Adjutant General's Office, November 4th, 1863. INTRODUCTION XV It was found, as the troops were massed in a few large armies, that it was requisite to obtain more prompt information of the aggregate of casualties than was afforded by the nominal returns Hence the following form was , employed. It appears to have been filled out with great fidelity: Classified Return of Wounds and Injuries received in action on the day of at Division Corjis, Army of ., 186 REGION OF BODY WOUNDED. £ Flesh Wounds. Head.................. Face.................. I Nock.................. Thoracic Parietes...... Abdominal Parietes___ Shoulder.............. Back and Hips......... Perineum, Genital, and Urinary Organs...... Cranial Bones.......... Bones of Face.......... Nati'kk (iv Missile or \V EAPON. a s .2 o 3 £ K CO pa o Pene- trating Wounds. Thorax... Abdomen . Flesh Wound....... Fracture............ Shoulder Joint...... Elbow Joint........ Flesh Wound....... Fracture............ Wrist Joint........ Metacarpus......... Fingers............. Hip Joint.......... Flesh Wound...... Fracture, upper 3d... Fracture, middle 3d. Fracture, lower 3d... Knee Joint.......... Flesh Wound....... Fracture............ Ankle Joint........ Metatarsus.......... Toes.............. Wounds with direct injury of large arteries, not being at the same time cases of compound fracture.......... Wounds with direct injury of large nerves, not being at the same time cases of compound fracture......... OPERATIONS AND DEATHS. S* s a o Suri/eon, Division, .................. Corps, Army of NOTE.—This statement will be transmitted, in dvplicate, by the Medical Directors of Army Corps to the Medical Director of the Army within five days after an engagement. No excase will be received for failure in its transmittal within the time here directed. JOSEPH K. BARNES, Acting Surgeon General. Hospital Number. PS* Ow0 ft X C O P5§0 Date of Operatiox. >> 3" 2, 2.!? 2 5 ^ ' T ~ - » 2 M y o P | %$~?\ s ^22-3 if 1 *?% 2" P< s i - ^ ^ S3« WHO ft- 2 35 ffl CD d 3 3 CD p KRT, M., 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 ; Baiitholow, R., A Manual of Instruction for enlisting and discharging soldiers, Philadelphia, 1864; Bowditch, H. I., A brief plea for an Ambulance System for the Army of the United States, Boston, 1863; and On Pleuritic Effusions, and the nee, sHty of Paracentesis for thnr removal, Am. Jour. Med. Sci., Vol. XXIII, 1852, p. 320 ; Brinton, J. H.. Consolidated Statement of Gunshot Wounds, Washington, 1863; BECKER, A. R., Gunshot Wounds, Particularly those caused by newly invented missiles, 1865; 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, 18fi6 ; and, Description of an Improved Extension Apparatus for the treatment of Fracture of the Thigh, Now York, ISti?; Derbv G., The Lessons of the War to the Medical Profession, Muss. Med. Soc. Pub. Vol. 2, Boston, 1867; Ellis, T. T., Leaves from the Diary of an Army Surgeon, New York, 1863; Green, J., On Amputation of the Thigh. Boston Med. and Surg. Jour., June, 1863 j Eve, P. I\. A Contribution to the History of the Hip-Joint Operations Performed during the late Civil War, in Transactions Am. Med. Association. INTRODUCTION. XXI The bulk of these documents were received from the officer entrusted with turning over public property under the convention between General Sherman and General John- ston, 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 documents were destroyed than were preserved,—being burned or scattered to the winds wantonly, or in ignorance of their value. It must be admitted further, that a few of the volunteer 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 Offi-ce 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 military 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 literally the same, with" the exception, in both cases, of the substitution of the words Confederate States for United Slates, 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 withdrawn 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 epidemics.f Among the means adopted in the Confederate army for collecting information on special 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 Vol. XVIH, pp. 256, 263; Gay, G. H., A few Remarks on the Primary Treatment of Wounds received in battle, Boston, 1862; Goldsmith, M., A Report on Hospital Gangrene, Erysipelas, and Pysemia, as observed in the Departments of the Ohio and Cumberland, Louisville, 1863; Hodgen, J. T., Wound of Brain, St. Louis Med. 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; Harwitz, P. T., Report of Casualties from Gunshot Wounds in the U. S. Navy, from April 2d, 1861, to June 30th, 1865, Washington, 1866; Letterman, J., Medical Recollections of the Army of the Potomac, New York, 1866 ; Lidkll, J. A., A Memoir on Osteo-myelitis, New York, 1866; and, On the Wounds of Blood-Vessels, etc.; On the Secondary Traumatic Lesions of Bone, etc.; and, On Pysemia, New York, 1870; MOTT, V., Hmmorrhage from Wounds and the best means of Arresting it, New York, 1863; Mitchell, S. W., Injuries of Nerves and Their Consequences, Philadelphia, 1872; MOSES, 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; McGlLL, G. M., Observation Book, National and Hicks U. S. A. General Hospitals, Baltimore, Maryland, Baltimore, 1865-66; ORDRONAUX, J., Manual of Instructions for Military Surgeons, on the Examination, of Recruits and Discharge of Soldiers, New York, 1863 ; OTIS, G. A., Surgical Part of the Reports on the Nature and Extent of the Materials available for the Prepa- ration of a Medical and Surgical History of the Rebellion, being Part I, of Circular 6, S. G. O., 1865; and A Report on Amputation 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., 1869; and A Report of Surgical Cases treated in the Army of the United States from 1865 to 1671, Circular No. 3, S. G. O., 1871; Packard, J. H., A Handbook of Operative'Surgery, Philadelphia, 1870; Smith, H. H., Principles and Practice of Surgery, Philadelphia, 1863; Smith, N. R.; Treatment of Frac- tures 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. Med. Times, 1862, Vol. IV, p. 331; Smith, G. K, The Insertion of the Capsular Ligament of the Hip-Joint, and its Relation to Intra- 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, 1864, p. 378; WAGNER, C, Report of Interesting Surgical Operations, Performed at the U. S. Army General Hospital, Beverly, New Jersey, 1864 ; WOODWARD, Report on the Causes and Pathology of Pysemia, Trans. Am. Med. Assoc, Vol., p. 172, 1866; Read, J. B., Report on Wounds of the large Joints, Southern Med. and Surg. Journal, July and October, 1866. * Provisional Army of the Confederate States. t Some of these reports, on gangrene, typhoid fever, and the mortality of prisoners at Andersonville, have been published by the Sanitary Com- mission : Memoirs of the War of the Rebellion, Vol. I, 1867, Vol. II, 1871, New York, Hurd and Houghton, 8 vo. pp. 067, 580, with colored plates. xxn INTRODUCTION. will indicate the general scope of their inquiries. Reference is frequently made in this work to the printed and unpublished proceedings of this society: .•Sir,- With the view of reaching the individual experience and opinions of surgeons and distant sumuons on debatable points in surgical pathology, based upon their observations in his war an "Association of Army and Navy Surgeons- has been organized, and your co-operation in earning out the successful fulfilment of its purpose is solicited. Questions proposed 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 gunshot wound,, do such differences exist between the orifices of entrance and exit as to indicate them with certainty f II. IIavegunshotwounds,in your experience, ever assumed the appearance of incised wounds and healed by first intention I III. When suppurating, which orifice seems to heal first? SAM'L PRESTON MOORE, Pres't Ass'n A. 4' X- Surgeons. Sir- In replying to questions, and in essays or papers sent to the association, a resumes requested, coming to some conclusion, in order to facilitate taking the vote in the decision on the subject. The following questions are proposed: I Ahv i»f vni from chloroform in YOUR practice? give particulars of the case, if any. Is this agent always used ? II 1st Does 'shock' postpone YOUR surgical interference? At what period of time, after injury, are YOU usually able to operate 1 2d. Any relation between the character of the injury and the GRAVITY of the shock ? 3d. Any death, in your practice, from shock alone? . . III. Do cicatrices from gunshot wounds furnish YOU information as to the nature of the missile which caused the injury, and the probable entrance and exit of the same ? Further particulars on these subjects, with accounts of any remarkable course which balls may have taken in transit through the body, in your own practice, are solicited. Third series of questions: V. What number of cases have been followed by secondary haemorrhage after ligation of artery ABOVE the wound ? Mention vessel, part of artery wounded, and the point ligated. VI. In arresting haemorrhage, has local deligation, or ligature above the wound proved the safer method in YOUR 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 YOUR experience ? How have they been used ? VIII. How many cases of gangrene have followed ligation for primary haemorrhage and how many for SECONDARY 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 intention, a procedure warmly advocated by the Confederate surgeons Chisholm and Michel, the theory and practice were alike rejected by the Union surgeons. The plan was tried in the New Zealand war, by instructions of the English Director- General, but the reports of Inspector General Mouat, and of Staff"-surgeon A. D. Home, thouah not decisive, were unfavorable. INTRODUCTION. XXIII Since the conclusion of our own struggle, two great wars have convulsed Europe,— the Austro-Prusso-Ttalian, or "Six Weeks War" of 1866, and the German-French War of 18,0-71. It has been sought to compare our results with those set forth in the already numerous publications of the German and French military surgeons.1 I have also contin- ually referred to the reports of the antecedent or contemporaneous or subsequent wars in Algeria,2 in Schleswig-Holstein (184S-50),3 in the Crimea.(1851-56),4 in Italy (1859),5 in the Prusso-Danish War of 1864,° in the Sepoy Mutiny,7 and the English and French expeditions to China,8 the New Zealand War (1863-65),9 and the Abyssinian invasion (1868).10 'DOYON, A., Notes ct Souvenirs d'un Chirurgicn D'Ambulance, Paris, 1872; Grellois, E., Histoire. Medicate du Blocus De Metz, Metz, 1872; CHIFAULT, A., Fractures par Armcs a Feu, Expectation, Resection sous-Periostic, Evidement- Amputation, Arme*dela Loire, Paris, 1872; Vaslin, L., £tudc sur les Plates par Amies a Feu, Paris, 1872; Fischer, H., Kriegschirurgische Erfahrungen, Erlangen, 1872 ; Le Fort, L., La Chirurgie Militaire it les Societes de. Sccours en France ct a I'Htrangtr, Paris, 1872; MacCormac, W., Notes and Recollections of an Ambulance Surgeon, London, 1871; MACDOWALL, C. J. F. S., On a New Method of Treating Wounds (Gruby's System) and the Medical and Surgical Aspects of the Siege of Paris, London, 1871; BILLROTH, T., Chirurgische Briefe aus den Kricgs-Lazarethcn in Weissenburg und Mannheim, 1870, Berlin, 1872; DESPRE8; A., Rapport sur Irs Travaux de la lime Ambulance a VArmie du Rhin ct & V Armee de la Loire, Paris, 1871; SazaRIN, M. 0., Cliniq'ie Chirurgicale de VHopital Militaire de Strasbourg, Strasbourg, 1870; Schatz, J., £tude sur les Hopitaux sous Tentes, Pqris, 1870; BonxafONT, J. P., Du Fonctionne- ment des Ambulances Civil's ct Internationales sur le Champ de Bataille, Paris, 1870; Langfnbf.CK, B., Ueber der Schusswunden der Gelenke und ihre Behandlung, Berlin, 18(8; Passayant, G>, Bemerkungen aus dem Gebiete der Kriegschurgie, Berlin, 1871; Iwanoff, Bericht uebcr die Besichtigung der Militar-Sanitatanstaltcn in Deuischland, Lothringen und Elsass in Jahre 1870, von N. Pirogoff, Leipsig, 1871; Rui'PRECHT, L., Militdrarztliche Erfahrungen wdhrend des Framochcn Krieges in Jahre 1870-71, Wfirzburg, 1871; ECKHAUT, Geschichte des k. b. Aiifnams-FeldspitaU XII, im Kriege gegen Frankreieh 1870-71, Wiirzburg, 1871; BECK, Kriegs-Chirurgische Erfarhungen wdhrend der Feldzuges 1866 in Siiddeutscheland, Freiburg, 1867; SIMON, G., Mitthcilungen aus der Chirurgischen Klinik, Prag, 1868 ; ROALDES, A. W. DE, Des fractures compliquies de la cuisse par Armes de guerre, Paris, 1871 ; COUYBA, Des Troubles trophiqucs consecutifs aux Lesions traumatiques de la Motile et des Nerfs; Christ6t, F., Du Drainage dans les Plaits par Armes de Guerre, Paris, 1871; Quesnov, F., Campagne.de 1870, Armee du Rhin, Camp de Chalons, Borny, Rezonville ou Gravelotte, Blocus de Metz, Paris, 1871 ; LATOUR, A., Journal du bombardement de Chdtillon, Paris, 1871; Joulin, Les caravanes d'un chirurgicn d''ambulances, Paris, 1871. 2Bertherand, A., Campagnes de Kabylie, Paris, 1862; BAUDENS, Clinique des Plaies d'Armes & Feu, Paris, 1836; BAUDENS, Relation Historique de VExpedition de Tagdempt, Paris, 1841; Armaxd, A., L'Algerie Medicate, Paris, 1854 ; Vincent, Expose clinique des Maladies des Kabyles, Paris, 1862; Sedillot, C, Campagnes de Constantine de 1837, Paris, 1838; MaRIT, Hygiene de VAlgerie, Paris, 1862; Lecerc, Une Mission Medicate en Kabylie, Paris, 1864. 3 STROMEYER, L., Maximen der Kriegsheilkunst, Hannover, 1855 ; EsMARCH, F., Beschreibung einer Rcscctionsschiene. Ein Beitrag zur Conser- vatiten Kriegsheilkunst, Mit Fiinf Holzschniiten, Kiel, 1859, and Ueber Resectionen nach Schusswunden, Kiel, 1851; SCHWARTZ, H., Beitrage zur Lehre von den Schusswunden: Gesammelt in den Feldziigen der Jahre 1848-50, Schleswig, 1854; GuitLT, E., Militdr-Chirurgische Fragmente, Berlin, 1864; LoHMEYER, Die Schusswunden und ihre behandlung, Goettingen, 1859 ; Lozfler, Grundsdrtze und Regelnfur die Behandlung der Schusswunden in Kriege, Berlin, 1859; BECK, Die Schusswunden, Heidelburg, 1850; STROMEYER, Ueber die bei Schusswunden vorkommenden Knochen-Verletzungen, Freiburg, 1850. 1 The principal authorities on the Surgery of the Crimean War are : MATTHEW, T. P., Surgical Part of the Medical and Surgical History of the British Army in the Crimea, during the War against Russia, in the years 1855 and 1856, London, 1858, Vol. II, p. 253; CHENU, J. C, Rapport au Conscil de Same des Armies sur les Resullats du Service Medico-Chirurgical aux Ambulances de Crimee et aux Hopitaux Militaires Francais en Turquie pendant la Campagne D'Orient en 1854-1856, Paris, 1865; PIROGOFF, N., Grundzuge der Allgemeinen Kriegschirurgie nach Reminiscenzen aus den Kriegen in der Krimund in dem Kaukasus, Leipzig, 1864; SCIUVE, G., Relation Medico-Chirurgical dela Campagne d' Orient, Paris, 1857; BAUDENg, L. La Guerre de Crimee, les Campements, les Abris, les Ambulances, les Hopitaux, etc., etc., etc., Deuxieme. edition, Paris, 1858; Fraser, P., A Treatis upon Penetrating Wounds of the Chest, London, 1859; Legouest, L., Traite de Chirurgie d'Armee, Paris, 1863 ; SALLERON, M., In Recucil de Mem. de Med. el de Chir. Mil., 2d Serie, T. 21, 1858, p. 320; LAWSON, On Gunshot Wounds of the Thorax, London ; ARJIAND, A., Histoire Midico-Chirurgicale, de la Guerre de Crimee, Paris, 1858; BLENKIXS, On. Gunshot Wounds, in 8th ed. of Cooper's Dictionary, London, 1869; BAUDENS, L., Souvenirs d'une Mission Medicate a VArmee d' Orient, Paris, 1857 ; MACLEOD, G. H. B., Notes on the Surgery of the War in the Crimea, London, 1858 ; CAZALAS, L., Maladies de VArmee d'Orient, Paris, 1860; PORTA. Delia Disarticulazione del Co'.ile, Milano, 1860; MaRROIN, Histoire Medicate de la Flotte Francain dans le Mcr Noire pendant le Guerre de Crimee, Paris, 1861. sChenu, J. C, Slatistique Medico-Chirurgicale de la Cimpogne d'ltalie en 1859 et 1860, Paris, 1869; R0DOLFI, R., Campagna Chirurgica del 1866, Osservazioni Cliniche, Milano, 1867; GlIERIM, A., Vade Mecum per le Ferile D'Arma da Fuoco, Milano, 1866; GRITTI, R., Dell Fratture del Femoreper Arma da Fuoco, Milano, 1866; ROUX, J., De L'Osleomyelite et des Amputations Secondaires d la Suite des Coups de Feu, Paris, 1860 ; Afpia, P. L., The Ambulance Surgeon, Edinburgh, 1862; DKJLME, H., Studien Allgemeine Chirurgie der Kriegswunden, WUrzburg, 1861; STROMEYER, Erfahrungen vcber Schusswunden in Jaher 1865, Hannover, 1866; LOHMEYER, C. F., Die Schusswunden und Hire Behandlung, Kurz bearbeitet, Gottin- gen 1859; BILLROTH, T., Historische Studien uber die Beurtheilung und Behandlung der Schusswunden vom 15 Jahrhundert bis axif die ncueste Zeil, ^ Berlin 1859- Bektherand, Campagne d'Italie, Paris, 1860; Bruce, A., Obscrva'ions in the Military Hospitals of Dresden, London, 1866; Maas, H., Kriegschirurgische Beitrage aus dem Jahre 1866, Breslau, 1870 ; GURLT, E., Der Internationale Schutz der im Felde Verwundeten und Erkrankten Krieger, etc. ^Berlin, 1869; BOUDIN, J. C. M., Souvenirs de la Campagne d'ltalie, Paris, 1861 ; Evans, T. W., Les Institutions Sanitaircs pendant le Conflit Austro-Prussien-Italien, Paris, 1867; NEUDORFER, Handbuch der Kriegschirurgie, Leipsig, 1864; Cazalas, Maladies de VArmees d'ltalie, Paris, 1864. 6HAXXOVER, A., Das Endresultat der Resectionen im. Kriege 1864, in den Unterklassen der Ddnischen Armee, und Die Ddnischen Invaliden aus dim Kriege 1864, Berlin, 1870 (from von Langenbeck's Arch. f. k. ch. B. XII, H. 2); LCEFLER, F., General-Bericht uber den Gesundheitsdienst im Feld- zuge gegen Danemark, 1864, Berlin, 1867; Heine, C, Die Schussverletzungen der untercn Extremitdten, Berlin, 1866; Ochwadt, Kriegschirurgische Erfahrungen, Berlin, 1865 ; RESSEL, J., Die Kriegshospitalcr des St. Johanniter-ordens im Ddnischen Fcldzuge von 1864, Breslau, 1866. 7 WILLIAMSON, G., Military Surgery, London, 1863; Fayrer, J., Clinical Surgery in India, London, 1863; COLE, J. J., Military Surgery or Experience of a Field Practice in India during the years 1848 and 1849, London, 1852; GORDON, C. A., Experiences of an Army Suigeon in India, London, 1872. 8CASTANO, F., LExpedition de Chine, Paris, 1864; DlDIOT, delation Medico-Chirurgicale de V Expedition de Cochinchine, Paris, 1865; LAURE, Histoire medicate de la Marine Francaise, pendant les Exp dition de Chine et de Cochinchine, Paris, 1864. OMOUAT, J., Special Report on Wounds and Injuries Received in Battle, Extracted from the Medical and Surgical History of the New Zealand War, London, 1867i iu General NAPIER'S Official Report, London, 1869 ; Papers connected with the Abyssinian Expedition, presented to both Houses of Parliament, 1867. XXIV INTKODUCTION. In arranging the surgical data of the American war, it has been thought wisest to proceed 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 ultimately 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 permanent registers, yet many thousands of cases, belonging chiefly to classes not considered in the first volume, remain to be investigated and entered. Hence general- izations 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 consequently on the results 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 observations to a later portion of the work. A chronological table of engagements and battles, compiled from official 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 wmich 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 feature, and the fifth to wounds and injuries of the chest. The operations performed are considered 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 volume, gunshot wounds in general, with the complications of pyremia, gangrene, tetanus, and secondary hasmorrhage will be considered, and also the materia chirurgica, the transportation 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 included. 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 consecutive series of reports in existence. The inadequacy of the entries in the class thanatici 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 sclopeticum* 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 injuries 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: CLASSIFICATION. Burns..................... Contusions................ Concussion of Brain........ Compression of Braint...... Drowning.................. Sprains.................... Dislocations................ Fractures.................. Simple Fractures........... Compound Fractures........ Gunshot Wounds........... Incised Wounds............. Lacerated Wounds........ Punctured Wounds......... Poisoning.................. Other Accidents and Injuries. Aggregates. White Troops. Colored Troops. TOTAL. Cases. Deaths. Cases. Deaths. Cases. Deaths. 9,487 94 613 4 10,100 98 44,323 161 2,649 11 46,972 172 873 193 49 22 922 215 61 17 61 17 672 3 4,317 125 42,704 797 3 38,387 2,908 9 108 1 3,016 10 1,287 53 1,287 53 4,215 61 131 15 4,346 76 1,316 378 55 19 1,371 397 229,119 32,731 6,466 922 235,585 33,653 21,444 186 1,305 3 22,749 189 14,153 459 595 8 14,748 467 5,285 191 499 8 5,784 199 3,087 93 67 17 3,154 110 13,099 1,003 2,174 72 15,273 1,075 389,044 36,304 19,028 1,227 408,072 37,531 * Circular No. 9, S. G. O., July 1st, 1863. Consolidated Statement of Gunshot Wounds. By Surgeon J. H. BRINTON, U. S. V. t After June 30th, 1863, this class was omitted, as it was found that depressed fractures of the skull were sometimes entered. d.* XXVI INTRODUCTION. The aggregate of 235,583 gunshot wounds here given, with the resulting mortality of 33,653, or 14.2 per cent., is explained, in the introduction to the medical volume, to repre- sent the total returned from about nine-tenths of the mean strength of the Union Army, and to be exclusive of the injuries of those killed in action. The latter category embraces, according to the Adjutant General, not less than 44,238; according to the alphabetical regis- ters of the Surgeon General's Office, 35,408; according to the Chronological Summary, 59,860* However useful these approximations may be for many purposes, any anticipation that they may afford reliable guidance, or much assistance in framing a surgical history of the war, must evidently prove illusory. But the consolidation of the data of the detailed quarterly surgical reports might be justly expected to furnish a very complete record of the surgical practice in the Union Army during the latter two years of the war; and for the last year, the classified return of wounds received in action should serve as a nearly- accurate check-list. The clinical histories contained in the quarterly surgical reports were provisionally classified in the order specified on page 6 of the Introduction to the surgical report in Circular No. 6, S. G. 0 , 1865. It has been severely criticised,f and would be open to graver objections than have been offered, had it been designed as a nosological system. It was simply a nomenclature for a series of blank books, in which surgical facts derived from a variety of sources might be entered for facility of reference, and has been modified as frequently as convenience dictated. It has been found to answer the purpose for which it was intended reasonably well. As the presentation of the naked statistics of the monthly reports of sick and wounded, as consolidated on the preceding page, would have been * The Chronological Summary, compiled by the faithful and indefatigable chief clerk of the Surgical Division, Mr. Frederick K. 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. tin the fifty-fourth volume of the Medico-Chirnrgical 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 surgery, 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 follow him through this discussion, but must correct • several serious errors in his description of the "collection and classification of surgical statistics of war injuries in the United States." After premising 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 the 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 clerks employed at the Surgeon General's Office in collecting and arranging the surgical statistics of the war, for the preparation and publication of which a very large sum of money had been liberally granted by Congress." I am sure that Dr. Longmore will wish 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 clerk, and sixteen hospital stewards, occasionally aided by one acting assistant surgeon; and the '' very large sum of money " (£G,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 War, 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 M. Chenu; 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 was 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 1" (p. 240). I cordially concur in the warm praise accorded to the histories of the Crimean and Italian campaigns by M. Chenu. I will observe 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 reports nine cases of trephining; in his Crimean history Dr. Matthew reports twenty-six cases. I shall record two hundred and twenty cases, and shall be disappointed if their results afford no useful information. Dr. Taylor's classification may be excellent for the British army, with its corps of trained medical officers ; it could not have been advantageously introduced in our service, chiefly 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. Loeffler is a man-el of accuracy and completeness to those who occupy themselves with these studies; and the extended treatises of Drs. H. Fischer, Smiin, and Klebs, following so soon upon the conclusion of the Franco-German war, are monuments of well-directed industry. I think that in war " systems " must be made to conform to the exigencies of the occasion and to national habits and organizations. There are certain great rules to which all nations will conform ; the details must be adapted to varying circumstances. The British system may be best for Britain; but not necessarily for all other countries. On pout etre plus sage qu'un gens, mais point que tous les gens. INTKODUCTION. XXVII barren,—as there was no other consecutive series of reports,—and as it was undesirable to sacrifice the information collected in the earlier period of the war, a plan was adopted which permitted the endeavor to group together data from any quarter, from case books, from field registers, from nominal casualty lists, from numerical classified returns, from the memoranda accompanying pathological specimens, from the careful clinical records of hospitals, and the hasty pocket-book memoranda of field surgeons. From a surgical point of view, there was no motive to exclude information that could be obtained of the Confederate wounded,—le vrai chirurgien ne regardepas Vuniforme. Estimates of the ratio of wounded to the forces engaged, and other attempts at approximations to unattainable numerical precision, were held to be very subordinate to the accumulation of the greatest possible number of practical surgical facts. In dealing with these large bodies of facts, I have thought best, commonly, to imitate the practice of the legal profession, and to set forth all the evidence regarded as important, on each particular subject, with as little interruption as possible, and to append the argument or discussion. As nearly as practicable, the wounds and injuries and surgical diseases of each region of the body have been arranged together, as the simplest and most natural order that could be adopted. The most interesting clinical histories have been printed in full, or in abstracts including the attainable essential details, and the remaining cases, or sometimes the whole number of cases of the class, are set forth in tabular statements. In many cases the result could not be ascertained, yet the proportion of undetermined cases, as indicated by the aggregates in the tables, was much smaller than could have reasonably been anticipated.* In the earlier part of the work, the number of histories, and especially of very brief histories, that are printed, may appear unnecessarily large; but it was desired to give some insight into the method by which cases were traced and followed to their termination, with the hope that the reader, on being assured that many of these brief memoranda presented a digest of the results of a search through half a dozen reports, perhaps, and that the cases represented numerically only had undergone precisely similar investigation, would entertain a reasonable confidence in the accuracy of the statistical conclusions. In the later portions of the work, the typical cases are more elaborated and fewer are selected to be printed in full. In stating in the abstracts that a case is reported by a medical officer whose name is given, it is not designed to intimate that he is responsible for the language employed. Very possibly some details are taken from several field or hospital reports or registers, each supplying some facts omitted in the others. It is simply designed to ascribe whatever merit belongs to the abstract to the surgeon giving the fullest account, or to give the history the authority of his name. Wherever the surgeon's own language is employed quotation marks are used, and whenever complete histories have been furnished by a single observer, they have been preferred, and printed in the reporter's own words. The classification adopted has rendered it necessary to encounter first in order the most obscure and complicated subjects, and the writer has been keenly sensible of the difficulties involved in this arrangement. On wounds of the extremities, on amputations, excisions, and conservative measures in fractures and wounds of joints, and almost all matters demanding prompt active interference, the materials at his'disposition have been very extensive, and the means of illustration almost unlimited; for the army surgeons showed great diligence in preserving statistical details on these *In computing percentages, the undetermined cases are not included. XXVIII INTRODUCTION. subjects, and freely expressed their opinions on the relative merits of different methods of treatment, while admirable drawings and specimens of recent injuries were early secured, and preparations showing their progress and results were largely accumulated. On wounds of the trunk, the materials were also abundant; but the obstacles to satisfactory analysis and exposition were great. Generally, the medical officers were very concise in reporting on wounds of the head, of the chest, and of the abdomen, often failing to record all important points of professional interest, and commonly refraining from critical discussion or comment. It was not easy to obtain good pictorial representations of these injuries, their progress and results.- Whether the obscurity attending them, or the comparative inadequacy of therapeutical resources against them, renders them less attractive to surgeons, it is certain that less real reliable information relating to them is to be found than in regard to those in which brilliant operative dexterity may be displayed. In regard to injuries of the head,f it may be that writers are deterred from enlarging on them by doubt of their ability to add to the knowledge imparted by the great teachers of the past; but the conditions the elder authors had in view were not identical with those observed by the moderns, and the latter cannot be exonerated from the duty of collecting facts with which to judge the conflicting views of their predecessors, or of applying to these difficult problems the more refined means of investigation that the advances of science have placed at their command. The obscurity which attends wounds of the head, and renders their pathology so ambiguous, does not, as Hennen observes, exist in an equal degree in those of the thorax; yet Dr. Fraser, inpreparing his monograph on the subject, was able to find but one treatise especially devoted to penetrating wounds of the chest, that by Dr. Mayer, of St. Petersburg.! As to wounds of the abdomen, it may be that their extreme fatality and brevity of the period through which, commonly, they remain under observation, deprive them of the interest with which they would otherwise be regarded ; for, as Sir Charles Bell has remarked, although wounds of the belly are common enough immediately after a battle, bearing a fair relative proportion to other wounds, yet a few days suffice to remove them, so that, by the end of the first week, there is scarcely one to be seen. That the experience acquired during the war should have added largely to every subject connected with military surgery was not to be anticipated. But it may be safely asserted that, in many directions, it has advanced the boundaries of our knowledge. Even in the very difficult field of investigation presented by the wounds and injuries of the *The gifted artist, Mr. STAUCH, whose services Surgeon Brinton had fortunately secured, after preparing many water-color drawings of recent injuries, at the field hospitals, died from pernicious fever contracted before Petersburg, without completing the exquisite studies of embolism, cranial abscess false aneurism, osteomyelitis, and gangrene, which he had drawn from dissections made at the Museum. '' Injuries of the head affecting the brain are difficult of distinction, doubtful in character, treacherous in their course, and, for the most part, fatal in their results. The symptoms which appear especially to indicate one kind of accident are freque'ntly prevalent in another. It may be even said that there is no one symptom which is presumed to demonstrate a particular lesion of the brain, which has not been shown to have taken place in another of a different kind. Examination after death has often proved the existence of a most serious injury, which had not been suspected ; and death has not unfrequently ensued immediately, or shortly after the most marked and alarming symptoms, without any adequate cause for the event being discovered on dissection. Such are the deficiences in our knowledge of the complicated functions of the brain, that although we think we can occasionally point out where the derangement of structure will be found, which has given rise to a particular symptom during life, the very next case may probably show an apparently s"und structure with the same derangement of function. One man shall lose a considerable portion of his brain without its being productive at the moment, or even after his restoration to health, of the slightest apparent functional inconvenience; whilst another shall fall and shortly die without an effort at recovery, in spite of any treatment which may be bestowed upon him, after a very much slighter injury inflicted apparently on the same part."—GUTHRIE, on Injuries of the Head affecting the Brain, 4to, London, 1842. "Of all the accidents met with in field practice, these are, beyond doubt, the most serious, both directly and remotely—the most confusing in their manifestions, and the least determined in their treatment, although they have engaged the attention of the master minds of all ages and countries from the time of the old surgeon of Cos down to the present day."—MACLEOD, Notes, etc. (op. cit., p. 175). J Dr. Fraser justly remarks (op. cit., p. 2) that " while Army surgeons have displayed* great care and attention on matters relating to statistics; while they have laboriously discussed the relrtive merits of excisions and disarticulations, and have displayed consummate skill in the treatment of wounds of the joints and extremities,—in a word, on all matters which demand active, and 'truth must out' showy manual ability, the less attractive, because more obscure, but not the less important subject of wounds of the head, chest, and abdomen, appears to have elicited only passing and imperfect notice.'' INTEODUCTION. XXIX head, we have learned something. Surgeons have been schooled to deal with the most ghastly injuries of the face without dismay, to obtain unexpected results, and to accomplish favorably reparative operations from which, formerly, they would have recoiled; and they have been taught the futility of tying the great arterial trunks of the neck for haemorrhage from face-wounds. The true principles of treatment of wounded arteries in the neck is now generally understood; and while, before the war, there were few surgeons who chose to undertake operations on the great vessels, there are now thousands who know well when and how a great artery shall be tied. Our information respecting injuries of the vertebral column has been augmented; and, passing to the wounds of the chest, we find a complete revolution in theory and practice. Without further illustration, we may claim that the additions to surgical knowledge acquired in the war are of real and practical value. On those topics in which the materials at his disposition merely corroborated or confirmed views already generally entertained, the editor has sought to be concise, and to enlarge on those subjects to which some material addition to our knowledge has been brought by the observations made during the war, either because of novelties in nature or in treatment, or through the large number of rare, or of analogous cases permitting the occasional presentation of crucial instances, and the more frequent application of the theories of averages and of probabilities.* Though the labor upon matters of detail, inseparable from carrying out instructions to regard the "preservation of the great mass of facts collected, in a form for convenient study," as the chief object in view, has generally confined the editor's attention to the arrangement and grouping and illustration of the observations, he has sought, whenever time and opportunity permitted, to facilitate the student's enquiries by analyses, and summaries, and references to the surgical results of other wars, without abstaining from critical comments; but censuring bad practice, intending no discourtesy to individuals, nor violation of the homines amare, errores immolare precept of St. Augustine. The learned historian of the inductive sciences has not included pathology and therapeutics in his outline, and we must perhaps be content to wait until some genius as sublime as Newton's shall explain the laws of life by a generalization as simple and perfect as the law of gravitation, before the physiological sciences shall be recognized among the strictly exact sciences. But, meanwhile, the tendency among surgeons to seek to establish, by inductive methods, at least those less general and more complicated rules to which the name of "empirical laws" has been given, cannot be gainsayed.f Though unable yet to aim at establishing laws of cause and effect, they are constantly seeking to determine by statistical calculation the influence exerted by different modes of practice, and thus to open the way for framing inductions; and as these less general relations require a very much larger number of cases than are needed to establish laws of causation, they continually resort to the numerical method. This is peculiarly applicable to military surgery; for some of the variable circumstances which contribute to * La Place, Essai philosophique sur le calcul des probability, page 220, says that the mathematical theory of probabilities is, fundamentally, only " le ban sens reduit au calcul. It has so often been misapplied in medical enquiries, that Peisse (La Medecine et les Medecins, Paris, 1857, Vol. I, p. 175) profanely suggests that the inverse operation might often be profitably instituted, and "cyphering put in accord with common sense." t Ars tota in observationibus, said an ancient master. Those who deride the numerical method as an absurd caricature of the inductive or experi- mental method in philosophy, say that in observatione would be better, and censure the unfortunate plural, as having promoted the introduction of the statistical system into the medical enquiries. MORGAGNI'S famous Non numerandse sed perpendendse sunt observationes is often cited against the numer- ists; but those who do not relish so formidable an adversary may, with Bouillaud (Essai sur la philosophic midicale, Paris, 1836, p. 186), write the aphorism : Non SOLUM numerandse sed etiam perpendendse sunt observationes. For more serious observations on this most important subject, consult: GAVARRET, Principes generates de Slatistique Medicate; LaycOCK, Medical Observation and Research; Guy, On the best Method of collecting and arranging Facts, in Jour, of Stat. Soc. of London, Vol. Ill; Barclay', Medical Errors, London, 1864; Todd, The Book of Analysis; QuETETET, Sur Vhomme. XXX INTRODUCTION. the production or modification of the result, and which cannot well be eliminated from ordinary statistics, are here excluded—for example, sex, age, and bodily vigor, within certain limits—while there is comparative uniformity in the external circumstances of food, air, nursing, and attendance. The simple rehearsal of cases would be a very profitless addition to our knowledge, unless, through their agency, we sought for analogies and relations that may establish rules of practice. The surgical lessons of the. war, like its other good results, were only obtained at the expense of great sacrifices. The army surgeon is not only exposed to the dangers arising from excessive fatigue, and constant contact with disease, but to the fatalities directly incident to war. I have not the names of the numerous Confederate medical officers whose devotion to duty cost their lives, nor space for the long list of Union surgeons who perished from diseases strictly consequent upon the nature of their avocations, but will, at least, record the names of the latter who fell in battle. The following officers of the medical staff of the regular and volunteer forces of the Union Army were killed in action: Surgeon Samuel Everett, TJ. S. V., at Shiloh, April 6th, 1862. Surgeon W. J. H. White, TJ. S. A., at Antietam, September 17th, 1862, while placing the field hospitals of the Sixth Corps, of which he was medical director. (See Appendix, p. 100.) Assistant Surgeon A. A. Kendall, 12th Massachusetts Volunteers, at Antietam, September 17th, 1862. (See Appendix, p. 100.) Assistant Surgeon Edward H. B. Eevere, 20th Massachusetts Volunteers, at Antietam, September 17th, 1S62. (See Appendix, p. 100.) Surgeon J. D. S. IIaslett, 50th Illinois Volunteers, at Perryville, October 8th, 1862. Surgeon J. Foster Haven, 15th Massachusetts Volunteers, at Fredericksburg, December 13th, 1S62. (See Appendix, p. 101.) Assistant Surgeon John Hurley, 69th New York Volunteers, April 15th, 1863. Surgeon Charles A. Hartman, 107th Ohio Volunteers, at Chancellorsville, May 2d, 1863. Acting Assistant Surgeon A. Hichborn, at Chancellorsville, May 3d, 1863. Surgeon E. L. Watson, 1st California Volunteers, near Fort Craig, New Mexico, July 19th, 1863. Surgeon J. S. Weiser, 1st Minnesota Cavalry, near Big Mound, Dakota Territory, in a fight with Sioux Indians, July 24th, 1863. Surgeon Thomas Jones, 8th Pennsylvania Eeserves, at Spottsylvauia, May 11th, 1864. Surgeon II. S. Potter, 105th Illinois Volunteers, near Ackworth, Georgia, June 2d, 1864. (See Appendix, p. 308.) Assistant Surgeon A. S. French, 114th Illinois Volunteers, at Guntown, June 10th, 1864. Surgeon L. B. Smith, 7th Minnesota Volunteers, at Tupelo, Mississippi, July 13th, 1864. Surgeon J. C. Stoddard, 56th U. S. Colored Troops, Wallace's Ferry, Arkansas, July 26th, 1864. Surgeon Charles J. Lee, 11th United States Colored Troops, near Fort Smith, Arkansas, August 21th, 1864. Surgeon W. H. Eulison, 9th New York Cavalry, medical director of the cavalry of the Middle Military Division, at Smithfield, Virginia, August 29th, 1864. (See Appendix, p. 226.) Assistant Surgeon Frederick Wagner, 3d Tennessee Cavalry, at Sulphur Branch Trestle, Alabama, September 25th, 1864. The following officers of the medical staff, while in the discharge of their duty, were killed by partizan troops or assassinated by guerrillas.or rioters : Surgeon H. N. Gregory, 1st Wisconsin Cavalry, June 9th, 1862. Assistant Surgeon F. L. Hunt, 27th Massachusetts Volunteers, November 18th, 1862. Assistant Surgeon Jared Free, S3d Pennsylvania Volunteers, December 10th, 1863. Surgeon Shuball York, 54th Illinois Volunteers, Charleston, Illinois, March 28th, 1864. Assistant Surgeon S. A. Fairchild, 6th Kansas Cavalry, Stone's Farm, April 6th, 1864. Assistant Surgeon J. A. Jones, U5th Illinois Volunteers, July 9th, 1864. Assistant Surgeon Eli M. Hewitt, 15th TJ. S. Colored Troops, July 24th, 1861. Surgeon J. B. Moore, 5th Tennessee Cavalry, September 5th, 1864. Acting Assistant Surgeon F. M. Osborne, September 22d, 1864. Surgeon J. B. Coover, 6th Pennsylvania Cavalry, September 27,1861. (See Appendix, p 226 ) Assistant Surgeon John B. Porter, 89th Indiana Volunteers, November 1st, 1861. Surgeon J. L. Sherk, 7th Pennsylvania Cavalry, atBardstown, Kentucky, December 29th, 1864. Acting Assistant Surgeon Samuel Faiinestock, April 13th, 1861. INTRODUCTION. XXXI The following medical officers died of wounds received in action : Assistant Surgeon S.Alexander, 1st Pennsylvania Cavalry, died November 29th, of wounds received at Drainosvillc, Virginia, on November 26th, 1801. Assistant Surgeon J. E. Hill, 19th Massachusetts Volunteers, died of wounds received at Fairfax, Virginia, on September 11th, 1862. Assistant Surgeon W. S. Moore, 61st Ohio Volunteers, died of wounds received at Gettysburg on July 2d, 1863. Acting Assistant Surgeon W. V>. Cary, died of wounds on January 20th, 18G4. Assistant Surgeon Hezekiah Fish, 15th Iowa Aroluuteers, died August 19th, of wounds received near Atlanta on August 17th, 1864. Surgeon Otto Soiienk, 46th New York Volunteers, died on August 21st, 1864, of wounds received near Petersburg, August 20th, 1864. (Sec Appendix, p. 175.) Acting Assistant Surgeon Emil Ohlensohlager, died October 8th, of wounds received in action on October 8th, 1864. (Sec Appendix, p. 226.) Surgeon Thomas J. Shannon, 116th Ohio Volunteers, died October 20th, of wounds received at Cedar Creek on October 19th, 1804. (See Appendix, p. 220.) The following medical officers died through accidents occurring in the line of duty: Surgeon Frederick S. "Wells, 9th New Jersey Volunteers, drowned at Hatteras Inlet, January 15th, 1862, in the courageous and perilous attempt to land to procure food and water for the famine-stricken regiment, its transport being driven offshore in a terrific storm. Assistant Surgeon AY. M. Knox, 78th Pennsylvania Volunteers, April 27th, 1862. Assistant Surgeon Jesse J. Thomas, 10th New Jersey Volunteers, May, 1862. Assistant Surgeon Charles Johnson, 10th Tennessee Volunteers, killed by a fall, April 5,1863. Surgeon George Hammond, U. S. A., drowned in the Mississippi River, August 14th, 1863. Assistant Surgeon W. B. Witt, G9th Indiana Volunteers, drowned at Saluria Bayou, Texas, March 13th,'1864. Assistant Surgeon S. C Ferson, 74th Illinois Volunteers, at Vara ell, October 7, 1864. Surgeon William K. Sadler, 19th Kentucky Volunteers, shot by a soldier, December 2d, 1864. Assistant Surgeon A. F. Marsh, 56th Illinois Volunteers, lost at sea, on the steamer General Lyon, March 31st, 1865. If the above sad mortuary record, proportionately larger than that of any other staff corps, is insufficient to correct the popular fallacy that, in time of battle, the post of the medical officer is one of comparative safety, that false impression may be removed by the following list of medical officers wounded in action: Surgeon J. Marcus Rice, 25th Massachusetts Volunteers, at Roanoke Island, February 7th, 1862. Acting Assistant Surgeon W. A. Kittredge, Fort Fillmore, New Mexico, June 25th, 1862. (See Appendix, p. 353.) Surgeon A. A. Edmeston, 92d New York Volunteers, at Savage's Station, June 27th, 1862. Assistant Surgeon G. M. McGill, U. S. A., at Beverly Ford, Virginia, October 22d, 1863. Assistant Surgeon W7. M. Notson, U. S. A., at Gettysburg, July 3d, 1863. Surgeon J. M. Stevenson", 3d Maryland Cavalry, at Gettysburg, July 3d, 1863. Surgeon Charles Alexander, 16th Maine Volunteers, at Gettysburg, July 2d, 1863. Assistant Surgeon E. B. Heckef., 27th Pennsylvania Volunteers, at Gettysburg, July 3d, 1863. Assistant Surgeon Joseph D. Stewart, 74th New York Volunteers, Gettysburg, July 2d, 1863. Surgeon F. H. Gross, U. S. V., at Chickamauga, September 19th, 1863. (See Appendix, p. 270.) Surgeon J. R. Weist, 4th Ohio Cavalry, wounded in 1863. Assistant Surgeon A. H. Landis, 35th Ohio Volunteers, at Chickamauga, September 19th, 1863. Surgeon E. A. Mekrifield, 44th Illinois Volunteers, at Chickamauga, September 19th, 1863. (See Appendix, p. 277.) Assistant Surgeon W. H. Forwood, U. S. A., at Brandy Station, October 8th, 1863. Surgeon N. R. DErby, U. S. V., on Cane River, Louisiana, April 21st, 1864. Permanently maimed and pensioned. Assistant Surgeon Robert Fenwick, 146th New York Volunteers, by a shell fragment, at the Wilderness, May 8th, 1864. Surgeon T. E. Mitchell, at Winchester, May 25th, 1861. (See Appendix, p. 230.) Assistant Surgeon W. A. Barry, 98th Pennsylvania Volunteers, Wilderness, May 6th, 1864. Assistant Surgeon R. S. Vickery, 2d Michigan Volunteers, Petersburg, July 30th, 1864. Femoral artery ligated. Assistant Surgeon Isaac Smith, 26th Massachusetts Volunteers, at Opequan, September 19th, 1864. He is a pensioner. (See Appendix, p. 226.) Surgeon John T. Scearce, 11th Indiana Volunteers, at Cedar Creek, October 19th, 1864. (See Appendix, p. 226. Assistant Surgeon Preston B. Rose, 5th Michigan Volunteers, Hatcher's Run, October 27th, 1864. He is a pensioner. Assistant Surgeon C. C. V. A. Crawford, 102d Pennsylvania Volunteers, Petersburg, July 12th, 1864. Assistant Surgeon Thomas Helm, 148th New York Volunteers, Petersburg, September, 1864. Assistant Surgeon Austin Mandeville, 169th New York Volunteers, Dutch Gap, August 13th, 1864. He is a pensioner. Assistant Surgeon D. W. Richards, 145th' Pennsylvania Volunteers, June 2d, 1864. Surgeon W. A. Smith, 103d New York Volunteers, Suffolk, May 3d, 1863. He is a pensioner. Assistant Surgeon Samuel B. Shepard, 7th Connecticut Volunteers, captured, June 2d, 1864. Surgeon Isaac Walburn, 17th Pennsylvania Cavalry, at Beverly Ford, June 9th, 1863. Assistant Surgeon H. T. Whitman, 5th Pennsylvania Volunteers, at Bethesda Church, Virginia, May 30th, 1864. Assistant Surgeon L. Barnes, 6th United States Colored Troops, explosion of magazine at Fort Fisher, January 16th, 1865. Surgeon M. M. Manly, 2d United States Colored Troops, at Fort Darling, Virginia, May 14th, 1864. Assistant Surgeon G. V. R. Merrill, 6th United States Colored Troops, at Petersburg, June, 1864. XXXII INTRODUCTION. Acting Assistant Surgeon Samuel H. Boone. January 17th, 1865. Surgeon J. T. Stewart, 64th Illinois Volunteers, Atlanta, July 19th, 1864, Assistant Surgeon A. G. Picket, 50th Illinois Volunteers, at Allatoona, October 5th, 1864. Surgeon A. N\ Dougherty, U. S. V., Wilderness, May 6th, 1864. Assistant Surgeon James Allen, 89th New York Volunteers, Petersburg, September, 1864. Assistant Surgeon O. H. Adams, 8th New York Cavalry, at La • ,'s Springs, December 21st, 18(51. (Sec. SURG. Hist. p. 2.) Assistant Surgeon Jacob C. Barr. 1st Ohio Volunteers, Wauhatchie, Tennessee, October 29th, 1864. Assistant Surgeon Julius Bray. 25th Missouri Volunteers, at Shiloh, April 6th, 1862. Assistant Surgeon James Brown, 4th Tennessee Cavalry, Franklin, Tennessee, September 23d, 1864. Assistant Surgeon G. B. Bailey, 9th West Virginia Cavalry, at Guyandotte, November 10th, 1861. Assistant Surgeon Charles Bunce, 59th Illinois Volunteers, July, 1864. Assistant Surgeon A. T. C. Conner, 9th New York Cavalry, Woodville, Virginia, May, 1864. Assistant Surgeon D. 0. Crouch, 13lh Pennsylvania Reserves, Fredericksburg, December 13th, 1862. Surgeon J. W. Green, 95th Illinois Volunteers, Spanish Fort, Alabama, April 8th, 1865. Assistant Surgeon T. Gilfillan, 59th Massachusetts Volunteers, Petersburg, July 8th, 1864. Assistant Surgeon Joseph Gardner, 24th Kentucky Volunteers, near Atlanta, August 5th, 1864. He is a pensioner. Assistant Surgeon C E. Goldsborough, 5th Maryland Volunteers, Petersburg, August 5th, 1864. Acting Assistant Surgeon Ralph C. Huse, January 16th, 1865. Assistant Surgeon Levi Jewett, 14th Connecticut Volunteers, Reams Station, August 28,1854. (SeeAppendix, p. 173.) Assistant Surgeon David D. Kennedy, .r>7th Pennsylvania Volunteers, Fredericksburg, December 13th, 1862. Surgeon James A. Morris, 117th New York Volunteers, Fort Fisher, January 16th, 1865. Assistant Surgeon Edwin W. Magann, 9th Indiana Cavalry, Sulphur Branch Trestle, Alabama, September 25th, 1864. Assistant Surgeon Thomas L. Morgan, 10th Missouri Volunteei*s, April, 1864. Assistant Surgeon Peter M. Murphy, 134th New York Volunteers, Resaca, Georgia, May 15th, 1864. Assistant Surgeon George A. Munroe, 3d Rhode Island Cavalry, on a scout, November 29th, 1864. Surgeon Charles Newhaus, 29th New York Volunteers, second Bull Run, August 29th, 1862. He is a pensioner. Surgeon William D. Newell, 28th New Jersey Volunteers, Fredericksburg, December 13th, 1862. Surgeon Fowler Prentice, 73d New York Volunteers, August, 1864. Surgeon Henry Root, 58th New York Volunteers, May, 1863. Surgeon Peter E. Sickler, 8th New York Cavalry, Petersburg, April, 1865. Assistant Surgeon George R. Sullivan, 15th New Jersey Volunteers, Fredericksburg, May 9th, 1863. Assistant Surgeon Thomas S. Stanway, 102d Illinois Volunteers, Nashville, December 22d, 1863. Surgeon William P. Thurston, 1st Rhode Island Artillery, Fairfax, June 28th, 1862, Surgeon James Wilson, 99th New York Volunteers, Suffolk, April 24th, 1863. Surgeon A. A. C. Williams, Second United States Sharpshooters, Chancellorsville, May 3d, 1863. Surgeon Arvin F. Whelan, 1st Michigan Sharpshooters, Petersburg, August 3d, 1864. Assistant Surgeon Charles A. Wheeler, 12th Massachusetts Volunteers, Wilderness, May 6th. 1864. Assistant Surgeon T. W. C. Williamson, 24th Indiana Volunteers, Champion Hills, May 16th, 1863. Assistant Surgeon J. S. Waggoner, 84th Pennsylvania Volunteers, in May, 1863. Surgeon John Dickson, 111th United States Colored Troops, at Sulphur Branch Trestle^Alabama, September 25th, 1864. I had hoped to complete, in this first part of the Surgical History of the War, the discussion of the Wounds and Injuries of the Head and Trunk. But the preliminary matter that has been included occupies so much space, that it is necessary to reserve many of the general observations upon the Injuries of the Head, Spine, and Blood-vessels, and the consideration of Wounds and Injuries of the Abdomen and of the Pelvis, and to place the latter at the commencement of the succeeding surgical volume. GEORGE A. OTIS. A. M. M. CHRONOLOGICAL SUMMARY OF ENGAGEMENTS AND BATTLES. 5* CHRONOLOGICAL SUMMARY OF THE ENGAGEMENTS AND BATTLES. i) ati:. 1861. April 12th and Eltli. April Ii)tli April 18th. May 10th .. May 10th .. Juno 1st... Juno 3d .. Juno 10th. Juno 1 lth.. Juno 17th.. Juno 17th.. Juno 17th.. Juno 17th.. Juno 17th.. Juno 18th.. Juno 20th.. Juno 27th.. July 2d.... July 5th... LOCALITY Fort Sumtor, South Carolina. . Stroots of Baltimore, Maryland........ Harper's Ferry, Virginia................ ('amp Jackson, Missouri..............., St. Louis, Missouri, corner of 5th and Walnut stroots. Fairfax Court-house, Virginia........... Phillippi, West Virginia................ Great Bethel, Virginia................. UNION TROOPS ENGAGED. UNION LOSS. CONKED. LOSS. Mattery E, 1st II. S. Artillery. (itli Massachusetts State Militia and 26th Pennsylvan: Volunteers. Romuey, West Virgi Vienna, Virginia.... Detachniont of Ordnance men....................... 1st, .')d, and 4th Mo. Reserve Corps and 3d Missouri Vols. 5th Missouri U. S. Reserve Corps..................... Company II, 2d U. S. Cavalry........................ 1st West Virginia, 16th Ohio. 7th Indiana, 9th Indiana, and 14th Ohio Volunteers. 1st, 2d, 3d,'5th, and 7th New York Vols., 4th Massachu- setts, and a detachment of 2d U. S. Artillery. 11th Indiana Volunteers. 1st Ohio Volunteers...... lioonvillo, Missouri.. Edward's Ferry, Virginia. Independence, Missouri... New Creek, West Virginia Camp Cole, Missouri...... Patterson Creek, Virginia. Mathias Point, Virginia___ Palling Waters, Maryland. Carthage, Missouri........ 2d Missouri (three months) Volunteers, Batteries II and L, 1st Missouri Light Artillery. 1st Pennsylvania Volunteers (300 men). Detachment of Missouri Volunteers.... Local Militia........................ Union Home Guards (800 men)........ 11th Indiana Volunteers............... July 5th...! Newport News, Virginia. Crews of U. S. Gunboats Pawnee and Freeborn. 1st Wisconsin and 11th Pennsylvania Volunteers. Ad- vance of Brigadier General George II. Thomas's command. 3d and 5th Missouri (three months) and Battery of Missouri Artillery. 9th New York (one company) I 15 I 25 13 30) 23j 50 125 REMARKS AND REFERENCES. There wereno casualties during the bombardment; but, in saluting the Hag, before the evacuation, on April 15th, Private Daniel Hough was killed and three other artillerists were wounded by the premature explosion of a gun. Casualty Lists, S. G. O., No. 555. ......I Official Report of Lieutenant R. Jones. (i39 Official Report of Capt. Nathaniel Lyon, 2d Infantry. ......| Report of Adjutant General of Missouri, 1865, p. 79. 5 i Official Report of Lieut. C. II. Tompkins for the Union losses. Confederate report of Confed. losses. 10 ' Official Report, Casualty Lists, S. G. ()., File A. 555, and Official Report of Major General B. F. Butler, U. S. V. Lieut. Groble, 2d Artillery, killed. Indiana Adjutant General's Report, Vol. 1, p. 31. Official Report of Brigadier General It. C. Schenck, U.S. V. 15 j Missouri Adjutant General's Report, 1865, p. 405. ] .....; Sundry unofficial reports. ..... Unofficial reports. ..... Rebellion Record, Vol. II, page 3. Sundry unofficial reports. 30 45 Indiana Adjutant General's Report, Vol. 2, p. 31. Casualty Lists, S. G. <)., File A, No. 155. Also designated Kelly's Island. Official Report of Captain T. C. Rowan, U. S. N. Commander T. 11. Ward, U. >S. N., was killed. Appendix to Part I, of the Medical and Surgical History of the War, p. 10. This engagement is also designated Haynesville and Martinsburg. Casualty Lists, S. G. ()., No. 20!), and Official Report of Colonel Franz Siegel, 3d Missouri Volunteers. Also designated Dry Porks. Newspaper report. July 6th. July 7th. July 8th. Middle Crook Fork, West Virginia......j 3d Ohio Volunteers (one company). Great Fulls, Virginia....... Laurel Hill, West Virginia. July Kith. . Monroe Station, Missouri July Nth July 12th July 12th July Mth llich Mountain, West Virginia....... Barboursvillo, West Virginia.. Beverly, West Virginia....... Currick's Ford, West Virginia . 8th Now York Volunteers....... 14th Ohio and 9th Indiana Volunteer July Kith-. Millsvillo, Missouri, North Missouri Rail- 8lh Missouri Volunteers road. 16th Illinois and 3d Iowa Volunteers and llannilial Homo Guards. Rth, KXIi, ami 13th Indiana and lilth Ohio Voluntoors 2d Kentucky Volunteers................... 4th and 9th Ohio Volunteers................. Mth Ohio and iltli and 7lli Indiana Volunteers July 17th. July 17th. July 17th. July 17th. July 18th and lilth. July 18th. July 21st. July22d.. July 22d... July 24th.. July 26th.. July 26th.. July 27th.. Fulton, Missouri . 3d Missouri Reserves (400 men). Scarytown, West Virginia............. Martinsburg, Missouri................. Bunker Hill, Virginia................. Ilarrisonvillc and Pnrkersvillc, Missouri Blackburn's Ford, Virginia............ 2d Kentucky, 12thand21st Ohio Vols, and IstOhio Bat'y. 1st Missouri Reserves (one company).................. Dotaclmient of General Patterson's command......... Van Horn's Battalion, (Mo.,) Cass County Home Guards. 1st Massachusetts, 2d and 3d Michigan, and 12th Now York Volunteers, detaclunont of 2d U. S. Cavalry, and Buttery \i, 3d 11. S. Artillery. Bull Run, Virginia.....................! Of infantry volunteers or militia, the 2d Maine, 2d Now Hampshire, 2d Vermont, 1st, lth, and 5th Massachu- setts, Island 2(1 Rhode Island, 1st, 2d, and 3d Con noeticut, 8th, Itth, 12th, 13th, 16th. 18th. 27th, 2!)th, 31st, 32d, 35th, 3811:, and 39th New York Volunteers, 2d, 8th, 14th, 69th, 71st, and 79th Now York Militia, 27th Pennsylvania Volunteers, 1st, 2d, and 3d Michi- gan, 1st Minnesota, 1st and 2d Ohio, 2d Minnesota, and detachments of the 2d, 3d, and 8th Regular In- fantry and a battalion of Murines; of artillery, bat- teries l>, E, (!. and M, 2d Artillery, E, 3d Artillery, D, 5th Artillery, and the 2d Ithod'e Island Battery; of cavalry, detachments from the 1st and 2d Dra- goons. Forsyth, Missouri. VEtnn, Missouri... Blue Mills, Missouri............... Lane's Prairie, near Rolla, Missouri. Ilarrisonville, Missouri............. Fort Fillmore, New Mexico........ 1st Iowa and 2d Kansas Volunteers, Stanley Dragoons, and Toften's Battery. 21st Missouri Volunteers. 5th Missouri Reserves......... .............. Heme Guards................................ Missouri Home Guards and 5th Kansas Cavalry 7th U. S. Infantry and U. S. Mounted Rifles____ disunity Lists, S. G. <>., No. 555, and Ohio in thn War, Vol. 2, p. 28. Also known as the action at Biiikhaunon. Rebellion Record, Vol. II, page 21, Also designated Bealington. Adjutant General's Report, Illinois, Vol. 1, p. 417. Sec Appendix to Part I of the Medical and Sur- gical History of the War, page 13; Report of Medical Director J. J. B. Wright, II. S. A.; also Official Report of Major General George B. McOlcllnn, U. S. V. Also designated Red House;. Official Report of General McClolIan. See Appendix to Parti, Medical and Surgical His- tory of the War, page 14. Confederate General R. S. Garnctt killed. Missouri Adjutant General's Report, 1865, p. 128. Also designated Wentzvillu. Tribune Almanac, 1862, page 44, and Report of Adjutant General of Missouri, 1865, page 71. Ohio in the War, Vol. 2, p. 89. Official Report of Adjutant General of Missouri 1865. Ucport of Adjutant General of Missouri, 1865, page 91. Official Reports of Generals McDowell and Beau- regard. Official Reports of Generals McDowell and Beau- regard. Appendix to Part I. Medical and Sur- gical 11 istory of the War, pages 1 to 10 inclusive ; MSS. Confederate casualty lists. This battle is also designated Manassas. Among the Confeder- ate killed were Brigadier Generals B. E. Bee and Barton. Unofficial sources. Official Report of the Adjutant General of Missouri, for 1805. Same Report. Unofficial. Official. DATE. 1801. LOCALITY. Aug. 2d... Dug .Springs, Missouri..... Aug. 3d... Mesilla, New Mexico...... Aug. 5th... Athens, Missouri........... Aug. 5th... Point of Rooks, Maryland.. Aug. 7th... Hampton, Virginia......... Aug. 8th... Lovettsville, Virginia...... Aug. 10th.. Wilson's Creek, Missouri... Aug. 10th. Aug. 13th. Aug. 17th. Aug. 19th.. Aug. 20th . Aug. 20th.. Aug. 21st.. Aug. 26th.. Aug. 27th.. Aug. 27th.. Aug. 29th.. Aug. 28th and 29th. Aug. 31st.. Sept. 1st... Sept. 1st... Sept. 2d... Sept. 2d... Grafton, West Virginia. Brunswick, Missouri ... Charlestown, Missouri. Hawk's Nest, West Virginia. Lookout Station, Missouri... Jonesboro', Missouri......... Cross Lanes, West Virginia.. UNION LOSS. UNION TROOPS ENGAGED | 13 tc 3 .22 1st Iowa and 3d Missouri Volunteers, and five batteries Missouri Light Artillery. 7th U. S. Infantry and U. S. Mounted Rifles........... Home Guards and 21st Missouri Volunteers............ 28th New York Volunteers........................... 20th New York Volunteers............................ 19th New York Volunteers.................... CONFED. LOSS. 40 Cavalry: 6th and 10th Missouri, 2d Kansas Mounted Volunteers, and one company of the 1st United States, infantry : 1st Iowa, 1st Kansas, 1st, 2d, 3d, and 5th Missouri, detachments of the 1st and 2d Regulars. Missouri Home Guards. Artillery: 1st Missouri Light, and Battery F, 2d United States. Commanded by Brigadier General Nathaniel Lyons. 323 12 14 3 3 1 265 Potosi, Missouri........................ Missouri Home Guards One company 4th West Virginia Volunteers. 5th Missouri Reserves..................... 22d Illinois Volunteers 11th Ohio Volunteers.. Ball's Cross Roads, Virginia........ Wayne Court-house, West Virginia. Lexington, Missouri................ Fort Hatteras, Cape Hatteras Inlet, North Carolina. Munson's Hill, Virginia........... Bennett's Mills, Missouri.......... Boone Court-house, West Virginia. Missouri Home Guards 7th Ohio Volunteers___ Two companies 23d New York Volunteers. 5th West Virginia Volunteers............. Missouri Home Guards___............... 9th, 20th, and 99th New- York Volunteers and a naval force commanded by Commodore Stringham. Two companies 23d New York Volunteers.....,...... Missouri Home Guards............................... 1st Kentucky Volunteers.............................. Dallas, Missouri....................... 11th Missouri Volunteers Worthington, Marion County, West Vir- ginia. 40 40 • 1 200 30 14 2 6 5 800 30 7 20 715 40 REMARKS AND REFERENCE." Appendix to Part I, Medical and Surgical History of the War. page 15. Unofficial sources. Rebellion Record, Vol. II, page 463. Unofficial. Unofficial statement. New York Times, August 13th, 1861. Official Report of Major General Fr6mont. Ap- pendix Medical and Surgical History of the War. Part I, pages 16, 17. Also known as Springfield and Oak Hills. Brigadier General Nathaniel Lyons was killed. Unofficial sources. Rebellion Record, Vol. II, page 65. Report of Adjutant General of Missouri, 1865, page 79. Official Report of Major General Fremont. Also known as Bird's Point. Confederate sources. Newspaper statements. Ohio in the War, Vol. 2, page 58. Also known as Summerville. Rebellion Record, Vol. Ill, page 7. Unofficial. St Louis newspapers. Vide Official Reports of Major General Butler, U. S. V., and Commodore Stringham, U. S. N. Newspaper statement. Unofficial statement. Appleton's Cyclopedia, 1861, page 741. Adjutant General's Report, Kentucky, Vol. 1, p. 527. Report of Adjutant General of Missouri, 1865, page 145. Rebellion Record, Vol. Ill, page 13. Q w o !zj O t-1 o Q M Q ► d w ►4 o Sept. 2d...I Dry Wood, Missouri. Beher's Mills, Virginia........ Shelbina, Missouri............ Petersburgh, West Virginia ... Carnifex Ferry, West Virginia. Sept. 11th.. j Lewinsville, Virginia Sept. 11th..; Elkwater, West Virginia. Black River, near Ironton, Missouri Cheat Mountain, West Virginia..... Booneville, Missouri Judah, Rebel privateer, destroyed near Pensacola, Florida. Pritchard's Mills, Virginia............. Lexington, Missouri. Sept. 17th.. Morristown, Missouri. Sept. 17th.. Blue Mills, Missouri.. Barboursville, West Virginia. Papinsville, Missouri.......... 5th and 6th Kansas Volunteers, one company 9th Cav- alry, and 1st Kansas Battery. 13th Massachusetts Volunteers....................... 3d Iowa Volunteers................................. Three companies of the 4th Ohio Volunteers.......... 9th, 10th, 12th, 13th, 28th, and 47th Ohio Volunteers .. 19th Indiana, 3d Vermont, and 05th New York Volun- teers, and 79th New York Militia. 3d Ohio and 15th and 17th Indiana Volunteers........ Three companies of the 1st Indiana Cavalry.......... 13th, 14th, 15th, and 17th Indiana Volunteers, 3d, 6th, 24th, and 25th Ohio, and 2d West Virginia Volunteers. Missouri Home Guards.............................. Crew of United States flag-ship Colorado............. 28th Pennsylvania and 13th Massachusetts Volunteers. 8th, 25th, and 27th Missouri Volunteers, 13th and Mth Missouri Home Guards, Berry's and Van Horn's Missouri Cavalry, 1st Illinois Cavalry, and 23d Illi- nois Volunteers. Colonel James A. Mulligan, 23d Illinois, commanding. 5th, 6th, and 9th Kansas Cavalry and 1st Kansas Bat- tery. 3d low a Volunteers................................. Kentucky Home Guards......... 5th, 6th, and 9th Kansas Cavalry Eliott's Mills, Missouri.................'' 7th Iowa Volunteers Sept. 23d .. | Romney, West Virginia . Chapmansville, West Virginia. Lucas Bend, Kentucky........ Shanghai, Missouri............ Sept. 29th..| Munson's Hill, (Camp Advance,) Va... I Oct. 3d___ Greenbrier, West Virginia............. Oct. 4th.. .1 Alimosa, near Fort Craig, New Mexico. Oct. 4th... i Buffalo Hill, Kentucky................ 4th and 8th Ohio Volunteers. 1st Kentucky and 34th Ohio Volunteers. Captain Stewart's Cavalry............ 69th Pennsylvania fire into 71st Pennsylvania through mistake. Battery G, 4th U. S. Artillery, Battery A, 1st Michigan Artillery, 24th, 25th, and 32d Ohio, and 7th, 9th, I3th, Mth, 15th, and 17th Indiana Volunteers. Mink's New Mexico Cavalry and U. S. Regulars...... 4 9 1 3 5 20 16 6 102 8 5 12 80 30 4 20 9 8 1 3 1 42 2 11 1 17 1 3 4 12 4 15 60 8 25 7 10 7 108 6 39 1 1,624 6 1 75 60 5 50 9 35 20 4 50 47 5 9 8 25 32 100 11 50 75 30 13 20 Official Register of Volunteer Officers, PartVHI. Also known as Fort Scott. Rebellion Record, Vol. Ill, page 13. Rebellion Record, Vol. Ill, page 15. Ohio in the War, Vol. 2, page 36. Official Report of Brigadier General Rosecrans. List of casualties, File F, No. 10, S. G. O. Ap- pendix to Part I, Medical and Surgical History of the War, page 14. List of casualties, File F, No. 33, S. G. O. Ohio in the War, Vol. 2, p. 29. Adjutant General's Report, Indiana, Vol. U, p. 278. Official Report of General J. J. Reynolds. Rebellion Record, Vol. HI, page 27. Official Report of Flag Officer W. Mervine. Official Report of Colonel J. W. Geary, 28th Penn- sylvania Vols. Also known as Darnestown. Official Reports of General's Fremont and Price. Official. Official Report of Lieutenant Colonel John Scott, 3d Iowa Cavalry. Unofficial. Official Register of Volunteer Officers. Also desig- nated as Osceola. Also designated Camp Crittenden. Iowa Adjutant General's Report. 1864. p. 1057. Ohio in the War, Vol. 2, pages 36, 66. Also known as Hanging Rock. Ohio in the War, Vol. 2, page 223. Rebellion Record, Vol. Ill, page 36, Tribune Almanac, 1862, page 45. List of casualties, File F, No. 29, S. G. O. Official Report of Brig. General J. J. Reynolds. Rebellion Record, Vol. Ill, page 41. Unofficial statement. 1). \TE. 1861. Oct 5th. Oct. 8th. Oct. 9th. Oct. 12th Oct. 12th Oct. 12th Oct. 13th Oct. 13th Oct. 15th Oct. 15th Oct. 16th. Oct. Kith. Oct. 19th. Oct. 21st. LOCALITY. Chickninicomico, North Carolina. Hillslioro', Kentucky............ Santa Rosa, Florida............. Cameron, Ray County, Missouri....... Upton Hill, Kentucky................ Bayles' Cross Roads, Louisiana........ Beekwith Farm, (12 miles from Bird's Point,) Missouri. West REMARKS AND REFERENCE 3 140 2 972 5 150 200 2,500 1,600 Official Report of Brigadier General I). C. Bucll. Report of Adjutant General of Missouri. 1865, pages 310 and 346. Also called Pea Ridge. Ohio in the War, Vol. 2, page 757. Casualties, Files 1). No. 49. and F. No. 261. S. G.O. Appendix to Part I. Medical and Surgical History of the War, page 346. Also known as Fort Craig. Newspaper statement. Official. Official Report of Major General H. W. Halleck List of casualties. File A, No. 570, S. G.O. Offi- cial Report of Commodore A. 11. Foote, U. S. N. Report of Adjutant General of Iowa, 1863, Vol. II, page 183. Unofficial Appendix to Part I, Medical and Surgical History of the Wiir, page 305. List of casualties. File A, Nos. 125 and 570, S. G. O. Official Reports Of Brigadier General Samuel R. Curtis, com- manding. Includes the engagements at Benton- villc on the 6th, Leetown on'the 7th, and Elkhorn Tavern on the 8th. Among the casualties on the Union side were Brigadier General Asboth and Acting Brigadier General Carr, wounded; on tlieOoiifedeiatesido, Brigadiei General B. MeCul- loeh and Acting Brig. General James Mcintosh, killed. Official. Adjutant General's Report, Wisconsin, 1865, p. 33. Adjutant General's Report, Massachusetts, 1862, page 286. List of casualties, File F, No. 85. Monitor and Merrimac. Flag Officer Buchanan, C. S. N., was wounded. Adjutant General's Report, Tennessee, 1866, p. 56. Official Report of Major General Ii. W. Halleck, U. S. A. Mar. 12th.. Lexington, Lafayette County, Mis Mar. 12th..I Near Lebanon, Missouri........., New Madrid, Missouri..... Newberne, North Carolina. Mar. Mth. Mar. 16th. Mar. 16th. Mar. 18th. Mar. 21st. Mar. 22d.. Mar. 23d.. Pound Gap, Cumberland Mountains, Tennessee. Aquia Creek Batteries, Virginia . Black Jack Forrest, Tennessee... Salem, Arkansas................ Mosquito Inlet, Florida Independence, Missouri Carthage, Missouri...... 10th and Kith Illinois, 27th, 39th, 43d, and 63d Ohio Volunteers; 3d Michigan Cavalry, IstU. S. Infantry, and Bissoll's Missouri Engineers; 51st New York. 8th, 10th, and 11th Connecticut, 21st, 23d, 24th, 25th, and 27th Massachusetts, 9th New Jersey, 51st Pennsylvania, and 4th and 5th Rhode Island Volunteers. Detachments of the 22d Kentucky, 40th and 42d Ohio Volunteers, and IstOhio Cavalry. F. S. Gunboats Yankee and Anacostia............... Detachments of the 4th Illinois and 5th Ohio Cavalry.. Detachments of the 6th Missouri and 3d Iowa Cavalry. U. S. gunboats Pengu'n and Her.ry Andrei 2d Kansas......... 6th Kansas Cavalry Mar. 23d... AVinchester, Virginia...... Mar. 26th.. Mar. 26th.. Mar. 26th to 28th. Mar. 27th.. Mar. 28th.. Mar. 28th.. Mar. 30th.. April 2d... April 4th.. April 4th.. April 5th to May 3d. Warrensburg, Missouri................. Humonsville, Polk County, Missouri___ Apache Canon, near Santa Fe, New Mexico. Strasburg, Virginia.................... Middleburg, Virginia.................. Warrensburg, Missouri................ Union City, Tennessee................. Putnam's Ferry,near Doniphan, Missouri Pass Christian, Mississippi. Great Bethel, Virginia___ Siege of Yorktown........ 1st "West Virginia, 84th and 110th Pennsylvania, 5th, 7th, 8th, 29th, 62d, and (>7th Ohio, 7th, 13th, and 14th Indiana, and 39th Illinois Volunteers; 1st West Virginia, 1st Ohio, and Co. E. 4th U. S. Artillery ; 1st Michigan and 1st Ohio Cavalry. Sixty men of the 7th Missouri Militia Cavalry Co. B, 8th Missouri Militia Cavalry........... 1st and 2d Colorado Cavalry................... Portion of Brigadier General Banks' command...... 28th Pennsylvania Volunteers, Colonel Geary, com'g. 1st Illinois Cavalry................................ 2d Illinois Cavalry................................. April 4th.. Crump's Landing, Tennessee April 2d... Thoroughfare Gap, Virginia. 5th Minos Cavalry. 21st and 38th Illinois Volunteers, and Kith Ohio Battery, Colonel Carlin's Brigade, (General Steele's command.) 9th Connecticut and 6th Massachusetts Artillery, Advance of the 3d Corps, Army of the Potomac. 2d, 3d, and 4th Corps, Army of the Potomac____ 5th Ohio Cavalry and 48th, 70th, and 72d Ohio Vols. 28th Pennsylvania Volunteers..................... 25 Official Report of Major General H. W. Halleck, U. S. A. Official Report of Brigadier General John Pope, U. S. A. Appendix to Part I, Medical and Surgical History of the War. page 237. List of casualties, File A, No. 348. S. G. O. Official Reports of Brigadier General A. E. Burnside, commanding. ■hio in the War, Vol. 2, page 268. Also known as Sounding Gap. Official Report of Major General H. W. Halleck. Also known as Spring River. Official Report of Commodore S. F. Dupont, U. S. N. Newspaper statement. Also called Little Santa F6. Official. List of casualties, File A, No. 345, S. G. O. Ap- pendix to Part I, Medical and Surgical History of the War, page 229. Official Report. Brig. General James Shields, commanding the Union forces, was wounded. Also designated Kearns- town. Also designated Briar. Official. Official Report of Brigadier General H. F. Sibley, C. 8. A. Also known as Glorietta. Adjutant General's Report, Michigan, 1862, p. 53. Newspaper statements. Newspaper statement. Adjutant General's Report, Illinois, Vol. Ill, p. 54. Official Report of Major General B. F. Butler. Official. Official Report of Major General G. B. MeCIellan. Appendix to Part I, Medical and Surgical His- tory of the War, page 44. Ohio in the War, Vol. 2, page 779. Also called Adamsville. Newspaper statements. Killed, wounded, and missing. DATE. 1862. LOCALITY. UNION LOSS. CONFED. LOSS. UNION TROOPS ENGAGED. April 6lh ' Shilob, Tennessee... and 7th. \pril 8th.. Island No. 10, Tennessee April 9th.. April 10th. April 11th. April 11th. April 12th. April 8th.., I April 12th. April 14th. April 14th. April 14th. April 14th. Owen's River, Californii Fort Pulaski, Georgia.. Huntsville, Alabama............... Skirmish before Yorktown, Virginia. Little Blue River, Missouri Reconnoissance on the Corinth Road, Mississippi. Montere}-, Virginia........... Pollocksville, North Carolina. Diamond Grove, Missouri___ Walkersville, Missouri....... Montavallo, Missouri......... April 15th. Pechacho Pass. I). T. April 15th. April 10th. April 16th. April 16th. April 14th. Peralto, New Mexico Savannah, Tennesset Whitemarsh, Georgi; 1st Division, Major General J. A. MeClernand; 2d Division, Major General C. F. Smith; 3d Division, Brigadier General Lewis Wallace; 4th Division, Brigadier General S. A. Hurlburt: 5th Division, Brigadier General W. T. Sherman; and (ith Divis- ion, Brigadier General B. M. Prentiss—Army of the District of Western Tennessee, commanded by Major General U. S. Grant: 2d Division, Brigadier General A. M. D. Cook; 4th Division, Brigadier General W. Nelson; 5th Division, Brigadier General T.L.Crit- tenden; and the 21st Brigade of the (ith Division- Army of the Ohio, commanded by Major General D. C. Buell; and gunboats Tyler and Lexington. Navy, commanded by Flag Officer A. H. Foote; Army, commanded by Major General John Pope. 2d California Cavalry................................ 6th and 7th Connecticut, 3d Rhode Island, 40th and 48th New York, and 8th Maine Volunteers; 15th U. S. Infantry and crew of U. S. S. Wabash. a 1, 735 3d Division Army of the Ohio. 12th New York and 57th and 63d Pennsylvania Volun- teers. 3d Brigade, 5th Division, Army of Western Tennessee, and 4th Illinois Cavalry. 75th Ohio Volunteers and 1st West Virginia Cavalry.. 6th Kansas Cavalry................ 2d Missouri Militia Cavalry......... Two companies of 1st Iowa Cavalry. 1st California Cavalry.............. Lee's Mills, Virginia............... Fort Pillow, Tennessee, bombarded. 8th Michigan Volunteers and Battery of Rhode Island Light Artillery. 3d, 4th, and 6th Vermont Volunteers, 3d New York Battery, and Battery of 5th U. S. Artillery. 35 35 3,956 1,728 8,012 10 200 17 200 REMARKS AND REFERENCES. Official Reports of Major Generals U. S. Grant and D.C. Buell, U.S. A., and G. T. Beauregaid, C. S. A. Appendix to Part I. Medical and Sur- gical History of the War. page 37. Also called Pittsburg Landing. A.....ng tne casualties in the Confederate army were Major General A. S. Johnson, commander-in-chief, and Brig. General A. II. Gladden, killed; Major General W. S. Cheatham, Brigadier Generals C. Clark, B. I". Johnson, and .1. S. Bowen, wounded. On Ihe Union side. Brigadier Generals W. T. .Sherman and W. II. L. Wallace, wounded, and B. M. Prentiss, captured. 3,000 : Official Reports of Commodore Foote and Major General Pope. Siege commenced March 16th. 300 j Official Report of Major Gen. 1). Hunter, U. S. A., commanding. Official Report of Brigadier General O. M. Mitch- ell, U. S. A., commanding. Newspaper statements. Newspaper statement. Official Report of Brigadier General W. T. Sher- man. Ohio in the AVar, Vol. 2, page 434. Confederate sources. 5 i Official Report of the Adjutant General of Iowa, 1863, Vol. II, page 845. ' Monthly Report of Sick and Wounded. 5th Cali- fornia Volunteers. Official. Rebellion Record, Vol. IV, page 90. 7 !........I Official Report of Colonel W. M. Fenton. 8th Mich- igan Volunteers. Also known as Wilmington Island. Casualty List, File A, No. 538, S. G. O. Official Dispatch of Commodore A. II.Foote, U.S.N. April 17th. Holly River, West Virginia April 18th. April 19th. Falmouth (near Fredericksburg), Va. Talbot's Ferry, Arkansas............ April lSth. Camden, North Carolina. April 18th.i Edisto Island, South Carolina April 23d..i Grass Lick, West Virginia....... April 25th J Fort Macon, North Carolina....... i April 26th.1 Turnback Creek, Missouri........ April 26th. Neosha, Missouri...................... April 23th. Redoubt before Yorktown, Virginia____ April 27th. Horton's Mills, near Newberne, North ! Carolina. April 28th. Paint Rock Railroad Bridge............ April 18th ! Forts Jackson and St. Philip and cap- to Apr. 28th. tare of New Orleans, Louisiana. April 28th April 28th. April 29th. Cumberland Mountain, Tennessee. Monterey, Tennessee.............. Bridgeport, Alabama.............. May 1st___j Clarke's Hollow, AVest Virginia... May 3d... Farmington, Mississippi.......... May 4th. Licking, Missouri............ May 4th... Cheese Cake Church, A'irginia May 5th__I Lebanon, Tennessee.......... May 5th... Loekridge Mills, Kentucky... May 5th... AA'illiamsburg. Virginia....... May 7th... West Point, A'irginia. 10th AVest A'irginia Volunteers........................ 2d New York Cavalry................................ 4th Iowa Cavalry.................................... 21st Massachusetts, 51st Pennsylvania, 6th New Hamp- shire, and 9th and 89th New'York A'olunteeers. Crew of IT. S. S. Crusader, 3d New Ilamphshirc, and 55th Pennsylvania Volunteers. 3d Maryland and Potomac Home Brigade............. U. S. gunboats Daylight, State of Georgia, Chippewa, and the bark Gemsbok (commanded by Commander S. Lockwood), and General Parkes' Division. 5th Kansas Cavalry.................................. 1st Missouri Cavalry................................. Three companies of the 1st Massachusetts Volunteers .. 103d New York Volunteers........................... Twenty-two men of the 10th Wisconsin ATolunteers Fleet of war-vessels, commanded by Commodore D. G. Farragut, and mortar-boats, commanded by Com- mander D. D. Porter. 22d Kentucky and 16th and 42d Ohio Volunteers....... 2d Iowa Cavalry..................................... 3d Division Army of the Ohio........................ Co. C, 23d Ohio Volunteers.......................... 10th, 16th, 22d. 27th, 42d, and 51st Illinois, and 10th and 16th Michigan A'olunteers, Yates' Illinois Sharp- shooters, 2d Michigan Cavalry, and Battery C, 1st Illinois Artillery. 5th Missouri Militia Cavalry and 24th Missouri Volun- teers. 3d Pennsylvania and 1st and 6th U. S. Cavalry........ Detachments of the 7th Pennsylvania Cavalry and 1st, 4th, and 5th Kentucky Cavalry. 5th Iowa Ca valry................................. Third and Fourth Corps, Army of the Potomac..... 16th, 31st, and 32d New York. 95th and 96th, Pennsyl- vania, and 5th Maine Volunteers, 1st Massachusetts, and Battery D, 2d U. S. Artillery. * Killed, wounded, and 4 456 2 16 6 7 193 16 1,400 72 t ..... Rebellion Record, Vol. IA', page 91. 19 | Casualty List, File A, No. 571, S. G.O. 3 Official Report of Major General A. E. Burnside, U. S. A., and .Major General B. linger, C. S. A. Also known as South Mills. Official Report of Commodore S. F. Du Pont. 5 j Official Report of Major General J. C. Fremont. 450 Official P.eports. Brigadier General A. E. Burn- side, commanding. 62 Official. Official. 14 Casualty List, File A, No. 571, S. G. O. 10 Major General D. C. Buell's Order, July 21st, 1862. 400 Official Report of Commodore D. G. Farragut, U. «. N. Ohio in the AVar, A'ol. 2, page 117. Report of Adjutant General of Iowa, 1863, p. 857. 18 350 Official Report of Brigadier General O. M. Mitchell, commanding. Newspaper statements. Casualty List, File A, No. 571, S. G. O. Official Report of Major General John Pope. Casualty List, File A, No. 548, S. G. O. 66 ! Official Report of Brigadier General E. Dumont. 1,000" Adjutant General's Report, Iowa, 1864, page 985, Also known as Dresden. Casualty List. File A, No. 521, S. G. O. Official Report of Major General G. B. McClellan. Ap- pendix to Part I, Medical and Surgical History ot the AArar, page 44. Casualty List, File A, No. 285. S. G. O. Also known as Eltham's Landing. Official Report of Major General McCIellan. g. t Killed and wounded. DATE. 1802. LOCALITY. UNION TROOPS ENGAGED Mny 7th... May 8th... May 8th... May 9th... May 9th... .May 9th... May 10th.. May 10th.. May 11th.. May 13th.. Somerville Heights, Virginia......... McDowell, Virginia................. Glciulale, near Corinth. Mississippi..... Elkton Station, near Athens, Alabama. Slatersville, A'irginia.................. Farming-ton, Mississippi................ Fort Pillow, Tennessee................ Norfolk, Virginia....................... Bloomfield, Missouri. Reedy Creek. Cumberland Mountains, West Virginia. May 13th... Kodgcrsville, Alabama. May 13th. May 14th. May 15th.. May 15th.. May 15th.. May 15th-. May 17th.. May 15th, li;t]'i,,v 18th Monterey, Tennessee........... Trenton Bridge, North Carolina. Linden, A'irginia...................... Fort Darling, James River, A'irginia--- Chalk Binds, Missouri.......... Butler, Bates County, Missouri. 13th Indiana A'olunte< 25th, 32d 75th, and 82d Ohio and 3d AVest A'irginia A'oluntcers, 1st AVest A'irginia and 1st Connecticut Cavalry, and 1st Indiana Battery, Brigadier General R. II. Milroy commanding. 7th Illinois Cavalry....... Company E, 37th Indiana. (ith U. S. Cavalry, and 98th Pennsylvania and 2d Rhode Island Volunteers. Two brigades of the Army of the Mississippi. Russell's House, before Corinth, Missis- sippi. Princeton, AVest A'irginia............... Mny 19th.. Searcy Landing, Little Red River, Ar- kansas. : 'ay 19th.. Clinton, North Carolina U. S. gunboats Cincinnati and Mound City............. 10th, 20th, and 99th New York, 1st Delaware, 58th Pennsylvania, 20th Indiana, and Kith Massachusetts Volunteers, Battery 1), 4th U. S. Artillery, and 1st New York Mounted Rifles. 1st AVisconsin Cavalry. 1st AA'isconsin and 38th Indiana A'oluntcers, and Cavalry commanded by Colonel Starkweather. Portion of Brigadier General M. L. Smith's Brigade... 17th, 25th, and 27th Massachusetts Volunteers, Battery B. 3d N. Y. Artillery, and two troops of the 3d New Y'ork Cavalry. One company of the 28th Pennsylvania Volunteers___ U. S. S. Galena, Port Royal,' Naugatuck, Monitor, and Aristook. 1st AVisconsin Cavalry. 1st Iowa Cavalry..... General M. L. Smith's Brig-tide of the 5th Division, Army of Tennessee. Kanawha Division, commanded by General J. D. Cox. Detachments of 4th Missouri Cavalry, 3d and 17th Mis- souri A'oluntcers, Battery B, 1st Missouri Light Ar- tillery. \TON LOSS. CONFED. I,Of 3 14 3 1 31 70 27 200 301 150" REMARKS AND REFERENCES. Report of Adiutant General of Indiana, page 110. Casualty List, File A, No. 571, S. G. O. Appendix to Part I, Medical and Surgical History of the AVar, page 117. Casualty List. File A, No. 409, S. G. O. Official Report. Also known as Bull Pasture Mountain. General Johnson, C. S. A., was wounded. Report of Adjutant General of Indiana. Also known as New Kent Court House. Casualty List, File A, No. 571. Casualty List, File A. No. 412, S. G. O. Official Report of Major General John Pope,commanding. Official Report of Captain C. II. Davis, U. S. N. Official Report of Major General John AA'ool. Newspaper statement. Official Report of Brigadier General B. F. Kelley. Reports of Adjutants General of Wisconsin and Indiana. Newspaper account. Ofiicial. Official Report of Commander John Rodgers, U.S.N. Official. Report of Adjutant General of Iowa, 1863, A'ol. II. page 845. Casualty List, File A, No. 504, S. G. O. Official Report of Brigadier General W. T. Sherman. Casualty List, File A, No. 410, S. G. O. official Report of Brigadier General H. Marshall, C.N.A. May 21st.. May 22d.. May 22d.. May 23d.. May 23d.. May 23d.. May 23d.. May 24th. May 24th. May 24th. May 24th. May 25th. May 27th.. May 27th.. May 27th.. May 28th.. j May 28th.. May 28th.. May 28th and 29th. May 29th. Mny 30th. May 30th.. May 30th. : May 30th.. Phillip's Creek, Mississippi........ Florida, Monroe County, Missouri, New Berne (near), North Carolina. Lewisburg, A'irginia.............. Front Royal, A'irginia............ Buckton Station, A'irginia............ Fort Craig, New Mexico............. Middletown, A'irginia................ New Bridge, A'irginia................ Chickahominy, A'irginia............. Newtown, Virginia.................. Winchester, Airginia................ Hanover Court House, Virginia...... Big Indian Creek, near Searcy, Arkansas Osceola, Missouri.................... Charlestown and Harper's Ferry, A'irgini: Cache River Bridge, Arkansas....... Wardensville, A'irginia.............. Sylamore, Arkansas................. Pocataligo, South Carolina........... Booneville, Mississippi.............. Tuscumbia Creek, Mississippi Front Royal, Virginia............... Evacuation of Corinth, Mississippi 1 Brigadier General Thomas A. Davis's 2d Division Army of Tennessee. 3 2 8 60 122 6 3 Company I, 17th Massachusetts Volunteers............ 36th and 44th Ohio A'oluntcers and 2d AA'est A'irginia Cavalry. 1st Maryland A'oluntcers and detachments of the 29th Pennsylvania, Captain Mape's 1'ionccrs. and 5th New A'ork Cavalry, and 1st Pennsylvania Artillery. 3 14 32 2 5 750 40 12 66 100 3d U. S. Cavalry......'............................... 46th Pennsylvania and 28th New York A'oluntcers, 1st Maine and 1st A'ermont Cavalry, and one battery of New Y'ork Artillery. 1 2 10 4 601 27 1 . Davidson's Brigade, Smith's Division, Fourth Corps___ . 28th New Y'ork, 2d Massachusetts, 29th Pennsylvania, 27th Indiana, and 3d AVisconsin A'oluntcers, and two batteries of Artillery. . 2d Massachusetts, 29th Pennsylvania, 27th Indiana. 3d AVisconsin. 28th New York. 5th Connecticut, and 46th Pennsylvania A'oluntcers, Battery M, 1st New Y'ork Artillery, and 1st, A'ermont, 1st Michigan, and 5th New York Cavalry. 12th, 13th, 14th, 17th, 25th, and 44th New A'ork, 62d and 83d Pennsylvania, Kith Michigan, and 9th and 22d Massachusetts A'oluntcers, 5th Massachusetts, 2d Maine, and Battery F, 5th U. S. Artillery, and 1st U. S. Sharpshooters. 38 53 '155 344 3 2 711 2001 25 730 5 3 9 3d Maryland Potomac Home Brigade and 3d Indiana Cavalry. 2 3 50th Pennsylvania, 79th New York, and 8th Michigan Volunteers, and 1st Massachusetts Cavalry. 2 9 2,000 3 5 8 3 1 1st Rhode Island Cavalry. Advance of Major General McDowell's command. 156 Official. Rebellion Record, A'ol. V, page 15. Casualty List, File A, No. 427, S. C. O. Official Report of Colonel George Crook. Casualty List, File A, No. 610, S. G. O. Official Report of Major General N. P. Banks. Report of Adjutant General of AA'isconsin, 1865, page 97. Rebellion Record, A'ol. V, page 15. Official Report of Major General N. P. Banks. Skirmish on Banks' retreat to AA'inchester. Casualty List, File A, 571, S. G. O. Official Report of Colonel George H. Gordon. 2d Massachusetts A'olunteers. Skirmish on Banks' retreat. Casualty Lists. File A, No. 178 and 616. Official Report of Major General N. P. Banks, command- ing. Appendix, Part I. Medical and Surgical History of the AVar, page 230. Casualty List, File A, No. 549. Official Report of Major General MeClellan. Appendix. Part 1, Medical and Surgical History of the War, p. 56. Report of Adjutant General of Missouri, 1865, p. 311. Report of Adjutant General of Iowa. 1863,A'ol. II, page 846. Official Report of Brigadier General R. Saxton. Rebellion Record, Vol. V, page 19. Newspaper statements. Official Report of Colonel B. C. Christ, command- ing. Official Report of Major General John Pope. 156 Report of Adjutant General of Rhode Island, page Official reports. Killed, wounded, and missing, t Killed and wounded. DATE. 1862. LOCALITY'. May 31st.. Neosho, Missouri...................... May 31st..: Greenville Road, near AA7ashington, N. C June 1st... Seabrook's Point, South Carolina........ UNION TROOPS ENGAGED. 10th Illinois Cavalry and 14th Missouri Militia Cavalry. 3d New York Cavalry............................... May 31st and June 1st. June 1st and 2d. June 3d .. June 4th.. June 4th.. June 4th.. June 5th.. Seven Pines and Fair Oaks, A'irginia....! Second Corps, Major General E. V. Sumner; Third Corps, MajorGener il S. P. Ileintzelmau ; and Fourth Corps, Major General E. D. Keyes, Army of the Potomac. Strasburg and Staunton Road, A'irginia (Jackson's Retreat). Legare's Point, South Carolina........ Fort Pillow, Tennessee................ Jasper, Sweden's Cove, Tennessee..... Blackland, Mississippi................. Tranter's Creek. North Carolina........ Memphis, Tennessee....... ! June 6th... Harrisonburg-, A'irginia...... June 8th... Cross Keys, A'irginia........ June 9th.. June 9th.. Baldwin. Mississippi---- Port Republic, A'irginia . ! June 10th.. James Island, South Carolina. 8th AVest Virginia and 60th Ohio A'oluntcers, 1st New Jersey and 1st Pennsylvania Cavalry. 28th Massachusetts and 100th Pennsylvania A'olunteers. Mississippi Flotill^, Commodore C. II. Davis.......... 5th Kentucky and 7th Pennsylvania Cavalry, 79th Penn- sylvania A'oluntcers, and 1st Ohio Battery. 2d Iowa and 2d Michigan Cavalry..................... 24th Massachusetts A'olunteers, Company I, 3d New Y'ork Cavalry, and Marine Artillery. U. S. gunboats Benton, Louisville, Carondelet. Cairo, and St. Louis, and rams Queen of the AVest and Monarch. 1st New Jersey Cavalry, 1st Pennsylvania Rifles, 60th Ohio and 8th AVest Virginia A'olunteers. 8th, 39th, 41st, 45th. 54th. and 58th New Y'ork, 2d, 3d, 5th, and 8th AVest A'irginia, 25th, 32d, 55th. 60th, 73d, 75th, and 82d Ohio, and 1st and 27th Pennsylvania A'oluntcers, and 1st Ohio Battery. 2d Iowa and 2d Michigan Cavalry. 5th, 7th, 29th. and 66th Ohio. 84th and 110th Pennsyl- vania, 7th Indiana, and 1st West A'irginia A'olunteers, and Batteries E, 4th U. S., and A and L, 1st Ohio Ar- tillery. UNION LOSS. CONFED. LOSS. 2,800 42 3,897 801 17 30 1,300 REMARKS AND I! I IT RI-NC I S. Rebellion Record, Vol. A', page 21. Official. Official Report of Major General MeClellan. List of casualties. File A, No. 522. S. G. <). Appen- dix. Part I, .Medical and Surgical History of the AVar, page 63. Among the casualties on the Union side were Brigadier Generals Wessells, Naglee, and O. O. Howard, wounded. On the Confederate side, General J. E. Johnston, com- manding, and Brigadier General R. E. Rhodes were wounded, Brigadier General Robert llatton killed, and J. J. Pettigrew captured. New Jersey and the Rebellion, page 415. Report of Adjutant General of Massachusetts, 1862, page 300. Official. Also known as Fort AA'right. Official Report of Brigadier General J. P. Negley. Report of Adjutant General of Iowa, 1863, p. 853. Report of Adjutant General of Massachusetts, 186: page 274. Official Report of Commander C. II. Davis, U.S.N. Official Reports of Generals J. C. Fremont and T. J. Jackson. General T. W. Ashby, commanding the Confederate cavalry, was killed. ]5 Casualty List. File A, No. 422. S. G. O. Official Reports of Major General J. C. Fremont,U.S. A., and Lieutenant General T. J. Jackson. C. S. A. Also known as Union Church. Among the casu- alties were Brigadier Generals J. H. Stewart and A. Elzey, C. S. A., wounded. Report of Adjutant General of Iowa, 1663, p. 853. 34 Official Reports of Brigadier General E. II. Tyler, U. S. A'., and Lieutenant General T. J. Jackson. C. S. A. 6 ! Official Reports. June 11th. June 12th. June 13th. June 13th. June 14th. June 16th, June 17th.. June 17th.. June 18th.. June 18th.. June 18th.. June 18th.. June 21st.. June 22d.. June 23d.. June 25th.. June 25th.. June 25th.. June 26th, 27th, 28th, and 29th. Monterey. Owen County, Kentucky. AVaddell's Farm, near Village Creek, Arkansas. Old Church, Virginia......... James Island, South Carolina. Tunstall Station, Virginia___ Secessionville, James Island, South Car- olina. St. Charles, White River, Arkansas. Warrensburg, Missouri___ Smithville, Arkansas.....j Cumberland Gap occupied. Talahatchie, Florida......... Williamsburg Road, Virginia. Battle Creek, Tennessee. Raceland, near Algiers, Louisiana.. Raytown, Missouri... Oak Grove, Virginia . Germantown, Tennessee___ Little Red River, Arkansas. Vicksburg, Mississippi...... Mechanicsville, Virginia. June 27th..j WilliamsBridge,AmiteRiver,Louisiana. Captain Blood's mounted provost guards and 13th Indiana Battery. Detachment of the 9th Illinois Cavalry. 5th U. S. Cavalry..................... 46th, 47th, and 79th New A'ork, 3d Rhode Island, 3d New Hampshire, 45th. 9Wh, and 100th Pennsylvania, 6th and 7th Connecticut, 8ch Michigan, and 28th Massachusetts A'olunteers, 1st New York Engineers. 1st Connecticut, Batteries E, 3d U. S., and 1, 3d Rhode Island Artillery, and Company H, 1st Massa- chusetts Cavalry. U. S. gunboats Lexington, Mound City, Conestoga, 105 and St. Louis ; 43d and 46th Indiana A'olunteers. 7th Missouri Militia Cavalry. Brigadier General G. AV. Morgan's command. 16th Massachusetts Volunteers. 2d and 33d Ohio, 10th Wisconsin, and 24th Illinois Vol- unteers, 4th Ohio and 4th Kentucky Cavalry, and Edgarton's Battery. 8th A'ermont Volunteers.............................. 7th Missouri Cavalry. Hooker's and Kearney's Divisions of the Third, and Palmer's Brigade of Couch's Division of the Fourth, and part of Richardson's Division of the Second Corps. 56th Ohio Volunteers guarding railroad train........... 4th Iowa Cavalry.................................... U. S. Fleet, commanded by Commodore D. G. Farragut. Fifth Corps, and McCall's Division of the First Corps, Army of the Potomac, Major General Fitz-John Porter. 21st Indiana Volunteers. * Killed, wounded, and missing, t 465 100 I Report of Adjutant General of Indiana, Vol. Ill, page 421. 28 * j Official Report of Colonel A. G. Brackett, 9th Illinois Cavalry. ..... Official Report of Major General McClellan. ...... Rebellion Record, A'ol. V. page 27. Railroad train fired into. 3,000" Official Reports of Brigadier Generals H. G.AVright and I. I. Stevens, U. S. V., and Major General J, C. Pemberton, C. S. A. Also designated as Fort Johnson. Official Report of Commander C. H. Davis,U.S.N. Official. Rebellion Record, Vol. V, page 29. Official. Rebellion Record, Vol. V, page 29. Report of Adjutant General of Massachusetts, 1862, page 190. Official Report of Major General B. Huger, C. S. A. Casualty List, File A, No. 570, S. G. O. News- paper statements. Report of Adjutant General of Vermont. Official. Casualty List, File A, No. 571, 577, S. G. O. Offi- cial Report of Major General G. B. McClellan, U. S. A., and Ben. Huger. C. S. A. Also desig- nated King's School House and The Orchards. Ohio in the AATar, Vol. 2, page 337. Official Reports. Official Report of Major General G. B. McClellan. First of the seven-days battles. Also known as Ellison's Mills. Among the casualties were Brig- adier General G. E. Pickett, C. S. A., wounded. Official Report of Lieutenant Colonel J. A. Keith, 21st Indiana Volunteers. DATE. 1862. LOCALITY UNION TROOPS ENGAGED. June 26th Seven-days'Retreat. to July 1st. First Corps. Brigadier General McCall's Division..... Second Corps, Major General E. V. Sumner........... Third Corps, .Major General S. P. Heintzleman........ Fourth Corps, Major General E. D. Keyes............ Fifth Corps, Major General Fitz-John Porter......... Sixth Corps.Major General AV. B. Franklin........... Cavalry, commanded by Brigadier General Stoneman. Engineers.......................................... Army of the Potomac, Major General G. B. McClellan, commanding. June 27th.. Swift Creek Bridge, North Carolina. June 27th.. | Village Creek, Arkansas........... 9tb-Illinois Cavalry. June 27th. ; Gaines' Mill, Virginia..................j Fifth Corps, Army of the Potomac, commanded by ! Major General Fitz-John Porter, reinforced by Meagher's and French's Brigades, 1st Division, Second Corps. June 27th.. AVaddell's Farm, Arkansas. June 28th.. Golding's Farm, Virginia... June 29th.. AVillis Church, Virginia--- Detachment of 3d Iowa Cavalry, guarding wagon train. 23d and 49th New York Volunteers and 3d New York Battery. Cavalry advance of Casey's Division, Fourth Corps ... June 29th.. Peach Orchard, Virginia............... Richardson's and Sedgwick's divisions of the Second Corps. Army of the Potomac. June 29th.. i Savage's Station, Virginia... June 30th.. AVhite Oak Swamp, Virginia Second and Sixth Corps, Army of the Potomac, com- manded by Generals Sumner and Franklin. Second (Sumner's*, Third (Heintzleman's), Fourth (Keyes'), Filth (Porter's), Sixth (Franklin's), and McCall s Division of the First Corps, Army of the Potomac. June 30th.. | Luray. Virginia.........................[ Detachment of cavalry of Brigadier General Craw- ford's command. UNION LOSS. CONFED. LOSS. ■a 1 ■a d ► o Aug. 16th..I Lone Jack, Missouri Aug. 18th.. Captnreof rebel steamer Fair Play, near Milliken's Bend, Louisiana. Aug. 18th.. Aug. 19th.. Aug. 19th.. Aug. 19th.. Aug. 20th.. Aug. 20th.. Aug. 20th.. Aug. 20th and 22d. Aug. 21st.. Aug. 21st.. Aug. 22d.. Aug. 22d.. Aug. 23d.. Aug. 23d to 25th. Aug. 23d.. Aug. 24th. Aug. 24th.. Aug. 25th.. Aug. 26th.. Aug. 25th and 26th. Aug. 25th. Aug. 26th. Aug. 26th.. Aug. 26th. Aug. 27th. Aug. 27th.. Redwood, Minnesota... Clarksville, Tennessee. Rienzi, Mississippi.................... White Oak Ridge, near Hickman, Ken- tucky. Brandy Station, Virginia...... Edgefield Junction, Tennessee. Union Mills, Missouri......... Fort Ridgely, Minnesota...... Kelly's Ford, Rappahannock River, Virginia. Pinckney Island, South Carolina. Courtland, Tennessee........... Crab Orchard, Kentucky........ Catlett's Station, Virginia.............. Skirmishes on the Rappahannock, at AVaterloo Bridge, Lee Springs, Free- man's Ford, and Sulphur Springs, A'irginia. Big Hill, Madison County, Kentucky__ Dallas, Missouri...................... Coon Creek, Missouri................. Fort Donelson, Tennessee............. Cumberland Iron Works, Tennessee___ New Ulm, Minnesota.................. Missouri Militia Cavalry, commanded by Major E. S. Foster, 7th Militia Cavalry. 58th and 76th Ohio Volunteers....................... One company 5th Minnesota Volunteers............... 71st Ohio Volunteers, commanded by Colonel R. Mason. 2d Illinois Cavalry, commanded by Captain F. Moore. Cavalry of Army of Virginia.............. Detachment of the 50th Indiana Volunteers. lst Missouri and 13th Illinois Cavalry...... Companies B and C, 5th Minnesota Volunteers, and Renville Rangers. Cavalry of Army of Virginia......................... 42d Illinois Volunteers 9th Pennsylvania Cavalry, commanded by Brigadier General G. C. Smith. Purnell Legion (Maryland) and 1st Pennsylvania Rifles Army of Virginia, commanded by Major General Pope 7th Kentucky Cavalry and 3d Tennessee Volunteers .. 12th Missouri S. M. Cavalry......................... Bloomfield, Missouri........... Madisonville, Kentucky........ Rienzi and Kossuth, Mississippi. Danville, Kentucky............ Bull Run Bridge, Virginia...... Kettle Run, Virginia. Aug. 27th.. Fort McCook, near Bridgeport Alabama 71st Ohio Volunteers and 5th Iowa Cavalry. 13th Illinois Cavalry..............................., Cavalry, commanded by Lieuteuant Colonel Foster... 2d Iowa and 7th Kansas Cavalry..................... Harrodsburg and Danville (Kentucky) Home Guards . llth and 12th Ohio and 1st, 2d, 3d, and 4th New Jeresy Volunteers. Major General Hooker's Division, Third Corps, Army of the Potomac. 1 22 201 3001 not 301 201 3001 33d Ohio Volunteers and detachment of cavalry--- * Killed, wounded, and missing, t Killed and wounded. § Wounded and missing. Official Report of Major General J. M. Schofield, U. S. A. Ohio in the War, Vol. 2, pages 350 and 440. Massacred by Indians. Official Report. The post was surrendered without an engagement. Official Report of Major General Pope. Indiana Adjutant General's Report, Vol. 2, p. 500. Official. Fight with Indians. Official Report of Major General Pope. Rebellion Record, Vol. V, page 63. Unofficial. Rebellion Record, Vol. V, page 63. Official. Official Reports of Major General John Pope, U. S. A., and Lieut. General R. E. Lee, C. S. A. Brigadier General Bohlen, U. S. V., was killed. Tennessee Adjutant General's Report, 1866, p. 73. Official. Official. Also known as Lamar. Iowa Adjutant General's Report, 1864, page 988. Casualty List, S. G. O. Official Report of Captain C. F. Flandrau. Indian fight. Rebellion Record, Vol. V, page 65. Official. Iowa Adjutant General's Report, 1863, page 854. Newspaper report. Official. Brigadier General G W. Taylor, com- manding Union troops, was mortally wounded. Appendix to Part I, Medical and Surgical History of the War, page 108. Ohio in the War, Vol. 2, page 219. O W S CO ► U a H DATE. 1862. LOCALITY". Aug. 28th..J Readyville, Tennessee........... Howard County, Missouri........ Shady Springs, Virginia......... Manchester, Tennessee........... Groveton and Gainesville, Virginia Aug. 30th.. Bull Run (2d), Virginia........... Aug. 28th. Aug. 28th. Aug. 29th. Aug. 28th and 29th. Aug. 30th.. Aug. 23d to Sept. 1st. Aug. 30th.. Aug. 30th.. Aug. 31st.. Aug. 31st.. Aug. 31st.. Aug. 31st.. Sept. 1st... Bolivar, Tennessee Pope's campaign in Virginia. McMinnville, Tennessee..... Richmond, Kentucky. Weston, West Virginia. UNION TROOPS ENGAGED. 10th Brigade, Army of the Ohio, commanded by Col- onel W. Grose. 4th Missouri Militia Cavalry. 2d West Virginia Cavalry... Medon Station, Missisippi Central Rail- road, Tennessee. Stevenson, Alabama.................. Yates' Ford. Kentucky................ Britton's Lane, near Denmark, Tenn___ Sept. 1st... Chantilly, Virginia...... Sept. 2d... Morgansville, Kentucky. Two companies 18th Ohio and one company of the 9th Michigan Volunteers. First Corps, Major General F. Sigel, and Third Corps, Major General I. McDowell, Army of Virginia; Hooker's and Kearney's Divisions of the Third Corps and Reynolds' Division of the First Corps, Army of the Potomac, and Ninth Corps, Major Gen- eral Reno. First Corps, Major General F. Sigel, and Third Corps, Major General 1. McDowell, Army of Virginia; Hooker's and Kearnej^'s Divisions, Third Corps, Porter's, Fifth Corps, and Reynolds' Division, First Corps. Army the Potomac, aiid Ninth Corps, Major General Reno. 2d and llth Illinois Cavalry, 9th Indiana Artillery, and 78th and 20th Ohio Volnnteers. 26th Ohio and 17th and 58th Indiana Volunteers and 8th Indiana Battery. 6th and 7th Kentucky Cavalry; 95th Ohio, 18th Ken- tucky, 12th, 16th, 55th, 66th, 69th, and 71st Indiana Volunteers ; and Batteries D and G, Michigan Artil- lery. Two companies 6th West Virginia Volunteers......... 45th Illinois and 7th Missouri Volunteers 94th Ohio Volunteers. 20th and 30th Illinois Volunteers, Battery A, 2d Illinois Artillery, 4th Illinois Cavalry, and Foster's Company of Ohio Cavalry. McDowell's Corps, Army of Virginia; Hooker's and Kearney's Divisions. Third Corps, Army of the Potomac, and Reno's Corps. A force of Union troops commanded by Colonel Schackleford, 8th Kentucky Cavalrv. UNION LOSS. 800 200 7, 00 0' 700 13 7,000 4,000 43 52 CONFED. LOSS. 3,000 lOOt 1,500 j 8,000 250 20 500 100 7,000" 800* REMARKS AND REFERENCES Official. Also known as Round Hill. Official. Rebellion Record, Vol. V, page 66. Ohio in the AVar, Vol. 2, page 130. Appendix to Part I, Medical and Surgical History of the War, page 108. Official Reports of Major General John Pope, II. S. A., and Lieutenant General R. E. Lee, C. S. A. Among the wound- ed were Major General Ewell and Brigadier General Taliaferro, C. S. A. Casualty List, Nos. 229, 445, S. G. O. Appendix to Part I, Medical and Surgical History of the War, page 108. Official Reports of Major Gen- eral John Pope. U. S. A., and Lieutenant Gen- eral R. E. Lee, C. S. A. Among the wounded were Brigadier Generals Tower and Schenck, U. S. V., and Field, Trimble, Jenkins, and Ma- hone, C. S. A. Also known as Manassas. Official Report of Colonel M. M. Crockett, 13th Iowa Volunteers. Official Reports of Lieutenant General R. E. Lee, C. S. A. ' Official. Also known as Little Pond. Casualty List, S. G. O. Appendix to Part I, Med- ical and Surgical History of the War, page 246. Report of Adjutant General of West Virginia, 1864, page 190. Official Report of Brigadier General L. T. Ross. Also known as Toon's Station. Rebellion Record, Vol. V, page 69. Ohio in the War, Vol. 2, page 524. Official Report of Brigadier General Leonard T. Ross. Official Reports. Major General Philip Kearney and Brigadier General I. I. Stevens killed. Also known as Ox Hill. Rebellion Record, Vol. V, page 70. 144 92 17 1 9,416 2 18 598 131 4 1,043 3,500 16,399 6,000 40 103 263 33 692 231 561 60* 5 REMARKS AND REFERENCES. Official Report of Major General B. F. Butler. Casualty List. File A, No. 572. S. G. O. Appen- dix to Parti, Medical and Surgical History of the AVar. page 92. Official Reports of Union und Confederate. Among the casualties were Briga- dier General R. E. Garland. C. S A., and Major General Jesse L. Reno, U. S. V., killed. Official Report of Colonel J. T. AVilder. Official. Official. Report of Adjutant General of Indiana, A'ol. I, page 522. Official. Official. Casualty List, File A, Nos. 571 and 284. Official Reports of Major General (1. B. McClellan, U. S. A., and Lieutenant General R. E. Lee, C. S. A. Appendix to Part I, Medical and Surgical His- tory of the War, page 92. Among the casualties in the Union Army were Brigadier General J. K. F. Mansfield, killed ; Major Generals Richardson and Hooker, and Brigadier Generals Rodman, AVeber, Sedgwick, Hartsuff, Dana, and Meagher,. wounded; in the Confederate Army, Brigadier General L. O'B. Branch, G. B. Anderson, and W. E. Starke were killed, and Major General R. H. Andersen, Brigadier Generals Toombs. Lawton, Ripley, Rodes, Gregg. Arniistead. and Ransom, wounded. Also known as Sharpsburg. Official. Official. Casualty List, S. G. O. Appendix to Part I. Med ical and Surgical History of the AVar, page 248. Official Reports Union and Confederate. Among the casualties were Confederate Brigadier Gen- erals H. Little, killed, and Whitfield, wounded. Official. Official. Official. Williamsport, Maryland........ Prentis and Bolivar, Mississippi. Cassville, Missouri..................... Mumfordsville, Kentucky.............. Shepherdsville, Kentucky............. Sturgeon, Missouri.................... Ashby's Gap, A'irginia.................. Yellow Medicine, Minnesota............ AA'olf Creek Bridge, near Memphis,Miss Sutton, A'irginia....................... AA'arrenton Junction, A'irginia.......... Cambridge, Missouri................... Buffalo, AA'est Virginia................. Augusta, Kentucky................... Blackwater, A'irginia................... Newtonia, Missouri.................... Russellville, Kentucky... Floyd's Fork, Kentucky. Gallatin, Tennessee...... Shepherdstown, Virginia. Olive Hill, Kentucky.......... Mount Washing-ton, Kentucky. Baldwin, Mississippi........... Reconnoissance to Franklin, on the Black- water, Virginia. Corinth, Mississippi. Bardstown, Kentucky......... Big Hatchie River, Mississippi. o 10 8 10 19 II. S. ram Queen of the West, with transports and 33d Illinois. 2 8 Cavalry commanded by Major Foster, 3d Ohio Cavalry. 2 12 5 28 3 4 40 30 1 % G uards. 57th Ohio A'olunteers......................... 6 • 3 34 th Ohio.................................. 7 9 90* 9 15 96 1st New Y'ork Mounted Rifles......................... 1st brigade, Army of Kansas, 4th brigade, Missouri State Militia, commanded by Brigadier General F. Salomon and Colonel G. H. Hall, 4th Cavalry, Mis-souri State Militia. Union troops commanded by Colonel Harrison, 17th Kentucky. 4th Indiana Cavalry, 34th Illinois and 77th Pennsylva-nia A'olunteers. Colonel E. N. Kirk's brigade, Army of the Ohio. 50 80 115 220 35 280 10 40 60 39 10 8th Illinois, 8th Pennsylvania, and 3d Indiana Cavalry, and Pennington's battery. 12 3 Union gunboats, commanded by Captain Flusser, and troops, commanded by General Spear. McKean's, Davies', Hamilton's, and Stanley's Divi-sions, Army of the Mississippi, commanded by Major General W. S. Rosecrans. 315 191 1,812 232 30 ( 594 } 1, 423 60 2,162 5,692 2,102 2,248 500* 400 Officia Official. Rebellion Record, Vol. V, page 84. Ohio in the AVar. Rebellion Record. Vol. V, page 84. Rebellion Record, Vol. V, age 84. Colonel H. H. Sibley's official report. Also called Wood Lake. Ohio in the War, Vol. 2, page 43. Newspaper report. Rebellion Record, A'ol. V, page 87. Rebellion Record, Vol. V, page 87. Official. Rebellion Record, Vol. V, page 87. Official Report of Major General J. M. Schofield, U. S.V. Rebellion Record, Vol. V, page 88. Report of Adjutant General of Illinois, Vol. I, page 579. Newspaper report. Official Report of Brigadier General Pleasanton, commanding. Rebellion Record, Vol. A', page 90. Official. Casualty Lists. S. G. O. Appendix to Part I, Med- ical and Surgical History of the War. page 248. Official Reports. Among the casualties were Brigadier Generals P. A. Hackleman, killed and Oglesby, wounded. Official. Casualty List. File A. No. 160, S. G, O. Appendix to Part I, Medical and Surgical History of the AVar. page 251. Official Report of Major General E. O. C. Ord. Also called Metumora. Killed, wounded, and missing, t Killed and wounded. Q > a si r/i b > tr PJ DATE. 1862. Ocl. 5th.. Oct. 5th.. LOCALITY. Glasgow, Kentucky..... Madisonville, Kentucky. Oct. 6th. ..i Charleston, Virginia.................... Oct. (ith...1 Liberty and Sibley's Landing, Missouri. Oct. 7th... La A'ergno, Tennessee.................. Oct. 8th...! Pcrryville, Kentucky.......... Oct. 9th... j Lawrcnceburg, Kentucky. Oct. 9th.. Oct. 10th. Oct. 10th. Oct. llth. Ocl. llth. Oct. llth. Aldic, Virginia......»....... Ilarrodsburg, Kentucky--- Upper Missouri River, Arkansas... La Grange, near Helena, Arkansas. Cape Fear River, North Carolina... Mouth of the Monocacy, Maryland. Oct. 14(h..l Stanford, Kentucky. Oct. 14th. Oct. 15th. Oct. 15th. Oct. 16th. Oct. 17th. Oct. 17 th. Oct. 18th. Oct. 18th. Oct. 20th. Oct. 20th. Hazel Bottom, Missouri...... Apalachicola River, Florida . Carsville, A'irginia.......... Charleston, A'irginia......... Lexington, Kentucky........ Thoroughfare Gap, A'irginia. Helena, Arkansas............ Hay market, A'irginia........ Near Nashville, Tennessee .. Anxvois River, Missouri..... UNION TROOPS ENGAGED. 20th Kentucky Volunteers. 4th Indiana Cavalry....... 6th U. S. Cavalry........... 5th Missouri Militia Cavalry. Palmer's Brigade........... First Corps, Major General A. McD. McCook, and Third Corps. Brigadier General C. C. Gilbert, Army of the Ohio, commanded by Major General D. C. Buell. 15th and 19th U. S. Infantry, 1st and 49th Ohio, Vol- unteers. Battery II, 5th U.S. Artillery, and 9th Ken- tucky Cavalry. Detachment'of Cavalry from Major General Sigel's command. Union troops, commanded by Lieutenant Colonel Boyle, 9th Kentucky Cavalry. Detachment of the 4th Iowa Cavalry. U. S. gunboat Maratanza............ 3d and 4th Mai ne Volunteers......... Advance of the Army of the Ohio. Naval Expedition................................... One company of the 7th Pennsylvania Cavalry....... Reconnoissance of the Army of the Potomac......... Detachments of the 3d and 4th Ohio Cavalry......... Detachment of Cavalry fromGeneral Stahel's command Detachment of the 43d Indiana Volunteers............ Detachment of the 6th Ohio Cavalry ................ Union troops, commanded by Colonel Miller.......... 10th Missouri Militia Cavalry........................■ UNION LOSS. 1 5 916 1 9 2,943 24 4 489 350 CONFED. LOSS. 1,300 SO, 3,000 2C0 2,500* 1,600 100 REMARKS AND REFERENCES. Newspaper report. Report, of Adjutant General of Indiana, Vol. Ill, page 19. Rebellion Record, Vol. V, page 93. Official. Official Report of Brigadier General J. S. Negley. Appendix to Part I, Medical and Surgical History (f the War. page 251. Casualty Lists, S. G. O. Official Reports if Ma'or Geaeral D.C. Buell. Among the casualties were Brigadier Generals J. S Jackson and AVilliam R. Tcnill, U. S. A'., killed and Wood, Cleburne, and Brown, C. S. A., wounded. Casualty List, S. G. O. Official Reports. Also knowu as Dog Walk. Rebellion Record, Vol. V, page 93. Adjutant General's Report of Kentucky. Vol. I, page 251. Indian fight. Official. Official. Report of Adjutant General of Maine, 1862, pages 45 and 51. Report of Adjutant General of Indiana, Vol.1, page 218. Also known as Lancaster. Official. Newspaper statement. Rebellion Record, Vol. VI, page 3. Newspaper report. Ohio in the AVar, Vol. II, page 766. Newspaper report. Unofficial. Ohio in the War, Vol. 2, page 791. Rebellion Record, Vol. AT, page 5. Oct. 20th. Oct. 21st. Oct. 21st. Oct. 21st. Oct. 22d. Oct. 22d. Oct. 22d. Oct. 23d.. Oct. 23d.. Oct. 23d.. Oct. 24th. Oct. 24th. Oct, 24th. Oct. 24th. Oct. 24th. Oct. 27th. Oct. 28th. Oct. 28th. Oct. 28th. Oct. 29th. Oct. 31st. Nov. 1st... Nov. 2d and 3d. Nov. 2d.. Marshfield, Missouri................... Lovettsville, Loudon County, Virginia. Woodville, Tennessee................. Fort Cobb, Indian Territory........... Old Fort Wayne, Arkansas............ Hedgeville, Virginia.................. Pocotaligo, South Carolina............ AA'averly, Tennessee..... Shelby Depot, Tennessee. Point Lick and Big Hill Road, Kentucky Manassas Junction, A'irginia........... Catlett's Station, A'irginia............. Grand Prairie, Missouri............... Black water, Virginia.................. Morgantown, Kentucky... Pittman's Ferry, Missouri. Labadissville, Louisiana............. Cross Hollows, Fayetteville, Arkansas . Clarkson, Missouri................... Williamsburg, Kentucky... Butler and Osage, Missouri. Aldie, Virginia . Franklin, Virginia .. Philomont, A'irginia. Bloomfield and Union, Loudoun County, Virginia. Snicker's Gap, A'irginia . 10th Illinois Cavalry....................A..... Detachment of General Geary's brigade......... 2d Illinois Cavalry, commanded by Major Mudd. Loyal Indians................................. 1st division, Army of the Frontier, commanded by Brigadier General J. G. Blunt. 4th Pennsylvania Cavalry........................... 47th. 55th, and 76th Pennsylvania, 48th New A'ork, 6th and 7th Connecticut, 3d and 4th New Hampshire.and 3d Rhode Island Volunteers, 1st NcwYork Engineers, 1st Massachusetts Cavalry, and batteries D and M, 1st U. S., and E, 3d LI. S." Artillery. 83d Illinois Volunteers.............................. Reconnoitering party, commanded by Col. D. Stuart, 55th Illinois Volunteers. Cavalry, commanded by Colonel E. McCook.......... Detachment of 3d AA'est Virginia Cavalry. Two battalions Missouri Militia Cavalry.. 1st New Y'ork Mounted Rifles, 39th Illinois and 62d Ohio Volunteets. and other troops commanded by Brigadier General Terry. 23d Iowa and 24th and 2"th Missouri A'olunteers, 1st Missouri Militia, and 12th Missouri Cavalry. 8th New Hampshire, 12th and 13th Connecticut, and 75th New A'ork A'olunteers, 1st Louisiana Cavalry, and 1st Maine Battery, commanded by Brig. General G. Weitzel. One division of the Army of the Frontier, commanded by Brigadier General Herron. Detachments, commanded by Captain Rodger's, 2d Illinois Artillery. 7th Kentucky Volunteers.................... 1st Kansas Colored Troops (79th U. S. C. T.). 1st New Jersey and 2d New York Cavalry, of General Bayard's Cavalry Brigade, Army of the Potomac. Cavalry of the Army of the Potomac, commanded by General Pleusonton. Cavalry advance of the Army of the Potomac, com- manded by General Pleasonton. Batteries of the Second Corps, Army of the Potomac.. 150f 401 Rebellion Record, Vol. VI, page 5. Newspaper statement. Newspaper report. Official Report of Major General J. M. Schofield. Also known as Maysville. Rebellion Record, Vol. VI, page 6. Official Reports of Brig: der Generals J. M. Bran- nan, U. S. V., and W. S. Walker, C. S. A. Also known as Yemassee. Report of Adjutant General of Illinois, VoL II, page -92. Rebellion Record, Vol. VI, page 7. Unofficial. Unofficial. Rebellion Record, Vol. VI, page 7. Unofficial. Ohio in the AVar, A'ol. 2, page 369. Newspaper report. Report of Adjutant General of Iowa. 1863, p. 825. Official Report of Colonel AY in. Dewey. Official Report of Major General B. F. Butler, U. S. V. Also known as Thibodeauxville and Georgia Landing. Official. Also known as Oxford Bend. Report of Adjutant General of niinois, Vol. Ill, page 202. Casualty List. File A, No.570, S. G.O. Official. Also known as Island Mounds. New Jersey in the Rebellion, page 433. Rebellion Record, Vol. A'l, page 9. Official Report of Major General McClellan. Official Report of Major General McClellan. • Killed, wounded, and missing, t Killed and wounded. W tei > a si H > o > H H SI LOCALITY. Uppcrvillo, Virginia Rawles' Mills, AVilliamston, North Caro- lina. Bayou Techo (14 miles from Brashear City), Louisiana. Ilarrisonvillc, Cass County, Missouri___ Lamar, Missouri....................... Manassas Gap, Virginia................ UNION TROOPS ENGAGED. Cavalry advance of the Army of the Potomac, com- manded by General Pleasonton. 24th and 44th Massachusetts and 9th New Jersey Vol- unteers, and New York and Marine Batteries. Union gunboats Kinsman. Estelle. St. Mary, Calhoun, and Diana, and 21st Indiana A'olunteers. Barbee's Cross Roads and Chester Gap, A'irginia. Greenville Road, Kentucky............ New Baltimore, flaleni, and Thorough- fare Gap, A'irginia. Nashville. Tennessee.................. Leather wood, Kentucky........ Garrettsburg, Kentucky........ Rhea's Mills, Arkansas......... Big- Beaver Creek, Missouri___ Marianna, Arkansas............ Rappahannock Bridge, A'irginia Hudsonvillo, Mississippi........ Fredericksburg, Virginia........ Moorcfield, Virginia. Perry County, near Kentucky River, Kentucky. Huntsville, Tennessee...... New Berne, North Carolina. Lebanon, Tennessee 5th and 6th Missouri Cavalry......................... 8th Missouri and 8th Missouri Militia Cavalry.......... Cavalry Brigade, advance of the Army of the Potomac, commanded by General Averill. Cavalry Brigade, Army of the Potomac, commanded by General Pleasonton. 8th Kentucky Cavalry................................ Cavalry Brigade, advance of the Army of the Potomac, commanded by Goneral Bayard. 16th and 51st Illinois, 69th Ohio,14th Michigan, and 78th Pennsylvania A'olunteers, and 5th Tennessee and 7th Pennsylvania Cavalry. Captain Ambrose Powell's command.................. 8th Kentucky Cavalry................................ 3d Kansas Indian Home Guards...................... 10th Illinois and two companies Alissouri Militia Cavalry. 3d and 4th Iowa and 9th Illinois Cavalry.............. Cavalry Brigade, Army of the Potomac, commanded by General Bayard. 7th Kansas and 2d Iowa Cavalry. 1st Indiana Cavalry............. 1st Now A'ork, Ringgold, and Washington Cavalry, and 23d Illinois Volunteers. 14th Kentucky Cavalry... Tennessee Home Guards. 1st Kentucky and 4th Michigan Cavalry. UNION LOSS. 10 300 CON'FED. LOSS. 85 REMARKS AND REFERENCES. 50 125 Official. Official Report of Major General J. G. Foster, commanding. Also called Little Creek. Report of Adjutant General of Indiana, Vol. II, page 208. Official. Official. Olucial Report of Major General McClellan. Official. Also called Markham. ! Official Report of Brigadier General James S. Negley, commanding. Rebellion Record, Vol. VI, page 12. Official. Rebellion Record, Vol. VI, page 12. 50* Report of Adjutant General of Illinois, Vol. Ill, page 96. Also called La Grange. 185 i Rebellion Record, Vol. VI, Doc. 39, page 189. Also known as Cold Water. Official Report of Captain Ulric Dahlgren. Official Report of Brigadier General B. F. Kelley. Also called South Fork, Potomac. Rebellion Record, Vol. A'l, page 14. Rebellion Record, Vol. VI, page 14. Newspaper report. Also known as Bachelor's Creek. Report of Adjutant General of Kentucky. Also designated La Grange. Lamar and Holly Springs, Mississippi.. Fayettevilleand White Sulphur Springs, A'irginia. Gloucester, Virginia.................. Cove Creek, North Carolina........... Rural Hills, Tennessee................ Bayou Bontecou, near Fort Pike, La___ Beaver Creek, Texas County, Missouri. Camp Babcock, Arkansas............. Crawford Count}-, Missouri............ Cold Knob Mountain, Virginia......... Summerville, Mississippi.............. Carthage, Arkansas.................. Scrougesville and La Vergne, Tennessee Cane Hill, Boston Mountains, and Boons boro', Arkansas. Little Bear Creek, Alabama........... Hartwood Church, Virginia............ Cold AVater River, Mississippi......... AA'aterford and Lumkin's Mills, Miss.... Stahel's reconnoissance to Snicker's Ferry, and Berryvillo, A'irginia. Charleston and Berryville, A'irginia--- Franklin, A'irginia.................... King George Court-House, Virginia ... Ozark, Missouri....................... Oakland, Mississippi.................. Oxford, Mississippi.................... AVireman's Shoals, Big Sandy River, Kentucky. Water Valley, Mississippi............. Coffeeville, Mississippi................ Helena, Arkansas..................... Reed's Mountains, Arkansas........... Lebanon, Tennessee.................. 2d Illinois, 3d Michigan, 2d Iowa, and 7th Kansas Cav. 1st and 2d Brigades, Sturgis's Division, Ninth Corps, and Cavalry, Army ol the Potomac. 104th Pennsylvania Volunteers ............... 3d New Y'ork Cavalry........................ 8th Kentucky Cavalry........................ 31st Massachusetts Volunteers................ 3d Missouri Cavalry and 21st Iowa Volunteers . 3d Kansas Indian Home Guards............. Missouri Enrolled Militia..................... 2d West A'irginia Cavalry, commanded by Colonel J. C. Paxton. 7th Illinois Cavalry.................................. 2d Kansas Cavalry.................................. 5th Brigade, Sill's Division, Army of the Ohio....... 1st Division, Army of the Frontier, commanded by Brigadier General James G. Blunt. Portion of the 2d Division, Sixteenth Corps........... 3d Pennsylvania Cavalry............................ 1st Indiana Cavalry................................. Advance Cavalry of General Grant's Army........... 1st Cavalry Brigade, Stahel's Division. 2d Division, Twelfth Corps....................... llth Pennsylvania Cavalry........................ 6th Pennsylvania Cavalry......................... 3d and 9th Missouri Cavalry....................... 1st Indiana Cavalry............................... 2d Cavalry Brigade, commanded by Colonel Hatch . 39th Kentucky Volunteers......................... 1st and 2d Cavalry Brigades, commanded by Colonels Hatch ai.d Lee. 1st, 2d, and 3d Cavalry Brigades, of General Grant's Army, commanded by Colonels Lee, Hatch, and Mizener. 30th Iowa and 29th Wisconsin Volunteers . 2d Kansas Cavalry....................... 93d Ohio Volunteers..................... 12 201 111 28 300 10 Report of Adjutant General of Maine. Also known as Little Washington. Rebellion Record, Vol. VI, page 16. Newspaper report. Newspaper statement. Newspaper statement. Official. Official. Official. Official. Also known as Sinking Creek and Frank- fort. Rebellion Record, Vol. VI, page 19. Official. Newspaper report. Official Report of Major General H. W. Halleck. Report of Adjutant General of Iowa, 1865, p. 157. Official. Official Report of General C. C. Washburne. Official Report of Major General F. Sigel. Official Report of Brigadier General J. W, Geary. Newspaper report. Rebellion Record, Vol VI, page 21. Official. Official Report of Brigadier General C. C. Wash- burne. Report of Adjutant General of Kentucky, p. 485. Official reports, Union and Confederate. Rebellion Record, Vol. VI, page 22. Official. Official. Killed, wounded, and missing, t Killed and wounded. DATE. 1862. Dec. 7th.. Deo. 9th.. Dec. 9th.. Dec. 12th. Dec. 12th. Deo. 12th. Dec. 12th to 18th. LOCALITY. Prairie Grove, Arkansas Hartsville, Tennessee Dobbin's Ferry, Tennessee...... Brcnlville, Tennessee........... Little Bear Creek, Alabama..... Zuni, near Blackwater, Virginia. Trenton, North Carolina......... Franklin, Tennessee Foster's expedition to Goldsboro', North Carolina. Fredericksburg, Virginia..... Dec. 13th. Deo. llth. Dec. 14th. Dec. 10th. Dec. 17th. Dec. 18th. Dec. 18th. South-AVest Creek, North Carolina. Kingston, North Carolina.......... Fort Brown Road, Texas... AVhitehall, North Carolina . Goldsboro', North Carolina. Lexington, Tennessee. Jackson, Tennessee ... UNION TROOPS ENGAGED. 1st, 2d, and 3d Divisions of the Army of the Frontier, commanded by Brigadier Generals J. G. Blunt and F. J. Ilcrron. 106th and lOPth Ohio and 104th Illinois Volunteers, 2d Indiana and llth Kentucky Cavalry, and 13th Indiana Battery. 35th Indiana, 51st Ohio, and 8th and 21st Kentucky Volunteers, and 7th Indiana Battery. 25th Illinois 8th Kansas, and 8lst Indiana Volunteers and 8th AVisconsin Buttery. Troops commanded by Colonel Sweeney, 52d Illinois Volunteers. Brigade, commanded by General Ferry............... 3d New York Cavalry, advance of Major General Fos- tei's troops. Stauley's Cavalry Division, Army of the Cumberland.. AA'essell's Brigade of Peck's Division, 1st, 2d, and 3d Brigades, lslDivison, Lepartmcut o( North Carolina. Second Corps, Major General Couch, and Ninth Corps, Mi jiirGeneral Wilcox—Right .-irand Division, Major General Sumner; First Corps, Major General Rey- nolds, and Sixth Corps. Major General AV. F. Smith- Left Grand Division, M .jo'r General Franklin; Fifth Corps, Major General Butterfield. and Third Corps, Major General Stoienan—Centre Grand Division, Major General Hooker; Army of the Potomac, Major General A. E. Burrs de. 9th New Jersey and 85th Pennsylvania A'olui teers, 3d New York Cavalry, aud 3d New York Artillery. AA'essell's Brigade of Peck's Division and the 1st, 2d, aud 3d Brigades, 1st Division, Department of North Carolina. 9th New Jersey, 17th, 23d, 24th, and 45th Massachu- setts Volunteers. 3d New York Cavalry, and 3d and 23d New A'ork Batteries. 9th New Jersey, 3d, 17th, 25th, 27th, and 43d Massa- setts A'olunteers, 3d New- A'ork Cavalry, and 3d and 23d New Ycrk Artillery. llth Illinois, 5th Ohio, and ~d Tennessee Cavalry...... llth Illinois and 5th Ohio Cavalry, and 43d and 61st Illinois Volunteers. UNION LOSS. 1 CONFED. LOSS. ri ■d -S (i a> its T3 a ! = ■d c ;S 3 'S O i/J z> 3 o £ Li £ a W £ S 167 798 183 300 1,200 § 55 1,800 21 114 14 5 1 48 1 6 2 11 30 40 3 11 3 5 71 10 268 18 12 400 1 9.0 478 9 1,180 9,028 2,145 579 ' 3,870 127 3 40 8 120 50 75 400 7 10 124 7 28 ........ 1 5 70 3 REMARKS AND REFERENCES. Appendix to Part I, Medical and Surgical History of the AVar. page 312. Official Report of Major General S. R. Curtis. Also known as Fnyettc- ville and Illinois Creek. I . 14 Official Report of Brigadier General John Morgan, C. S. A. Ohio in the AVar, page 310. Casualty List, S. G. O. Also known as La Vergnc. Official Report of Colonel John A. Marl in. Report of Adjutant General oflllinois, Vol. 11, p. 59. Ohio in the AVar, Vol. 2, pago 369. S. G. O. Official. Casualty List, Official Reports of Major Generals J. G. Foster, commanding Union, and G.W. Smith, command- ing Confederate forces. Casualty List, S.G.O. Appendix to Part I, Medical and Surgical History of the War, page 92. Offi- cial Reports of Major General A. E. Burnsidc, U. S. V., aud Lieut. General R. E. Lee, C. S. A. In the Union Army, Brigadier Generals C. F. Jackson and G. D. Bayard were killed and Gibbons and Vinton wounded ; in the Confederate Army, Brigadier General T. R. R. Cobb was killed and Maxcy Gregg wounded. New Jersey and the Rebellion, page 220. Casualty List, File A, No. 581, S.G. O. Official Report of Major Gen. J. G. Fester, commanding. Newspaper report. Casualty List, S. G. O. Official Report of Major General J. G. Foster, commanding. Casualty List, S. G. O. Official Report of Major General J. G. Foster, U. S. A. Report of Adjutant General of Illinois, Vol. I, page 664. Also called Salem Cemetery. Dee 19th.. Dec 20th.. Dec 20th.. Occoquan, Dumfries, Virginia. Holly Springs, Mississippi..... Trenton, Tennessee.................. Davis' Mills, AA'olf River, Mississippi. Dec. 22d.. Deo. 24th.. Dec. 24th.. Dec. 25th.. Dec. 25th.. Dec. 26th.. Dec. 26th.. Dec. 27th.. Dec. 27th.. Dec. 28th.. Dec. 28th.. Dec. 28th.. Dec. 28th.. Dec. 28th.. Dec. 28th.. Dec. 28th and 29th. Isle of Wight Court-House, A'irginia... Middleburg, Mississippi Central R. R.. G lasgow, Kentucky................ Green's Chapel, Kentucky............. Bear AYnllow, Kentucky.............. Bacon Creek, Kentucky............... Nolansville, Tennessee............... Elizabcthtown, Kentucky............... Dumfries, A'irginia..................... Muldraugh's Hill, Kentucky............ Suffolk, A'irginia....................... Dripping Springs, near A'an Buren, Ark. Elk Fork, Campbell County, Tennessee. Occoquan, Virginia.................... Clinton, Louisiana.................... Chickasaw Bayou,Vicksburg,Mississippi AA'agon train guard of the Twelfth Army Corps 2d Illinois Cavalry........................... Detachments 7th Tennessee Cavalry, 122d Illinois Volunteers, and convalescents. Six companies 25th Indiana A'olunteers and two com- panies 5th Ohio Cavalry. Detachment of 2d New A'ork Mounted Ritles.......... One hundred and fifteen men of the 12th Michigan Volunteers. Five companies of the 2d Michigan Cavalry.......... Detachment of the 4th and 5th Indiana Cavalry....... Two battalions of the 12th Kentucky Cavalry........ Detachment of the 2d Michigan Cavalry.............. 2d brigade, 1st division, MeCook's Corps, advance of the right wing of the Army of the Cumberland. 91st Illinois Volunteers. 5th. 7th. and (Kith Ohio A'olunteers, Gth Maine Battery, 12th Illinois and 1st Maryland Cavalry. 6th Indiana Cavalry................................. Reconnoitering force, commanded by Acting Brigadier General Gibbs. Army of the Frontier............. 6th and 10th Kentucky Cavalry___ 2d and 17th Pennsylvania. Cavalry. Dec. 29th.. St swart Creek, Tennessee. Dec. 30th.. AVautauga Bridge and Carter's Station, Tennessee. Dec. 30th.. Parker's Cross Roads, Tennessee...... Dec. 30th.. Jefferson, Tennessee. BrigadierGencrals O.AA'. Morgan's, Frederick Steele's, Morgan L. Smith's, and A. J. Smith's divisions, right wing, Army of Tennessee, commanded by Major General AV. T. Sherman. 3d Kentucky, in advance of Crittenden's Corps, left wing of the Army of the Cumberland. 7th Ohio and 9th Pennsylvania Cavalry.............. 1,000 250 18th, 100th, 119th, and 122d Illinois, 27th, 39th, and 23 03d Ohio, 50th Indiana, 39th Iowa, and 7th Tennessee Volunteers. 7th Wisconsin Battery, commanded by Colonel C. L. Dunham, and Brigadier General J. C. Sullivan. 2d brigade, 1st division, Thomas's Corps, guarding- I 20 wagon train. I § AVounded and missing-. 9 11 3 3 9 22 1 3 15 150 ..... Casualty List, S. G. O. ..... Surrendered by Colonel Murphy, 8th AVisconsin Vols., to the Confederates under A'an Dorn. .....j Official Report of Colonel Jacob Fry, 61st Illinois A'olunteers. Post captured by Forrest. 20 j Official Report of Colonel AVm. H. Morgan, 25th Indiana, commanding post. ..... Unofficial. 15 ReportofAdjutantGcneralof Michigan, 1862, p.83. Official Report of Colonel E. H. Hobson. Official Report of Colonel E. II. Hobson. Official Report of Colonel E. H. Hobson. Official Report of Colonel E. H. Hobson. Also known as Knob Gap. Report of Adjutant General of Illinois, A'ol. II, page 345. Post captured by General Morgan. Ohio in the AVar, A'ol. II, page 45. Report of Adjutant General of Indiana, A'ol. II, page 663. ...... Rebellion Record, A'ol, AT. page 29. 120 Official Report of Brigadier General J. G. Blunt. 51 , Official dispatches ..... Unofficial. Confederate sources. ...j Casualty List, File A, No. 273. Official reports. Major General M. L. Smith, wounded. Report of Adjutant General of Kentucky, A'ol. I. page 029. 273 Ohio in the AA'ar. Vol. II, page ' into East Tennessee. Carter's raid 300 i Casualty List, S. G. O. Official reports. Also known as Red Mound. Official Report of Major General G. H. Tin UNION LOSS. CONFED. LOSS. DATE. 1863. LOCALITY. UNION TROOPS ENGAGED. Dee. 31st, , Slonc's River, Tennessee 1862, to ! Ian. 2d,'63. 1803. Jan. 1st..! Galveston, Texas. McCook's Corps, right wing ; Thomas's Corps, centre ; and Crittenden's Corps, left wing, Army of the Cum- berland, commanded by Major General AA'. S. Rose- crans. 1,533 7,245 | 2,800 REMARKS AND REFERENCES. 9, 0001 I 2,000 14, 560*| Casualty List, S. G. O. Appetidix t(> Part I, Med- U. S. gunboats AA'estfield, Harriet Lane, Owasco, S Jan. 1st... Stewart's Creek, Tonnes Jan. 1st__ La A'ergne, Tennessee..... Jan. 3d....' La Newspapi r report. Report of Adjutant General of Michigan. 1863. Official Report of Colonel Charles L. Ellct. Newspaper statement. Newspaper reports. Unofficial. Official Report of Lieutenant General R. E. Lee, C. S. A. Report of Adjutant General of Michigan, 1863, p.26. Official. Report of Adjutant General of Missouri, 1865 page 366. Official Report of David 1). Porter. Official. Official. Newspaper reports. Unofficial. Newspaper reports. Official. Newspaper report. Also known as Sn tin's Quarter. a W o Szi o f o Q i—i Q > tr1 Mar. 4th [Thompson's Station, Tennessee and 5th. i Mar. 8th. ..I Fairfax Court-House, A': I Mar. 9th... Bolivar, Tennessee Mar. 9th... 13d and 85th Indiana, 22d AVisconsin, 19th Michigan, and 12-lth Ohio \ olunteers, 18th Ohio Buttery, and 2d Michigan, 9th Pennsylvania, and 4th Kentucky Cavalry, commanded by" Colonel John Coburn, 33d Indiana, Mar. 10th.. Mar. 10th.. Mar. llth.. Mar. 13th to Apr. 5th. Franklin, Tennessee................... Covington, Tennessee.................. Rutherford's Creek, Tennessee........ Paris, Kentucky....................... Fort Pemberton, Greenwood, Mississippi 125th Ohio A'olunteers, commanded by Colonel E Opdykc. 6th and 7th Illinois Cavalry, commanded by Colonel B. II. Grierson, (ith Illinois Cavalry. 300 1,306 4th Cavalry Brigade, commanded by Colonel Minty. Mar. 13th.. Berwick City, Louisiana........... Mar. 14th.., Port Hudson, Mississippi River, La. Mar. 14th.. New Berne, North Carolina....... AA'agon -train guard.................................,. U. S. gunboats Chillicothe and De Kalb, and troops of the Thirteenth and Seventeenth Corps, com- manded by Brigadier Generals L. F. Ross and J. F. Quiinby. 160th New A'ork A'olunteers.......................... Mar. 16th to 22d. Mar. 18th. Mar. 20th. Expedition up Steele's Bayou, Miss. Blaekwater, A'irginia............. Kelly's Ford, Virginia............. Union fleet, commanded by Admiral D. G. Farragut. and Union troops commanded by Major General N. P. Banks. Troops of the Department of A'irginia and North Caro- lina, commanded by Major General Foster; aud gun- boats. Brashear City, Louisiana............. Vaught's Hill, near Milton, Tennessee Mar. 21st..] Salem Pike, near Murfreesboro', Tcnn. Mar. 21st.. Cottage Grove, Tennessee............ Mar. 21st.. ■ Deer Creek, Mississippi.............. Mar. 22d... Blue Springs, Missouri--- Alar. 22d... Mount Sterling, Kentucky. Alar. 24th.. Danville. Kentucky....... 2d Division, Fifteenth Corps, commanded by General Sherman, and navy commanded by Admiral Porter. llth Pennsylvania Cavalry, commanded by Colonel S. P. Spear. 1st and 5th U. S., 3d. 4th, and Kith Pennsylvania, 1st Rhode Island, (ith Ohio, and 4th New A'ork Cavalry, and (ith'New A'ork Battery, commanded by Brigadier General AV. AV. Averill. 1st Louisiana Cavalry. 105th Ohio, 101st Indiana, 80th and 123d Illinois Volun- teers, 1st Tennessee Cavalry, and 9th Indiana Battery. 3d Tennessee Cavalr 2d Division. Fifteenth Corps, commanded by Major General Sherman, aud Mississippi fleet, commanded by Admiral Porter. 1st and 5th Missouri Militia Cavalry. 10th Kentucky Cavalry............ 1st Kentucky and 2d Tennessee Cavalry. 18th and 22d Michigan Volunteers, and 1st Indiana Battery. 20 300 Casualty List, S..G. O., and official reports. Also known as Spring Hill and Unionville. Official. Mosby's midnight raid. Brigadier Gen- eral Stoughton captured in his tent. Ohio in the AVar, Vol. 2, page 642. Report of Adjutant General of Illinois, A'ol. Ill, page 65. Report of Adjutant General of Indiana. A'ol. II, . page 19. Unofficial. Official. Official Report of Major General N. P. Banks. Official Report of Major General Halleck. Official Report of Brigadier General Fitz-Hugh Lee, C. S. A. Casualty List, S. G. O. Official Report of Major General H. AA'. Halleck. Report of Adjutant General of Tennessee, 1866, page 387. Engagement during the expedition up Steele's Bayou. Official. Skirmish with Quantrell's guerillas. Official. Report of Adjutant General of Michigan. * Killed, wounded, and missing. DATE. 1863. Mar. 24th.. Alar. 25th. Mar. 25th.. Mar. 28th.. Mar. 28th.. Mar. 28th.. Mar. 29th.. lAIur. 29th. Mar. 30th. Mar. 30th. Mar. 30th. Alar. 30th. LOCALITY. Mar. 30th to Apr. 4th. April 1st. April 1st April 2d April 2d and 3d. April 4th.. April 4th.. Ponchatoula, Louisiana............... Brentwood, Tennessee ...»........... Franklin and Little Harpeth, Tennessee Pattersonville, Louisiana.............. Hurricane Bridge, AVest A'irginia...... Amite River, Louisiana............... Sotncrville, Tennessee................ Expedition to Jacksonville, Florida--- AA'illiamsburg, A'irginia............... Tahliquah, Indian Territory.......... Massacre on the steamer Sam Gat}-, at Sibley's Landing, Missouri. The Island, Missouri.................. Dutton's IIill. Kentucky................ Point Pleasant. AVest A'irginia......... Richmond, Louisiana................. AA'ashington, North Carolina........... Chalk Bluff, Arkansas................ Broad Run, A'irginia.................. Little Rock Road, Arkansas........... Woodbury and Snow Hill, Tennessee.. Carroll County, Arkansas............. Madison, Arkansas.................... UNION TROOPS ENGAGED. 127th und 165th New A'ork, 9th Connecticut, 14th and 24th Maine, and 6th Michigan A'olunteers. Detachment of 22d AVisconsin and 19th Michigan A'ol- unteers, commanded by Colonel Bloodgood. 4th and (ith Kentucky, 9th Pennsylvania, and 2d Michi- gan Cavalry, commanded by Brigadier General G. C. Smith. Gunboat Diana, with detachments of the 12th Con- necticut and 160th New A'ork A'olunteers on board. Four companies of the 13th West A'irginia Volunteers.. 14th and 24th Maine A'olunteers....................... (ith Illinois Cavalry.................................. 8th Maine and (ith Connecticut A'olunteers, and 33d U. S. Colored Troops (1st South Carolina). 5th Pennsj'lvania Cavalry................... ........ 3d Kansas Indian Home Guards....................... Civilians, Missouri Militia, and contrabands........... 3d AA'isconsin Cavalry................................ ist Kentucky and 7th Ohio Cavalry, and 44th and 45th Ohio Mounted A'oluntcers. One company of 13th AA'est A'irginia Volunteers, com- manded by Captain J. D. Carter. 69th Indiana A'olunteers and a detachment of the 2d Illinois Cavalry. Troops commanded by Major General Foster.......... One company of the 2d Missouri Militia Cavalry....... Detachments of the 1st Vermont and 5th New York Cavalry. One company of the 5th Kansas Cavalry............. 3d and 4th Ohio Cavalry, commanded by General Stanley. 1st Arkansas Cavalry, commanded by Captain J. J. AVorthington. 3d Iowa Cavalry..................................... UNION LOSS. CONFED. LOSS. 300 19 i 40 99 13 25 22 11 501 12 290= 27 4 REMARKS AND REFERENCES. Official Report of Colonel Thomas S. Clark, 6th Michigan A'olunteers, commanding. Official reports. Post surrendered to Forrest. Official. Report of Adjutant General of Connecticut, 1864, page 135. Report of Adjutant General of AA'est A'irginia, 1864, page 371. Report of Adjutant General of Maine, 1863, p. 81. Report of Adjutant General of Illinois, Vol. Ill, page 05. Official Report of Colonel John D. Rust, 8th Maine A'olunteers, commanding. Slight skir- mish at Baldwin. Unofficial. Official. Newspaper report. | Official. Official Report of Brigadier General Q. A. Gilmore, commanding. Also designated Somerset. Report of Ad'utant General of AA'est Virginia, 1864, page 371. Official Report of Major General J. A. McCIernand. Also designated Round Away Bayou. Including the skirmish at Rodman's Point, April 4th, J 863. Report of Adjutant General of Missouri, 1865, page 456. Official. Official. Ohio in the AVar, Vol. 2, page 768. Report of Adjutant General of Iowa, 1865, p. 114. Q X o o f o Q Q > f el > O April 5th Black Bayou expedition, Mississippi... to Kith. April 7th.. Bombardment of Fort Sumter, Charles- ton Harbor, South Carolina. April 8th.. April 8th.. April 9th.. April 9th.. April 10th. April 10th. April 10th. April llth. April 12th to llth. April 12th to May 4th. April 14th April 15th. April 15th. April 15th. April 16th. April 16th. April 17th. April 17th. April 17th. April 17th to May 2d. St. Francis County, Missouri........... Broad River, South Carolina............ East Pascagoula, Mississippi............ Blount's Mills, North Carolina.......... AA'averly, Tennessee................... Franklin and Harpeth River, Tennessee Antioch Station, Tennessee............ AVhittaker's Mills, near Williamsburg-, Virginia. Irish Bend and Bisland, Louisiana...... Siege of Suffolk, Virginia............. AA'est Branch and Nansemond, A'irginia . Spanish Fork Cation, Utah Territory-. Pikeville, Kentucky.................. Dunbar's Plantation, Louisiana........ Running the Vicksburg batteries...... Mcdalia, Minnesota................... South Quay, A'irginia................. Bear Creek, Cherokee Station, and Lundy's Lane, Alabama. Bayou A'ermilion, Louisiana........... Grierson's expedition from La Grange, Tennessee, to Baton Rouge, Louisiana. A division of the Fifteenth Corps, commanded by Major General Frederick Steele. South Atlantic squadron, Keokuk, Weohawken, Pas- saic, Montauk, Fatapseo, New Ironsides, Cntskill, Nantucket, and Nahant, commanded by Rear- Admiral S. F. Du Pont, U. S. N. Detachment of cavalry and one company of the 4th Iowa Cavalry, commanded by Major E. F. AVinslow. 3d Rhode Island Artillery, on the gunboat George Washington. 74th U. S. C. T. (2d Louisiana), commanded by Col- onel N. AV. Daniels. 3d and 17th Massachusetts, 1st Rhode Island, and 3d New York Artillery. One company of the 5th Iowa Cavalry 40th Ohio, guarding the railroad, and a portion of Granger's Cavalry Division, commanded by Colonel Stanley. Detachment of the 10th Michigan Volunteers.......... 5th Pennsylvania Cavalry...............,..........., Grover's Division, Nineteenth Corps, at Irish Bend, and Emory's and Weitzel's Divisions, Nineteenth Corps, at Bisland. Troops of the Department of Virginia and North Caro- lina, commanded by Major General John J. Peck. Gunboats Commodore Barney, AVest End, Mount AA'ashingtou, and Stepping Stones. 2d California Cavalry............................... 39th Kentucky Mounted Infantry 2d Illinois Cavalry................................... Ironclads and transports belonging to Commodore Por- ter's fleet and General Grant's army. Eighteen soldiers of the 7th Minnesota Volunteers---- 99th and 130th New York Volunteers.................. 10th Missouri and 7th Kansas Cavalry, of Major Gen. G. M. Dodge's forces. Division of the Nineteenth Corps, commanded by Brigadier General Grover. Gth and 7th Illinois and 2d Iowa Cavalry * Killed, wounded, and missing-, 19 350'' 202. 7 4 Official Reports of Union and Confederate com- manders. Also designated Stono Inlet. .... Report of Adjutant General of Iowa, 1864, p. 529. .... Unofficial. 3 Official. Report of Adjutant General of Massachusetts, 1863, page 650. 400 500 t 21 Official. 83 Official Report of Major General Granger. Report of Adjutant General of Michigan, 1863, page 78. Confederate sources. 2, 000 j Official Report of Major General Banks, command ] ing. Also designated Bayou Teche, Indian Ridge, and Centreville. 400 Casualty List, S. G. O. Official reports. ......: Official Report of Lieutenant AV.B. Cushing, U.S.N. I 30 !........I........| Official. Fight with Indians. 78 2 Official Report of Major General J. A. McClernand. i .....i Official. loot Report of Adjutant General of Kentucky, A'ol. II, page 425. Fight with Indians. Also designated South Branch of the AV'atonwan. Skirmish during the siege of Suffolk. Official reports. Union and Confederate. Also designated Hillsborough. Official Report of Major General Banks. 500 | Official Report of Colonel B. H. Grierson, 6th Illi- nois Cavalry. t Killed and wounded. DATE. 1863. LOCALITY. April 18th. April 18th April 18th. April 18th April 19th. April 19th. April 20th April 20th April 20th. April 20th. Hernando, Mississippi............... Sabine Pass, Texas................. Fayetteville, Arkansas.............. Battery Huger, Hills Point, A'irginia. New Albany, Mississippi............ Coldwater, Mississippi.............. Celina, Kentucky....... Patterson, Missouri...... McMinnvillo, Tennessee.. Bute La Rose, Louisiana . UNION TROOPS ENGAGED 2d Brigade, Cavalry Division, commanded by General Smith, and a force-of infantry and artillery from the Sixteenth Corps, commanded by Colonel Bryant, 12th AVisconsin Volunteers. Crews of the gunboats Cayuga and New London..... 1st Arkansas A'olunteers and 1st Arkansas Cavalry Detachments of the 89th New York and 8th Connecti- cut A'olunteers. 7th Illinois Cavalry. 2d Brigade, Cavalry Division, coniinanded by General Smith, and a force of infantry and artillery from the Sixteenth Corps, commanded by Colonel Bryant, 12th AVisconsin A'olunteers. 5th Indiana Cavalry................................. April 21st Palo Alto, Mississippi. and 22d. April 2id Tompkinsville, Kentucky April 22d.. April 23d.. Strasburg Road, Virginia. Chuckatuck, A'irginia--- Tuscumbia, Alabama .. Beverly, AVest A'irginia . White AA'ater, Missouri.. April 24th April 21th April 24th April 24th April 25th.; Greenland Gap, West A'irginia.. 3d Missouri Militia Cavalry, commanded by Colonel Smart. 1st Brigade of Cavalry, Army of the Cumberland, commanded by Colonel Mint}'. Union gunboats Estrella, Clifton, Arizona, and Cal- houn, under Lieut. Commander A. P. Cooke, U. S. N. 2d Iowa Cavalry, commanded by Colonel E. Hatch. 3d West A'irginia Cavalry, under Major McGee. Crew of the gunboat Commodore Barney....... 2d Division. Sixteenth Corps, commanded by Major General G. M. Dodge. 5th AA'est A'irginia Cavalry, commanded by Colonel G. R. Latham. 1st AA'isconsin Cavalry Little Rock Landing, Duck River Shoals, Tennessee. Ellet's Mississippi ram fleet. Detachments of the 23d Illinois and 14th AA'est A'irginia A'olunteers, commanded by Captain AA'allace, 23d Illinois. UNION LOSS. CONFED. LO'IS. 10 6 j 7 1 '....... 4 I 60 25 t REMARKS AND REFERENCES. Report of Adjutant General of AVisconsin, 1865, page 481. Official Report of Colonel M. LaRue Harrison, 1st Arkansas Cavalry, commanding post. Official. Skirmish during siege of Suffolk. (See April 12th.) Skirmish during Grierson's raid through Mississippi. Ohio in the AVar, Vol. 2, page 780. Report of Ad- jutant General of AA'isconsin, pages 202 and 481. Report of Adjutant General of Indiana, Vol. Ill, page 108. Report of Adjutant General of Missouri, 1865, page 465. 60 j Official Report of Major General N. P. Banks. Skirmish during Grierson's expedition through Mississippi. (See April 17th.) Official Report of Colonel Hatch. 100* Unofficial. Unofficial. Official Report of Lieutenant Cushing, U. S. N. Unofficial. Report of the Adjutant General of AA'est Virginia, 1864, page 625. Official. Official Report of Lieutenant Fitch, U. S. N. Official Report of Brigadier General B. F. Kellcy. April 26th. Cape Girardeau, Missouri. April 27th. April 27th to May 3d. April 27lh to May 8th. April 28th. April 28th. April 28th April 28th April 29th April 29th April 29th April 29th and 30th. April 30th and May 1st. April 30th. April 30th and May 1st. April 30th. Franklin, Tennessee. Streight's raid fromTuscumbia, Alabama, to Rome, Georgia. Stoneman's Raid, Virginia..... Howe's Ford, Kentucky.............. Dover Road, North Carolina.......... Town Creek, Alabama............... Union Church, Mississippi............ Castor River and Bloomfield, Missouri Fairmont, West A'irginia............. Grand Gulf, Mississippi............... Fitzhugh's Crossing. Rnppahanock River, A'irginia. Chalk Bluff and St. Francois River, Missouri. Spottsylvania Court House, Virginia.. Day's Gap, Sand Mountain, and Black AVarrior Creek, Alabama. Snyder's Bluff, Mississippi. 1st AA'isconsin and 2d Missouri Militia Cavalry, 32d Iowa A'olunteers, and Batteries D and L, 1st Missouri Light Artillery, commanded by Brigadier General John McNeil. Cavalry, commanded by Colonel Watkins . 3d Ohio, 51st and 73d Indiana A'olunteers. 80th Illinois Mounted Infantry, and two companies of the 1st Ala- bamaCavalry.ciimmanded by Colonel A. D. Streight, 51st Indiana A'olunteers. Cavalry Corps, Army of the Potomac, Major General Stoneinan. 1st Kentucky Cavalry, commanded by Captain F. N. Alexander. Troop of the District of North Carolina, commanded by Brigadier General Palmer. Portion of the Sixteenth Corps, commanded by Major General G. M. Dodge. 6th Illinois Cavalry. 1st Wisconsin Cavalry, of Brigadier General John McNeil's forces. Detachments of the 106th New A'ork, 6th West Vir- ginia, and Virginia Militia. Gunboats Louisville, Carondelet, Mound City, Pitts- burg, Tuscumbia, Benton, and Lafayette. First Corps, Army of the Potomac. 3d Missouri and 1st Iowa Cavalry, 2d Missouri Militia, and Batteiy E, 1st Missouri Light Artillery, of Brig- adier General McNeil's forces. 6th New A'ork Cavalry, commanded by Lieutenant Colonel Duncan McVicar. 3d Ohio and 80th Illinois, and 51st and 73d Indiana Mounted Infantry, and 1st Alabama Cavalry. Portion ot the Fifteenth Corps, Major General Sherman. * Killed, wounded, and missing, f Killed and wounded, § Wounded and missing. 5 2 6 !....... 275§ Report of Adjutant General of Iowa, 1865, p. 302. Official reports, Union and Confederate. Includes skirmishes at Day's Gap, April .'SOtli, Black AA'ar- rior Creek, May 1st, and Blount's Farm, May 2d. Averill's Division crossed the Rappahannock at Beverly Ford, advanced to the Rapidan, and re- turned. Buford's and Gregg's Divisions crossed at Kelly's Ford and proceeded to Louisa Court House, where detachments were sent out ; one under Colonel Wyndham to Columbia de- stroyed a portion of the James Canal: one under Colonel Davis destroyed the A'irginia Cen- tral Railroad from the South Anna River to Rich- mond; one under Colonel Kilpatriek destroyed a portion of the Fredericksburg Railroad at Hun- gary, passed within two miles of Richmond, crossed the Chiekahominy, and proceeded to Tappahannock. and finally reached the Union lines ac Gloucester. Unofficial. Also designated Weaver's Store. Report of Adjutant General of Massachusetts, 1863, page 314. Official Report of General Bragg, C. S. A. Skirmish during Grierson's raid through Missis- sippi, April 17th to May 2d. 100* ! Casualty List, S. G. O., File A, No. 618. Official Report of Admiral Porter, commanding. 103 Reports of Adjutants General of Michigan and In- diana. Official reports, Union and Confederate. Skir- mishes during Streight's raid, April 2Tth to Mav 3d. Also designated Driver's Gap and Crooked Creek. Official. DATE. 1863. LOCALITY. May 1st--- Port Gibson, Mississi .May 1st to 4th. Chancellorsville, A'irginia. UNION TROOPS ENGAGED. Thirteenth Corps, Major General J. A. MeClernand, and 3d division of the Seventeenth Corps, Major General J. B. McPhcrson, commanded by Major General U. S. Grant. First Corps, Major General J. F. Reynolds; Second Corps. .Major General D. N. Couch; Third Corps, Major General D. E. Sickles; Fifth Corps, Major General G. G. Meade; Sixth Corps, Major General J. Sedgwick; Eleventh Corps, Major General O. O. Howard; Twelfth Corps, Major General H. AV. Slocuni,—Army of the' Potomac, commanded by Major General Joseph Hooker. May 1st.. May 1st... May 1st... May 1st... May 1st... May 1st... May 2d.... May 3d.... May 3d___ May 3d.... May 4th... May 4th... May 4th... May 6th... May 10th.. La Grange, Arkansas..................; 3d Iowa Cavalry, commanded by Captain J. Q. A. Dclluff. Monticello, Kentucky. South Quay Bridge, Nansemond River, A'irginia. Tickfaw River, Mississippi___ Rapidan Station, A'irginia..... Louisa Court House, Virginia. Blount's Farm, Alabama...... AA'arrenton Junction, A'irginia..... Nansemond River, A'irginia....... Forty Hills, Mississippi........... Shannon Hill, A'irginia........... Tunstall Station, A'irginia........ Siege of Suffolk, A'irginia, raised. Tupelo, Mississippi............... Civiques Ferry, Louisiana....... 2d Tennessee, 1st Kentucky, and 2d and 7th Ohio Cav- alry, and 45th Ohio and 112th Illinois Mounted In- fantry, commanded by Brigadier General S. P. Car- ter. 99th New York Volunteers. 7th Illinois Cavalry.................................. Averill's Cavalry Division, Army of the Potomac...... Two companies of the 1 st Maine Cavalry.............. 51st and 73d Indiana and 80th Illinois Volunteers, 3d Ohio Mounted Infantry, and 1st Alabama Cavalry. 1st West Virginia and 5th New York Cavalry........ Major General John J. Peck's troops................. Seventh division, Seventeenth Corps.................. 5th New York Cavalry.............................. 12th Illinois Cavalry................................ Troops of the Depart't of A'irginia and North Carolimi 10th Missouri and 7th Kansas Cavalry................ 14th and 24th Maine and 177th New A'ork Volunteers, and 31st New York Battery. REMARKS AND REFERENCES. . Casualty List. S. G. O. Appendix to Part I, -Medi- cal and Suraiciil History ( f the AVar. page 331. Official reports. Brigadier General R. D. Tracy, C. S. A., was killed. The first engagement in Grant's campaign against Viekslmrg. Also doig- nated Thompson's Hill and Magnolia Hills, and includes the skirmishes at Bayou Pierre. Official reports, Union and Confederate. Appen- dix to Part I, Medical and Surgical History of I the AVar, page 135. List of casualties, S. G. O. Includes the battles of the Sixth Corps at Fred- ericksburg. Salem Heights.and Maryes Heights. Among the casualties in the Union army were Major General Hiram G. Berry und Brigadier | Gen. A. AV. Whipple, killed, and Brigadier Gen- I eralsDevan and Kirby, wounded; in the Confed- erate army, Brigadier General E. !'. Paxton, killed, und Lieutenant General J. S. Jackson. Major General A. P. Hill, and Brigadier Generals Hoke, Nichols, Ramseur, McGowun, Heth, and Pender, wounded. Report of Adjutant General of Iowa, 1864, p. 525. Official reports, Union and Confederate. Skirmish during the siege of Suffolk. April 12 to May 4. Skirmish during Grierson's raid, April 17 to Alaj- 2. Skirmish during Stoneman's raid, April 27 to May 8. Report of Adjutant General of Maine. 1863, p. 53. Detachment of Stoneman's iaiding forces. Skirmish during Streight's ^aid, April 27 to May 3. Official. Official. Skirmish during siege of Suffolk, A'irginia. Official. Skirmish during Grant's campaign against A'icksburg. Also designated Hankinson's Ferry. Official. Skirmish during Stoneman's raid. Official. Skirmish on Stoneman's raid in A'irginia. Official Report of Major General John Peck. Unofficial. Report of Adjutant General of Maine, 1863, p. 82. Horse Shoe Bend, Kentucky............! Detachments of Union troops commanded by Colonel j 10 R. T. Jacobs. Mount Vernon, Arkansas......... Linden, Tennessee.............. Fourteen-mile Creek, Mississippi. Raymond, Mississippi........... Ponchatoula, Louisiana. Hall's Ferry, Mississippi South Union, Kentucky. Jackson, Mississippi--- Warrenton Junction, Virginia... Camp Moore, Louisiana......... CarsviUe and Suffolk, Virginia. Carthage, Missouri........ Piedmont Station, A'irginia. Cripple Creek, Tennessee.. Champion Hills, Mississippi. Berry's Ferry, Virginia...... Big Black River, Mississippi. Fayetteville, Virginia. Sherwood, Missouri... 5th Kansas and 5th Illinois Cavalry, commanded by Colonel Powell Clayton. 6th Tennessee Cavalry, commanded by Colonel AV. K. M. Breckenridge. Thirteenth Corps, Major General J. A. McClernand, and Fifteenth Corps Major General A\'. T. Sherman, of Major General Grant's army. Seventeenth Corps, Major General J. B. McPherson's, of Major General Grant's army. Colonel Davis's command. 2d Illinois Cavalry....... Seventeenth Corps, Major General J. B. McPherson, and Fifteenth Corps, Major General AV. T. Sherman, of Major General Grant's army. Expedition commanded by Colonel Davis............ Expedition commanded by Brigadier General R. S. Foster. 7th Missouri Militia Cavalry......................... West Virginia and Pennsylvania Cavalry............. Detachment of the 5th Tennessee Cavalry, escort to Brigadier General Palmer. Hovey's Division, Thirteenth Corps, Major General J. McClernand, and Seventeenth Corps, Major General J. B. McPherson. Detachment of the 1st New York Cavalry, commanded by Lieutenant Vermillion. Carr's and Ostcrhaus's divisions of Thirteenth Corps, Major General J. B. McClernand,—Army of the Ten- nesse, Major General Grant. 12th and 91st Ohio Volunteers and 2d West Virginia Cavalry. Detachments of the 2d Kansas Artillery and 1st Kansas (79th U. S Colored Troops) Volunteers. 2,500 t 5 600 i 450* 40 18 1,800 10 2,500 Report of Adjutant (ieneral of Michigan, 1863, page 99. Also designated Greasy Creek. Unofficial Official report of Commodore S. L. Phelps, U. S. N. Official. Skirmish during Grant's campaign against Vicksburg. Appendix to Part I, Medical and Surgical History of the AVar, page 331. Casualty List, S. G. O. Official Report. Engagement during Major Gen- eral Grant's campaign against A'icksburg. The Confederate General Tilghinan was killed, Cavalry advance of McClernand's Corps in Grant's campaign against Vicksburg. Official. Official Reports, Union and Confederate. Casualty List. S. G. O. Appendix to Part I, Medical and Surgical History of the AA'ar. page 331. En- gagement during Grant's campaign against Vicksburg. Casualty List, File A. No. 554, S. G. O. ignated Holland House. - Also designated Bradysville. Official Reports of Major General Grant, command- ing Union troops, and Lieutenant General Pem- berton, commanding Confederate forces. Appen- dix to Part I, Medical and Surgical History of the War, page 331. Casualty List, S. G. O. Engagement during the campaign against A'icks- burg. Also designated Baker's Creek and Ed- ward's Station. Unofficial. Official Reportsof Major General Grant, command- ing Union forces, and Lieutenant General Pem- berton, commanding Confederates. Casualty List. S. G. O. Appendix to Part I, Medical and Surgical History of the AA'ar, page 331. Engage- ment during Grant's campaign against A'icksburg. Ohio in the AVar, Vol. 2, page 90. Official Report of Major R. G. Ward. * Killed, wounded, and missing, t Killed and wounded. W Q > Q M s a H > H DATE. 1863. May 18th. Muv 18th to July 4th. LOCALITY. Attack, by guerrillas, on the transport Crescent City, near Island No. 82. ('arsvillo, A'irginia............. Siege of A'icksburg, Mississippi. UNION TROOPS ENGAGED 3d Iowa Volunteers . 170th New A'ork Volunteers fired into by their comrades. Thirteenth Corps, Major General J. A. McClernand, Fifteenth Corps, Major General W. T. Sherman, and Seventeenth Corps, Major General J. B. McPherson, commanded by Major General Grant, U. S. A., as- sisted by the navy on the Mississippi River, com- manded by Admiral Porter. After the assault, Lau- man's division, Smith's and Kimball's divisions of the Sixteenth Corps, two divisions of the Ninth Corps, Major General J. G. Parke, and a division from the Department of the Missouri, Major General F. J. Ilcrron, were added to the besieging forces. May 19th.. May 19th.. May 20th.. May 20th.. Detachment of Cavalry from Milroy's command. 25th Missouri Volunteers....................... Winchester, A'irginia.............. Richfield, Clay County, Missouri... Fort Gibson and Fort Blunt, Indian Ter- : 6th Kansas and 3d AA'isconsin Cavalry, and 1st, 2d, ritory. I aud 3d Kansas Indian Home Guards. Second assault on fortifications at Vicks- Army of Tennessee.................................. burg-, Mississippi. Clendenin's raid below Fredericksburg, ■ 8th Illinois Cavalry, commanded by Lieutenant Colonel A'irginia. D. R. Clendenin. Middleton, Tennessee..................■ 4th Michigan, 3d Indiana, 7th Pennsylvania, 3d and 4th Ohio, and 4th U. S. Cavalry, and 39th Indiana Mounted Infantry, commanded by Major General Stanley. May 21st... Plain Stores, Port Hudson Plains, La... 1st Division, Auger's, Nineteenth Corps.............., May 20th to' 28th. May 21st. May 22d... Gum Swamp, North Carolina . May23d...! Bachelor's Creek, North Carolina— May 23d... Beaver Dam Lake, near Austin, Miss May 25th.. Fishing Creek, Hartford, Kentucky---- May 25th.. I Polk's Plantation, near Helena, Arkansas. May 25th.- Franklin, Louisiana................... May 25th. Senatobia, Mi sippi. 58th Pennsylvania and 5th, 25th, 27th, and 46th Massa- chusetts Volunteers, and Bogg's Battery, commanded by Colonel J. R. Jones, 58th Pennsylvania Vols. 58th Pennsylvania and 46th Massachusetts Volunteers, commanded by Colonel J. R. Jones. Mississippi Marine Brigade of Cavalry and Infantry___ 3d Iowa and 5th Kansas Cavalry..................... 41st Massachusetts A'olunteers and several other regi- ments, commanded by Colonel Chickering. 3d Illinois Cavalry, commanded by Colonel Lafayette McCrillis. UNION LOSS. 3 545 303 CONFED. LOSS. « 3 S i * 2 i £ 31,277 REMARKS AND REFERENCES. (i ........ 7 2 25 1 12 40 100 80 6 19 80 51 I 165 3 12 2 10 14 24 ' 6 3 Report of the Adjutant General of Iowa. 1864, p. 424. Unofficial. On May 19th, an unsuccessful assault on Fort Hill was made by Blair's division of Sherman's Corps. On the 20th, a general assault was made ; Brig. General Green, ('. S. A., was killed, and Brig. General Baldwin wounded. On June 25tha mine was exploded under the Fort Hill bastion, and a struggle followed in the breach. On the 28th, another breach was made in the Fort Hill bastion, aud another hand-to-hand conflict ensued. On July 4th, the Confederates surrendered. Official Reports of Major General Grant, commanding Union forces, andLieutenantGeneial Peiubcrton, commanding Confederate forces. List of casu- alties, S. G. O. Appendix to Part I. Medical and Surgical History of the AVar, page 331. Unofficial. Official Report of Colonel AA'illiam A. Phillip commanding. See siege of Vioksburg, May 18th Official Report of Major General Halleck, U. S. A. Official Report of Major General Banks, command- ing. Official Report of Major General J. G, Foster, U. S. V. Official. Official. Rebellion Record, A'ol. VI, page 77. Official. Report of Adjutant General of Massachusetts. 1863, page 893. May 27th.. May 27th.. Lake Providence, Louisiana. Florence, Alabama......... Mny 27th Siege of Port Hudson, Louisiana to J*uly 9th. May 28th.. May 29th.. May 30th.. 47th U. S. Colored Troops........................... Brigade of Cavalry, commanded by Colonel Cornyn, luth Missouri Cavalry. Major Generals AA'eitzel's. Grover's, Painc's, Augur's, aid Dwight's Divisons ot the Nineteenth Corps.— Major General Banks' Army of the Gulf, assisted by by the navy under Admiral Farragut. Bushy Creek, Missouri................ 13th Hlinois Cavalry, commanded by Major L. Lippert Mechanicsville, Mississippi........ Greenwich, A'irginia . June 1st... Rocheport, Missouri. June 4th... Clinton, Louisiana June 4th...- Mechanicsburg and Sartoria, Mississippi June 4th.... Frying Pan, Virginia.................. June 4th... [ Franklin, Tennessee................... Portion of the Seventeenth Corps, commanded by Major General F. P. Blair, U. S. V. 1st Vermont, 5th New York, and 7th Michigan Cavalry. June 4th___ Bluffton, South Carolina........... .. I June 5th...1 Franklin's Crossing, Rappahannock River, Virginia. June 6th...! Murfreesboro', Shelbyville Pike. Ten- nessee. June 6th... Shawneetown, Kansas. June 6th...! Berryville, Virginia... June 6th ] Milliken's Bend, Louisiana . to 8th. I June 9th... June 9th... Fort Lyons, Virginia................. Monticello and Rocky Gap, Kentucky. 1st Missouri Enrolled Militia and 9th Missouri Militia Cavalry. Cavalry, commanded by Colonel B. II. Grierson, 6th Illinois Cavalry. 5th Illinois Cavalry and 8th Wisconsin Volunteers, portion of General Nathan Kimball's command. Detachment of the 5th Michigan Cavalry, commanded by Captain Gray. 85th Indiana Volunteers and 7th Kentucky Cavalry, commanded by Colonel J. P. Baird. 85th Indiana A'olunteers, and the 4th and 6th Kentucky, 9th Penn- sylvania, and 2d Michigan Cavalry, 1st Brigade General Granger's Cavalry Division. 26th New Jersey and 5th Vermont Volunteers, and 15th and 50th New York Engineers, supported by the Sixth Corps. 2d and 8th Indiana Cavalrj', commanded by Colonel Thomas J. Harrison. 67th Pennsylvania Volunteers....................... 5th I'. S. Colored Heavy Artillery (9th Louisiana), 49th U. S. Colored Troops (llth Louisiana), 51st U.S. Colored Troops (1st Mississippi), and 23d Iowa Vol- unteers, commanded by Colonel H. Leib, 5th U. S. Colored Heavy Artillery. 3d New York Artillery............................... 2d and 7th Ohio and 1st Kentucky Cavalry, and 45th Ohio and 2d Tennessee Mounted Infantry, com- manded by Colonel A. A'. Kautz, 2d Ohio Cavalry. 211 6,408 Official. Official. Official Reports of Major General Banks, com- i manding the Union forces, and Major General Frank (tardner, commanding the Confederate forces. Port Hudson was invested on May 24th. On the 27th a general assault was made, and the Confederates driven under the shelter of their I fortifications. A serious engagement occurred I on June llth, and another general but unsuccess- ful assault was made on the 14th. On July 9th the Confederate garrison surrendered. Among j the Union casualties were Brigadier Generals AV. ! T. Sherman and H. E. Paine wounded. Ap- pendix to Part I, Medical and Surgical History of the War, page 335. Official. Also designated Little Black River. Report of Adjutant General of Iowa, 1865, p. 214. Report of Adjutant General of Vermont, 1863, page 85. Report of Adjutant General of AA'isconsin, 1865, page 638. Report of Adjutant General of Illinois, Vol. Ill, page 54. Report of Adjutant General of Michigan, 1863, page 26. Official. Unofficial. Report of Adjutant General of Indiana, Vol. II. page 390. Unofficial. Unofficial. Official Report of Brigadier General E. S. Dennis, U. S-V. Also designated Ashland. The Union troops engaged being mostly colored, no quarter was shown them. Accidental explosion of a magazine. Ohio in the War, A'ol. 2, page 578. Killed, wounded, and missing, t Killed and wounded. DATE. 1863. LOCALITY. June 9th... Beverly Foul and Brandy Station, Va. June 9th... June 10th.. June llth.. June llth. June llth.. June llth.. June 12th.. June 13th. and 15th. June 13th. June 14th.. June 14th.. June 15th.. June 16th.. June 16th.. June 17th.. June 17th.. Triune, Tennessee................... Lake Providence, Louisiana.......... State Creek, near Mount Sterling, Ky. Port Hudson, Louisiana.............. Seneca, Maryland.................... Middleton, A'irginia.................. Berryville, Virginia.. AViuchester, A'irginia. Wilson's Creek, near Boston, Kentucky. Martinsburg, A'irginia................. UNION TROOPS ENGAGED. 2d, 3d, and 7th AA'isconsin, 2d and 33d Massachusetts, 6th -Maine, and 86th and 104th New A'ork Volunteers; 1st, 2d. 5th, and (ith U. S., 2d, (ith, 8th, 9th and 10th New York, 1st Maryland, 8th Illinois. 3d Indiana, 1st New Jersey, 1st. 6th. and 17th Pennsylvania, 1st Maine, and 3d AA'est A'irginia Cavalry,—Brigadier Generals Gregg's and Buford's Cavalry Divisions, Army of the Potomac. General Mitchell's Cavalry Division................... UNION LOSS. Second assault on fortifications at Port Hudson. Louisiana. Richmond. Louisiana...... Triplett's Bridge, Fleming County, Kentucky. Jornado Del Mucrto, New Mexico. Orleans, Indiana.................. Aldie, A'irginia................... 1st Tennessee and HthKenti by Colonel Sanders. Army of the Gulf........... ;y Cavalry, commanded (ith Michigan Cavalry............................... 13th Pennsylvania Cavalry, 87th Pennsylvania Volun- teers, and Battery L, 5th Artillery. 1st Brigade, Milroy's Division, commanded by Colonel IIcReynolds. 2d, 07th, and 87th Pennsylvania. 18th Connecticut, 12th AVest Virginia, 110th, 116th. 122d, and 123d Ohio, and 3d, 5th, and (ith Maryland A'oluntcers; 12th and 13th Pennsylvania, 1st New York, and 1st and 3d AVest Virginia Cavalry ; Battery L, 5th U. S. Artillery, 1st AVest A'irginia Buttery, Baltimore Bat- tery, and one company 14th Massachusetts Heavy Artillery, of the 2d Division, Eighth Corps. Kentucky Provost Guard............................. June 17th.. AVestport, Missouri. 106th New York and 126th Ohio Volunteers, and West A'irginia Battery, 3d Brigade, 2d Division, Eighth Corps, commanded by Brigadier General Tyler. General Mower's Brigade and Ellet's Mississippi Ma- rine Brigade. 10th and 14th Kentucky and 7th and 9th Michigan Cavalry, 15th Michigan A'olunteers, and llth Michi- gan Batter}-, commanded by Colonel De Courcey. One company of the 1st New Mexico Cavalry. Home Guards............................... 2d and 4th New York, 6th Ohio, 1st Massachusetts, 1st Maine, and 1st Rhode Island Cavalrj-. commanded by Colonel Kilpatrick. Two companies of the 9tb Kansas A'olunteers......... 15 24 14 300 3,000 CONFED. LOSS. 6001 42 100 100 850* 100 REMARKS AND REFERENCL Official Report of Major General Pleasanton, com- manding. Casualty List, S. G. O. Official Report of Major General Halleck. Official. See siege of Port Hudson, May 24th. Unofficial. Official Report of Major General Milroy, com- manding. Official Report of Major General R. II. Milroy, commanding. Ohio in the AA'ar, Vol. 2, page 649. Official Report of Lieutenant General R. E. Lee, C. S. A. Official. See siege of Port Hudson, May 24th. Official. Unofficial. Official Report of Brigadier General Carleton. Unofficial. Morgan's raid in Indiana and Ohio. Casualty List. S. G. O. Report of Adjutant Gen- eral of Massachusetts, 1863, page 925. Official Report of Major General Pleasanton. Official. June 17th.. Capture of the Atlanta . Plaqueminc, Louisiana................ Blue Island, near Leavenworth Indiana Middleburg, A'irginia................. U. S. ironclad AA'eehawkc Rockj- Crossing-, Tallahatchee River, Mississippi. Greencastle, Pennsylvania............. Home Guards, commanded by Major Clendeuin...... 1st Alaine, 2d, 4th, and 10th New York, 4th and 16th Pennsylvania, and 6th Ohio Cavalry. 9th Illinois Mounted Infantry and 5th Ohio Cavalry... Warm Springs, Fort McRae, New Mex- ico. Pawnee Reservation........... Jackson Cross Roads, Louisiana 1st New A'ork Cavalry..................... Detachment of the 1st New Mexico Cavalry. One companj* of the 2d Nebraska Cavalry... Hernando, Mississippi........... La Fourche Crossing, Louisiana. Upperville, Virginia............ Detachments of the 6th and 7th Illinois and 2d Rhode Island Cavalry, 52d Massachusetts A'olunteers, and a section of artilleiy. - 5th Ohio, 2d Illinois, and 1st Missouri Cavalry......... Low Creek, West Virginia .. Hill's Plantation. Mississippi. Cypress Bend, Mississippi River. Brashear City, Louisiana........ Detachments of the 23d Connecticut, 176th New A'ork, 1 8 26th, 42d, and 47th -Massachusetts, and 21st Indiana A'olunteers, commanded by Colonel A. Sticknej-, 47th Massachusetts A'olunteers. Cavalry Corps, Army of the Potomac........................ Portions of three companies of the 4th Iowa Cavalry, commanded by Major Parkell. Union gunboats...................................... Rosecrans' campaign from Murfreesboro' to Tullahoma, Tennessee. June 24th.. Middleton, Shelbyville Pike, Tennessee. Hoover's Gap, Tennessee . McConnellsburg, Pennsylvania. Chackahoola Station, Louisiana Liberty Gap, Tennessee. Fort Hill, Vicksburg. Detachments of the 176th and 114th New York, 23d Connecticut, 42d Massachusetts, and 21st Indiana A'olunteers, commanded by Major Anthony. Fourteenth Corps, Major General G. H. Thomas; Twentieth Corps, Major General A. McD. McCook; Twenty-first Corps, Major General T. L. Crittenden; Reserve Corps, Major General G. Granger; and Cavalry Corps, Major General Stanley,—Army of the Cumberland, Major General A\'. S. Rosecrans. 1st Cavalry Division, Army of the Cumberland, ad- vance of Major General Rosecrans's army. 17th and 72d Indiana, 123d and 98th Illinois Mounted Infantry, and 18th Indiana Battery, AVilder's Brig- ade,—advance of the Fourteenth Corps, Major Gen. G. H. Thomas. 12th Pennsylvania Cavalry....................... Five companies of the 9th Connecticut Volunteers . Twentieth Corps, Major General A. McD. McCook, of the Army of the Cumberland. 3 100 145 Official Report of Rear-Admiral S. F. Dupont, U. S. N. 1,634 Official Report of Major General Banks. 70 j Unofficial. 40 ; Casualty List, S. G. O. Official Report of Major General Pleasanton. Ohio in the War, Vol. 2, page 782. 20 Unofficial. .....i Official Report of Brigadier General Carleton. Official. Reports of Adjutant Generals of Massachusetts and Rhode Island. Official Report of Major General N. P. Banks. Also designated Thibodeaux. Official Report of Brigadier General A. Pleasanton, commanding. Casualty List, S.G.O. Report of Adjutant General of Iowa, 1864, p. 530. Unofficial. Official Report of Major General N. P. Banks. Appendix to Part I, Medical and Surgical History of the AA'ar. page 266. Official Report of Major General Rosecrans, commanding. Includes Jlid- dleton. Hoover's Gap, Beech Grove, Liberty, June 22d, and Guy's Gap, June 27th. Official report. Official Report of Major General Rosecrans, com- manding. Official Report of Lieutenant Colonel R. Fitz- gibbous, commanding. Official Report of Major General Rosecrans. Also designated Beech Grove. See siege of Vicksburg, May 18th. * Killed, wounded, and missing, t Killed and wounded. 1863. June 26th.. June 26th.. LOCALITY South Anna, near Hanover Court-House, A'irginia. Baltimore Cross Roads, A'irginia........ June 27th..| Fairfax, A'irginia....................., June 27th.. \ Beaver Creek, Floyd County, Kentucky. June 27th. Guy's Gap and Shelbyville, Tennessee.. June 28th..! Donaldsonyillo, Louisiana..... June 28th. June 29th. June 29th. Fort Hill, Vicksburg, Mississippi..... McConnellsburgk, Pennsylvania...... AVestminster, Maryland June 29th..; Lake Providence, Louis June 30th June 30th.. Sporting Hill, near Harrisburgh, Penn- sylvania. Hanover, Pennsylvania June 30th.. I Bayou Tensas, Louisiana. July 1st... Tullahoma, Tennessee--- July 1st ! Gettysburg, Pennsylvania. to 3d. I UNION TROOPS ENGAGED. llth Pennsylvania Cavalry and 2d Massachusetts and 12th Illinois A'olunteers. Fourth Corps, commanded by Major General Keyes. llth New York Cavalrj', commanded bjr Major Rem- ington. 39th Kentucky A'olunteers........................... Cavalry Division of the Army of the Cumberland, supported bjr Major General.Granger's Infantry Di- vision. 28th Maine A'olunteers and convalescents, commanded by Major J. D. Bullen, assisted by gunboats. 1st New York Cavalrj-. Detachment of the 1st Delaware Cavalry, oommanded by Major N. B. Knight. 22d and 37th New A'ork Militia and Lander's Battery, commanded by Colonel Roome, 37th New York Militia. 3d Division (Brigadier General Kilpatrick), Cavalry Corps (Major General Pleasanton), Annj' of the Potomac. Mississippi Brigade of Infantry and Cavalry, command- ed by Colonel C. R. Ellet. Occupied by Major General Rosecrans' army......... First Corps, Major General J. F. Reynolds; Second Corps, Major General AV. S. Hancock ; Third Corps, Major General D. E. Sickles; Fifth Corps, Major General George Sykes ; Sixth Corps, Major General J. Sedgwick; Eleventh Corps, Major General O. O. Howard; Twelfth Corps, Major General H. AV. Slocum ; and Cavalry Corps, Major General A. Pleasanton, — Army of the Potomac, commanded by Major General G. E. Meade. UNION LOSS. CONFED. LOSS. •d Wounded. .5 Killed. ■d ■d p 3 O 20 150 80 700 150 39 112 1 7 118 10 2 3 15 30 2 12 1 43 75 60 2,834 13,709 6,643 3,500 14, 500 13, 621 REMARKS AND REFERENCES. Report of Adjutant General of Massachusetts, 1863, page 935. Unofficial. Unofficial, Report of Adjutant General of Kentucky, A'ol. II, page 425. Official Report of Major General Rosecrans. Olneial Reportsof Major General Banks. U. S. A., and General Greene, C. S. A. Report of Adju- tant General of Maine, 1863, page 104. Sec Vicksburg, May 28th. Unofficial. Official. Confederate sources. Official. Casualty List. S. G. O. Official Report of Major General Meade. Official reports, Union and Confederate. Appendix to Part I, Medical and Surgical History of the AVar, page 140. Casualty List, S. G. "<). In- cludes the cavalry skirmish at Hunterstown. Among the casualties in the national army were Major General John F. Reynolds, Brig. Generals Stephen II. AVeed, Kosciusko Zook, and Ehm J. Farnsworth. killed; Major Generals D. E. Sick- les and AV. S. Hancock,' and Brigadier Generals Paul, T. A. Rowley, J. Gibbons, and F. C. Bar- low, wounded. In the Confederate army. Major General Pender. Brigadier Generals R. B. Gui- nea, W. Bitrksdalc. and Senimes. 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. July 1st to 26th. * July 1st and 2d. July 1st and 2d. Morgan's raid into Kentucky, Indiana, Cavalry, commanded by Brigadier General E. II and Ohio. Hobson. Black River, at Messenger's and Bridge- port Ferries, Mississippi. Cabin Creek, Indian Territory.......... Portion of the Seventeenth Corps. July 2d.— j Baltimore Cross Roads, A'irginia........ 3d AVisconsin, (ith and 9th Kansas, and 2d Colorado Cavalry, 1st Kansas (79th U. S. 0. T.) and 3d Kansas Indian Home Guards. Portion of the Fourth Corps, commanded by Major General Kej-cs. July 2d... July 2d ... July 2d... July 2d... July 2d... July 3d ... July 3d ... July 4th... July 4th... July 4th and 5th. July 4th. July 4th. July 5th... July 5th... July 6th... July 6th.... July 6th... July 6th. .. Elk River, Tennessee..... Bottom's Bridge, Virginia. Beverly, A'irginia......... Marrowbone, Kentuckj"-......... Springfield Landing, Louisiana. Fairfield, Pennsylvania........ Columbia, Kentucky........... Cavalry, Army of the Cumberland . 5th Pennsylvania Cavalry.......... 10th AA'est Virginia A'olunteers and Battery G, AVest A'irginia Artillery, commanded by Colonel Thomas Harris. 1st and 9th Kentucky Cavalry and 24th Indiana Battery 2d Rhode Island Cavalry............................ 6th U. S. Cavalry..................................... University Place, Tennessee........... Green River Bridge, Kentuckj'......... Bolton and Birdsong Ferry, Big Black River, Mississippi. 1st Kentucky and 2d Ohio Cavalry, and 45th Ohio Mounted A'olunteers. 6th Kentucky Cavalry, commanded by Colonel L. D. AA'atkins. Five companies of the 25th Michigan Volunteers, com- manded by Colonel O. H. Moore. Nationals, commanded by Major General AV. T. Sher- man. Vicksburg, Mississippi, surrendered. Helena, Arkansas.................. Monterey Gap aud Smithsburg, Mary- land. One division of the Sixteenth Corps, commanded by Major General B. M. Prentiss, assisted by the Union gunboat Tyler. 3d Cavalry Division, Kilpatrick's, Army of the Potomac. Fairfield, Pennsj-lvania . Lebanon, Kentucky..... Pound Gap expedition, Tennessee. Quaker Bridge, North Carolina___ Hagerstown, Maryland.. AVilliamsport, Maryland. Cavalry of the Army of the Potomac................, 20th Kentucky Volunteers, commanded by Colonel C. S. Hanson. 10th Kentucky and 1st Ohio Cavalry, commanded by Major J. M. Brown, 10th Kentucky Cavalry. 9th New Jersey, 17th, 23d, and 27th Massachusetts, and 81st and 158th New York Volunteers, and Belger's and Angel's Battery, commanded by Brigadier Gen- eral C. A. Heckman. 3d Cavalry Division, Kilpatrick's, Arinj- of the Potomac 3d Cnvahy Division, Army of the Potomac, com- manded by Brigadier General Kilpatrick. 301 300 3,000 2 40 200 2,000 301 100 Skirmishes sit Burkcsvillc, July 2d ; Columbia, 3d ; Green River Bridge. 4tb ; Lebanon, 5th; Bran- denburg, 8th; Corydon, Indiana, 9th ; Vernon. 12th; capture of the greater part of Morgan's troops at Buflington Island. Ohio, 19th, and final capture at New Lisbon on the 26th. Report of Adjutant General of Iowa, 1865, p. 216. Report of Adjutant General of AVisconsin, lt(65, page 619. Unofficial. Official. Unofficial. Report of Adjutant General of AVest A'irginia. 1864, page 286. Morgan's raid. Also known as Burkesville. Report of Adjutant General of Rhode Island, p. 431. Unofficial. Morgan's raid. Unofficial. Report of Adjutant General of Ilichigan. 1863, page 109. Also designated Tebb's Bend. Mor- gan's raid. See May 18th. siege of A'icksburg. Official reports. Union and Confederate. Casualty List, S. G. O. Unofficial. Report of Adjutant General of Kentucky. A'ol. II, page 67. New Jersey and the Rebellion, page 233. Also designated Comfort. Unofficial. Unofficial. t Killed and wounded. DATE. 1863. July (ith. LOCALITY. Jones' Ford, Black River, Mississippi.. July 7th Iuka, Mississippi. and 9th. j Julj' 7th | Boonsboro', Maryland...... to 9th. j July 7th.. J Grand Pass, Fort Halleck, Idaho Terri- tory. July 7th...' Redwood Creek, California............ July 7th.. July 7th.. July 8th... July 9th... Convalescent Corral, near Corinth, Mis- sissippi. Harper's Ferrj- Bridge, Virginia....... Bradenburg, Kentucky................ Port Hudson, Louisiana, surrendered... July 9th... | Corj'don, Indiana. Jackson, Mississippi. July 9th to 16th. July 10th I Fort Wagner, Morris Island, South Car- to Sep. 6th. j olina. July 10th and llth. Assault on Fort Wagner . July lOth-.j Union City, Tennessee. July 10th..j Big Creek, Arkansas... July llth.. July 12th.. July 12th. July 12th.. July 13th. Hagerstown, Maryland, Funkstown, Maryland. - Vernon, Indiana Ashbj- Gap, A'irginia. Yazoo City, Mississippi UNION TROOPS ENGAGED. 6th Iowa and 48th Illinois A'olunteers, a portion of the troops commanded by Major General AV. T. Sherman. 10th Missouri and 7th Kansas Cavalry, commanded by Colonel F. M. Cornyn, 10th Missouri Cavalry. 1st Division, Buford's, and 3d Division, Kilpatrick's,__ Cavalrj- Corps, Army of the Potomac. 9th Kansas Volunteers............................... One company of the 1st Battalion of the California Mountaineers. One company of the 39th Iowa Volunteers, commanded bj' Captain Loomis. Potomac Home Brigade and 1st Massachusetts Heavy Artillery, commanded by Brigadier General J. R. Kenly. Indiana Home Guards..............................., Army of the Gulf. Indiana Home Guards, commanded bj'Colonel Lewis Jordan. Ninth Corps, Major General Parke; Thirteenth Corps, Major General E. O. C. Ord ; FilteenthCorps, Major General AV. T. Sherman, and a portion of the Six- teenth Corps, of Major General U. S. Grant's forces. Troops of the Deparment of the South, commanded bj- Major General Q. A. Gillmore, and U. S. Navy, under Admiral Dahlgren. 67th Connecticut, 76th Pennsylvania, 9th Maine, 3d New Hampshire, and 48th and 100th New York Vols. 4th Missouri Cavalrj'................................ Cavalrj-, Army of the Potomac...................... Infantrj-, cavalrj-, and artillery of the Army of the Potomac. Indiana Minute Men , 2d Massachusetts Cavalry. Major General Herron's Division, assisted by thr« gunboats under Admiral Porter. UNION LOSS. 1 7 5 3 9 45 1 6 10 3 100 12 800 345 100 130 § 100 § CONFED. LOSS. 764 REMARKS AND REFERENCES. Report of Adjutant General of Iowa, 1864, p. 435 Report of Adjutant General of Missouri, 1865, p369. j Unofficial. Official. Indian fight; 21 Indians killed and 39 wounded. Official. Engagement with Indians. Report of Adjutant General of Iowa, 1864, p. 507. Report of Adjutant General of Massachusetts 1863, page 956. Morgan's raid. See siege of Port Hudson, May 24th. Morgan's raid. Report of Adjutant General of Indiana. Official reports, Union and Confederate. Includes skirmishes at Rienzi, Bolton Depot, Canton, and Clinton. Appendix to Part I, Medical and Sur- gical History of the AVar, page 334. Casualty List, S. G. O. » Appendix to Part I, Medical and Surgical History of the AA'ar, page 241. List of casualties, File A, No. 167, S. G. O. Official reports, Union and Confederate. Report of Adjutant General of Iowa, 1805, p. 299. Official. Official Report of Major General Meade, com- manding. Morgan's raid. Report of Adjutant General of Mn-sachusetts, 1863, page 937. 250 Official reports, Union and Confederate. July 13th.. July 13th.. Julv 13th to" 15th. July 14th.. July 14th.. July 14th.. July 14th-. July 14th.. July 15th.. July 15th. July 16th.. July 16th.. July 16th.. July 17th.. July 18th.. July 18th.. July 18th.. Jackson, Tennessee....................I 3d Michigan, 2d Iowa, and 1st Tennessee Cavalry, and 9th Illinois Volunteers. Donaldsonville, Louisiana.. Draft riots, New York City. Lawrenceburg, Ohio....... Portions of AVcitzcl's and Grover's divisions of the Nineteenth Corps. 105th Indiana Minute Men. Falling AVaters, Maryland.............: 3d Cavalry Division of the Army of the Potomac, com- manded by Brigadier General Kilpatrick. Elk River, Tennessee.. Advance of the Fourteenth Corps, Major General G. H. Thomas,—Army of the Cumberland, Major Gen. A\'. S. Rosecrans. Shadj- Spring, AA'est A'irginia..........' 2d AA'est Virginia Cavalry. Near Bolivar Heights. A'irginia.........j 1st Connecticut Cavalry... Pulaski, Alabi Halltown, Viri Jackson, Mississippi............ Sheppardstown, A'irginia........ 3d Ohio and 5th Tennessee Cavalry................... 16th Pennsylvania and 1st Maine Cavalry, commanded by Colonel Gregg, 1st Maine Cavalry. 1st. 4th, and 16th Pennsylvania, 1st Maine, and 10th New A'ork Cavalrj-, commanded by Colonel Gregg, 1st Maine Cavalry. Secessionville, James Island, South Car- Troops commanded by Brigadier General Terry....... olina. Honey Springs, Elk Creek. Indian Ter- 2d, 6th, and 9th Kansas Cavalry, 2d and 3d Kansas ritorj-. ! Batteries, and 2d and 3d Kansas Indian Home Guards, commanded by Major General Blunt. Brandon, Mississippi..... Rio Hondo, New Mexico. Portion of G eneral Sherman's troops.......... One company of the 1st New Mexico Cavalry. Second assault on Fort AA'agner, South Carolina. July 18th..; AVythcville, West Virginia. July 18th.. Canton, Mississippi....... July 18th Raid, Tar River and Rocky Mount, to 21st. North Carolina. July 19th. Bitffinglon Island, Ohio. 1,500* 54th Massachusetts (colored), 6th Connecticut, 48th and 100th New York, 3d and 7th New Hampshire, 76th Pennsylvania, 9th Maine, and 02d and 67th Ohio Vol- unteers. 34th Ohio Volunteers and 1st and 2d AA'est A'irginia Cavalry, commanded by Colonel John T. 'Poland, 34th Ohio A'olunteers. 2d AA'isconsin, 5th Illinois, and 3d and 4th Iowa Cav- alry ; 76th Ohio, 25th and 31st Iowa, and 3d. 13th, and 17th Missouri Volunteers, and a battery of artil- lery. 3d and 12th New A'ork and 1st North Carolina Cavalry, commanded by Brigadier General Potter. 1st, 3d. 8th. 9th, llth, and 12th Kentucky, 8th, 9th and 12th'Michigan, 2d and 7th Ohio, and 5th Indiana Cav- alry, 45th Ohio and 2d Tennessee Mounted Infantry, commanded bv Brig.Generals Hobson and Shackle- ford, and militia and Union gunboats. * Killed, wounded, and missing, t Killed and wounded. § Wounded and missing. 251 1251 3 150 1,500 201 75 50 12 3 400 77 lOOt 800 Official Report of Colonel Hatch, 2d Iowa Cavalry. commanding 2d Brigade Cavalrj-, Sixteenth Corps. Report of Adjutant General of Massachusetts, 1863, page a03. Also designated Rock's Plantation. Over 1,000 of the rioters were killed and wounded. AVhile marching to intercept Morgan's raiders, in- discriminate firing took place among the men. Official Report of Major General Meade. Major General Pettigrew, C. S. A., killed. Report of Adjutant General of Connecticut, 1864, page 259. Unofficial. Report of Adjutant General of Maine, 1863, p. 55. Evacuated by the Confederates. See July 9th. Report of Adjutant General of Maine. 1863, p. 55. Skirmish during the siege of Fort AA'agner. See July 10th. Official reports. Official Report of Major General Halleck. Official. Engagement with Indians. See Fort AA'agner, July 10th. Brigadier General G. C. Strong and Acting Brigadier General H. S. Putnam killed. Official reports, Union and Confederate. Official Report of Brigadier General Seammon. Official Report of Colonel Cyrus Bussej-, command- ing detachment of General Sherman's forces. Capture of Morgan's raiders. Also designated St. George's Creek. 1863. LOCALITY July 21st..I Manassas Gap, A'irginia. Chester Gap, A'irginia... July 21st und 22.1. July22d.- Concha's Springs, New Mexico. ... UNION LOSS. UNION TROOPS ENGAGED. July23d... AA'apping Heights. A'irginia July 24th.. Iuly26th.. July 26th.. July 26th.. July 28th. July C8th.. July 28th.. July 28th.. July 28th.. July 29th.. July 30th.. July 30th.. July 30th.. Aug. 1st to 3d. Aug. 3d... Aug. 5th... Big Mound, Dakota Territory New" Lisbon, Ohio................... Dead Buffalo Lake. Dakota Territory. Pattacassey Creek, North Carolina___ Marshall, Missouri................... Richmond and Lexington, Kcntuckj'. . Cold water, Mississippi............... Stouej' Lake, Dakota Territory........ St. Catherine's Creek, near Natchez, Mississippi. Paris, Kentucky................ Irvine, Estill County, Kentucky. Saline County, Missouri.......... Missouri River, Dakota Territory. Rappahannock Station. Kelly's Ford, and .Brandy Station, A'irginia. 1st, 2d, and 5th U. S. Cavalry, advance cavalry, Army of the Potomac. 8th New York, 3d Indiana, and 12th Illinois, advance cavalrj', Army of the Potomac. One company of the New Mexico ('avalry............ Third Corps, Annj' of the Potomac, commanded bj' Alajor Genera] French. 1st Minnesota Oavaby, 3d Minnesota Batterj', and 6th, 7th, and 10th Minnesota Volunteers, commanded by Brigadier General 11. H. Sibley. Portion of Brigadier General Shackleford's Cavalry .. 1st Minnesota Cavalrj-, 3d Minnesota Buttery, and fith, 7th, and 10th Minnesota A'olunteers, commanded bj' Brigadier General 11. II. Sibley. Troops of the District of North Carolina, commanded bj- Brigadier General lleckman. 4th Missouri Militia Cavalry......................... 3 14 2 8 2 3 30 80 1st Minnesota Cavalrj'. 3d Minnesota Artillery, and (ith, 7th, and 10th Minnesota Volunteers. Detachment of the 72d Illinois Volunteers, commanded bj- Captain \A'm. James. Jackson, Louisiana............... Dutch Gap, James River, A'irginia. Aug. 7th... !■ AA'aterford, A'irginia 14th Kcntuckj- Cavalry, commanded by Colonel H. C. Lilly. 1st and 4th Missouri Enrolled Militia, commanded by Captain Cannon. 1st Minnesota Cavalry, 3d Minnesota Batterj', and 6th Minnesota A'olunteers. 1st Division of Cavalrj', commanded by Brigadier General Buford.. 73d, 75th, and 78th U. S. Colored Troops......... U. S. gunboats Commodore Barney and Cohassctt Detachments of the 1st Connecticut and 6th Michigan Cavalij-, commanded by Captain Vinton, 6th Michi- gan Cavalry. 134 » 2 1 CONFED. LOSS. 3001 REMARKS AND REFERENCES. Casualty List, S. G. O. Casualty List, S. G. O. 60 75 Casualty List, File A, No. 49S. S. G. O. Also des- ignated Manassas Gap. Brigadier Genetal F. B. Spinola, U. S. V., wounded. Official. Fight with the Sioux Indians. Surrender of John Morgan and the remnant of his forces not captured at Burlington Island. Official. Fight with the Sioux Indians. New Jersey in the Rebellion, page 234. A1- know n as Mount Tabor Church. Report of Adjutant General of Illinois, A'ol. 111. page 96. Official Report of Brigadier General II. If. Sibley, commanding. Fight with the Sioux Indians. Unofficial. Rebellion Record, A'ol. All, page 37. Official Report of Brigadier General II. II. Siblej'. Fight with Indians. Official. Casualty List, S. G. O. Official. Unofficial. Report of Adjutant General of Connecticut, 186}, page 2.58. Aug. 7th... Aug. 9th... Aug. 13th. Aug. 13th. Aug. 14th. Aug. 18th.. Aug. 18th.. Aug. 21st.. Aug. 21st.. Aug. 21st.. Aug. 24th. Aug. 24th. Aug. 25th to 30th. Aug. 25th and 26th. Aug. 26th. Aug. 26th.. Aug. 26th. Aug. 27th.. Aug. 27th.. Aug. 27th. Aug. 28th. Aug. 29th. Aug. 31st. Sept. 1st.. New Madrid, Missouri Sparta, Tennessee--- Grenada, Mississippi .. Pincville, Missouri................ AA'est Point, AA'hitc River, Arkansas Pasquotank. North Carolina........ Pueblo Colorado, New Mexico..... Lawrence, Kansas................ Coldwater, Mississippi............. One companj' of the 24th Missouri A'olunteers. Cavalry of the Army of the Cumberland...... 3d, 4th, 9th, and llth Illinois, 3d Michigan, audi 2d Iowa Cavaby, and 9th Illinois Volunteers, com- manded by Colonel Phillips, 9th Illinois Volunteers. 6th Missouri Militia Cavalry.......................... Union gunboats Lexington, Cricket, and Mariner, with the 32d Iowa Volunteers. 1st New A'ork Mounted Rifles and llth Pennsylvania Cavalry, coniinanded by Colonel B. F. Ondcrdonk. Three companies of the 1st New Mexico Cavalry. Chattanooga, Tennessee. Coyle Tavern, near Fairfax Court-IIouse, A'irginia. King George Countj-, A'irginia. 3d and 4th Iowa and 5th Illinois Cavalry, commanded by Colonel E. F. Winslow, 4th Iowa Cavalry. Artillery of Major General Rosecrans' army........... 2d Massachusetts Cavalry, commanded bj- Colonel Lowell. 3d Division, Kilpatrick's Cavalrj'Corps, Army of the Potomac. AA'aj-nesville, Missouri..................j Detachment of the 5th Missouri Militia Cavalry Averill'sraid in West A'irginia....... Davidson's Cavalry Division, Department of Missouri. Browr sville, Arkansas............ Perrj-ville, Arkansas............. Rocky f tap, near AA'hitc Sulphur Springs, 2d and 3d West A'irginia and 14th Pennsylvania Cav 6th Missouri Militia, 3d Wisconsin and 2d Kansas Cav- alry, and 2d Indiana Battery. Virginia Vinegar Hill, Morris Island, South Car- olina. Vicksburg, Mississippi................ Clark's Neck, Lawrence, County, Ky... Bayou Metoe, Arkansas Maj-sville, Alabama...... Bottom's Bridge, Virginia. airy, and 3d and 8th AA'est A'irginia A'olunteers. Troops commanded by Major General Q. A. Gillmore. 5th Heavy Artillery (U. S. Colored Troops).......... 39th Kentucky Volunteers........................... Davidson's Cavalry Division, Department of the Mis- souri. 4th Kentucky Cavalry............................. 1st New York Mounted Rifles and 5th Pennsylvania Cavalry, commanded by Colonel B. F. Onderdonk. Davidson's Cavalry Division, Department of the Mis- souri. Austin, Arkansas................. Bayou Metoe, Arkansas................I Rice's Division, Department of Art t Killed a Official. Official. Report of Adjutant General of Missouri, 1865, page 492. Report of Adjutant General of Iowa, 1865, p. 303. Official. Plunder and massacre by Quantrell. Reportsof Adjutant Generals of Iowa and Illinois. Official. Report of Adjutant General of Massashusetts, 1863, page 937. Official. Official. Averill's command passed through Hardy, Pendle- ton, Highland, Bath, Greenbrier, and Pocahon- tas Counties. Official Report of Major General Fred Steele, com- manding. Official. Official Report of Brig. General AY. W. Averill, commanding. Casualty List, File A, No. 226, S. G. O. See Fort Wagner, July 10th. Official. Report of Adjutant General of Kentucky, A'ol. II, page 425. Official Report of Major General Steele, command- ing. Also designated Dry Creek. Official. Official Report of General Steele. 1863. Sept. 1st. .. Sept. 1st... Sept. 3d to 5th. Sept. 5th.. Sept. 5th.. Sept. (ith... Sept. 7th... Sept. 7th.. Sept, 7th. Sept. 7th. Sept. 8th. Sept. 8th. Sept. 8th. Sept. 8th. Sent. 9th. Sept. 9th.. Sept. 9th.. Sept. 10th. Sept. 10th. Sept. 10th. LOCALITY. Ilarhee's Cross-Roads, A'irginia........ Devil's Back Bone, Arkansas.......... White Stone Hill, Dakota Territory... Limestone Station, near Telford, Tenn. Moorefield, A'irginia.................. Brandy Station, A'irginia. Evacuation of Battery Gregg and Fort Wagner, .Morris Island, South Caro- lina. Bear Skin Lake, Missouri .. Ashley's Mills, Arkansas... Atchafalaj'a River, Louisiana Baton Rouge. Louisiana...... Night attack on Fort Sumter, South Carolina. Bath, A'irginia......... Sabine Pass, Louisiana. Cumberland Gap, Tennessee ... AA'eber's Falls, Indian Territorj' Dardenelle, Arkansas---...... UNION TROOPS ENGAGED. UNION LOSS. Detachment of the 6th Ohio Cavalry, commanded by Major John Ciyor. 1st Arkansas A'olunteers, 6th Missouri Militia, 2d Kan- sas Cavalrj-, and 2d Indiana Batterj-. 2d Nebraska, 6th Iowa, and one company of the 7th Iowa Cavalry. Five companies of the 100th Ohio Volunteers......... 1st AA'est A'irginia Volunteers, commanded by Major E. A\'. Stephens. Cavalrj', Army of the Potomac......................, Graj-sville, Georgia... Little Rock, Arkansas. Brimstone Creek, Tennessee. Sept. 10th. Knoxville, Tennessee, occupied Sept. llth. Ringgold, Georgia. Sepl. llth. Dug, Alpine, and Steven's Gaps, Ga___ Major General Q. A. Gillmore's troops and the U. S. Navy. 2d Missouri Cavalry................................. Davidson's Cavalrj' Division, Department of the Mis- souri. 2d Brigade, 2d Division, Thirteenth Corps 4th AA'isconsin Cavalrj'................... Four hundred and thirteen marines and sailors, com- manded by Commander Stevens, U. S. N. 7th Pennsj-lvania Cavalry........................... U. S. Navj', escort to the troops of the Ninteenth Corps, commanded bj- Major General Franklin. Cavalrj- Division, Brig. General J. M. Shackleford,— Army of the Ohio, Major General A. E. Bumside. 2d Colorado Cavalry................................ 2d Kansas Cavalry and 2d Indiana Battery, commanded by Colonel Cloud. Cavalrj-, Armj- of the Cumberland................... Troops of the Department of Arkansas, Major General Steele, and Cavalrj- Division of the Department of Missouri, General Davidson. llth Kentucky Mounted Volunteers, commanded by Colonel Love. Arm j- of the Ohio, Major General Bumside........... Advance of the Twenty-first Corps, Crittenden's,— Arm j- of the Cumberland. Advance of the Army of the Cumberland............. 2 4 4 12 20 38 12 20 19 24 200 CONFED. LOSS. 25 100 6 2,000 100 REMARKS AND REFERENCES. Ohio in the AA'ar, Vol. 2, page 791. Also known as Fort Smith and Cotton Gap. Official Report of Brigadier General Alfred Sully, commanding. Fight with Indians. Ohio in the War, Vol. 2, page 547. Report of Adjutant General of AA'est Virginia, 18(34, page 75. ee Fort AA'agner, July 10th. Official reports, Union and Confederate. Official. Official Report of General Steele. Official. Official reports, Union and Confederate. Official reports, Union and Confederate. Official Report of Major General Halleck. Official. Official. Official reports, Confederate. * Official Report of Major General F. Steele, com- manding. Unofficial. Official reports. Official Report of Major General Rosecrans, com- manding. Official Report of Major General Rosecrans, com- manding. Also known as Davis' Cross Roads. . llth. Mooreficld, AA'est A'irgi AA'aldron, Arkansas............ Sterling's Plantation, Louisiana . Texas County, Missouri........ Paris, Tennessee Culpeper, A'irginii Lett's Tan Yard, near Chickamauga, Georgia. Brownsville, Arkansas. Raccoon Ford, Rapidan Station,A'irginia Seneca Station, Buffalo Creek, Indian Territorj-. A'idalia, Louisiana..... Hendricks, Mississippi . Smithfield, Virginia___ 14th Kansas Cavalry............ Batterj- E, 1st Missouri Artillery. 5th Missouri Militia Cavaby, commanded by Captain AVhyback. 1st, 2d, and 3d Divisions, Cavalry Corps, Army of the Potomac. AA'ilder's Brigade of Mounted Infantrj',—advance of the Twcntj'-first Corps of General Rosecrans' army. 5th Kansas Cavalrj'................................. Cavalrj- Corps, Army of the Potomac................. 1st Arkansas A'olunteers, commanded by Colonel M. L. Harrison. 3d Missouri A'olunteers, commanded bj' Colonel Farrar 10th Missouri Cavalrj-............................... Raccoon Ford, A'irginia Chickamauga, Georgia Detachments of the 1st New York and 12th Pennsyl- vania Cavalry, commanded bj' Captain Jones, 1st New York Cavalrj'. Reconnoisanee by 1st Cavalry Division, Buford's, Army of the Potomac. Bristol, Tennessee....... Sept. 21st.. AA'hite's Ford, A'irginia. 'ourteenth Corps, Major General G. H. Thomas; Twentieth Corps, Major General A. McD. McCook ; Twentj'-first Corps, Major General T. L. Crittenden ; and Reserve Corps, Major General G. Granger,— Arm j- of the Cumberland, Major General W. S. Rosecrans. Cavalrj-Brigade, Foster's; Cavalry Division, Shackle- ford's,—Armj' of the Ohio, Major General A. E. Bumside. Johnson Depot, Tennessee Jack's Shop, Madison Court-House, Ten- nessee. Carter's Station, Tennessee. Blountsville, Tennessee___ Rockville, Maryland....... Cavalry of the Army of the Potomac. 8th Tennessee Volunteers , 1st Division Buford's Cavalrj' Corps, Army of the Potomac. 3d Brigade, Cavalry Division, Army of the Ohio, Major General Bumside. 2d Mounted Brigade Cavalrj- Division of Major General Burnside's forces, commanded by Colonel Foster. llth New York Cavalry.............................. 4 1,644 40 501 9,262 4,945 2,389 13,412 50 34 J 2,003 Report of Adjutant General of AA'est A'irginia, 1864, page 75. Official. Official. Official. Unofficial. Official Report of Major General Meade. Casu- alty List, S. G. O. Official. Casualtj- List, S. G. O. Casualty List, S. G. O. Appendix to Part I, Aledical aud Surgical Historj- of the AA'ar, page 265. Casualtj- List, S. G. O. Official Report of Major General Rosecrans. com- manding. Among the casualties in the Union armj- were Brig. General AV. H. Lytle, killed, and Brig. Generals Starkweather, AA'hittaker, and King, wounded; in the Confederate army, Brig. Generals Preston Smith, Deshler, and B. H. Helm, killed, and Major General J. B. Hood and Brig. Generals Adams, Brown, Gregg. McNair, Bunn, Preston, Cleburne, Benning, and Claj-ton, wounded. Official. Report of Adjutant General of Michigan, 1863. Report of Adjutant General of Tennessee, 1866, page 158. Casualty List, S. G. O. ' Killed, wounded, and missing. t Killed and wounded. DATE. 1863. LOCALITY UNION TROOPS ENGAGED. Sept. 24th. Zollicoffer, Tennessee. 3d Brigade. Cavalry Division, Army of the Ohio, Majr Genera] Burnsidc . Sept. 25th Uppcrvillo, A'irginia....... Sept. 25th. Red Bone Church, Missouri Sept. 26th. Calhoun, Tennessee....... Sept. 27th.. Moffat's Station, Franklin County. Ar- kansas. 1st Maryland Potomac Home Brigade of Cavalrj- 2d AVisconsin Cavalry........................... Cavalry of the Armj- of the Ohio................ Detachment of the 1st Arkansas A'olunteers, com- manded by Captain Parker. Sept. 28th..I MeMinnville, Tennessee Sept. 29th..i Sterling's Farm, near Morganzia, Louisi- ana. Sept. 30th.. Swallow's Bluff, Tennessee........... Oct. 1st___■ Anderson's Gap, Tennessee........... Oct. 2d...., Anderson's Cross Roads, Tennessee___ Oct. 3d.__| Thompson Cove, Tennessee........... Oct. 3d.. .. MeMinnville, Tennessee............ Oct. 4th...i Murfreesboro'Road, Tennessee..... Oct. 4th... Newton, Louisiana................. Oct. 4th..., Neosho, Missouri.................. Oct. 5th...! Stockade at Stone River, Tennessee. 19th Iowa and 26th Indiana A'olunteers. 7th Kansas and 7th Illinois Cavalry, commanded bj- Colonel Rowett. 21st Kentucky Volunteers 1st AA'isconsin, 2d Indiana, and 1st Tennessee Cavalry. 2d Brigade, 1st Division, Cavalry Corps, Army of the Cumberland, commanded by Colonel Edward McCook. 1st Brigade, Colonel Minty's, 2d Division Cavalry and AA'ildcr's Brigade of Mounted Infantry, commanded by General Crook. 4th Tennessee A'olunteers 2d Kcntuckj- Cavalry and Wilder's Brigade of Mounted Infantrj-, commanded by General Crook. Oct. 5th... Harper's Ferry, A'irginia............. Oct. 5th...' Near Blue Springs, Tennessee....... Oct. 5th... New Albany, Mississippi............ Oct. 5th...j Glasgow, Kcntuckj-................. Oct. 5th... AA'artrace, Tennessee................ Oct. 6th...! Baxter Springs, near Fort Scott, Ark, Three companies of the 6th Missouri Militia Cavalry. One company of the 19th Michigan A'olunteers...... UNION LOSS. Portion of General Burnside's forces 37th Kentucky Mounted Infantrj'. 5th Iowa Cavalry............... Detachments of the 3d AVisconsin and 14th Kansas i 54 Cavalry, and 12th Kansas A'olunteers (83d U. S. Col- ored Troops),—escort to Major General Blunt. 70 f CONFED. LOSS. 20 701 23 f 200 REMARKS AND REFERENCES. Report of Adjutant General of Michigan. 1863. Also called llagucw ood Prairie. Reports of the Adjutant Generals of Iowa and In- diana. Official. Report of Adjutant General of Kcntuckj-, Vol. II, page 96. Report of Adjutant General of AA'isconsin, 1865, page 539. Report of Adjutant General of Tennessee, 180(5. page 98. Unofficial. Report of Adjutant General of Missouri, 1865, page 492. Report of Adjutant General of Michigan, 1863, page 97. Confederate official reports. Ohio in the AA'tir, Vol. 2, page 558. Official. Report of Adjutant General of Iowa, 1864, p. 993. Official reports. The prisoners were robbed and murdered bj' the rebels, who were coniinanded bj- Quantrell. Oct. (ith... Fort Blair, AA'aldron, Arkansas Detachment of the 3d AVisconsin Cavalry Oct. 7th... Oct 7th... Oct. 8th... Oct. 8th... Oct. 8th... Oct. 9th... Oct. 10th.. Oct. 10th.. Oct. 10th.. Oot. 10th.. Oct. 10th.. Oct. llth.. Oct. llth.. Oct. llth.. Oct. 12th.. Oct. 12th.. Oct. 12th and 13th. Oct. 12lh and 13th. Oct. 13th.. Oct. 13th.. Oct. 13th. Oct. 13th. Oct. 13th.. Conio, Mississippi. Shelbyville Pike, near Farmingtc Tennessee. 1st, 3d, and 4th Ohio and 2d Kentucky Cavalry of the 2d Brigade, Long's, 2d Cavalrj' Division, and AA'ild- er's Brigade of Mounted Infantry. Churlestown, Virginia. Salem, Mississippi___ AVarsaw, Missouri..................... Sugar Creek, near Pulaski, Tennessee. Rapidan, Virginia................... Ingraham's Plantation, Mississippi... James Citj*, Rappahannock Virginia . Blue Springs, Tennessee............ Vermilion Bayou, Louisiana. Rheatown, Tennessee....... Henderson's Mill, Tennessee. Colliersville, Tennessee.......... Jeffersonton, Virginia............ Ingham's Mills, near Byhalia, Miss Culpeper and White Sulphur Springs, A'irginia. Merrill's Crossing to Lamine Crossing, Missouri. AA'j'atts, Tallahatchie, Mississippi. Big Black River, Mississippi...... Maysville, Alabama.............. Blountsville, Tennessee.......... Colonels McCrellis' and Phillips' Cavalry Brigades. 7th Missouri Militia Cavalry. 3d Brigade, Lowe's, 2d Cavalry Division, commanded bj- General Crook. 1st Division Cavalry, Buford's, Armj- of the Potomac. 2d AA'isconsin Cavalry............................... 3d Cavalrj' Division, Brigadier General Kilpatrick, Armj' of the Potomac, commanded by Major General Pleasanton. Cavalry Division. Shackleford's. and infantry of the Ninth Corps, Army of the Ohio, Major General Burn- side. 1st Brigade, 1st Division of the Nineteenth Corps...... 2d Brigade, Cavalry Division, Army of the Ohio 5th Indiana Cavalry of the 2d Brigade, Foster's, of the Cavalry Division commanded by General Shackle- ford. 66th Indiana Volunteers and 13th U. S. Regulars. 2d Cavalry Division, Army of the Potomac...... 2d Brigade Cavalry of the Sixteenth Corps, command- ed by Colonel E. Hatch, 2d Iowa Cavahy. Cavalry Corps, Army of the Potomac................ Bulltown, Braxton County, Virginia. 1st, 4th, and 7th Missouri Militia Cavalry, Enrolled Militia Infantry, and 1st Missouri Militia Battery, commanded by Brigadier General E. B. Brown. 2d Brigade, Cavalry Division of the Sixteenth Corps, commanded by Colonel Hatch, 2d Iowa Cavalry. Reconnoisance of infantry and cavalry, commanded by Major General McPherson. 1st Division Cavalry Corps, Army of the Cumberland.. 3d Brigade, Carter's, of the Cavalry Division, Shack- leford's, of the Army of the Ohio, Major General Bumside. Detachments of the 6th and llth West Virginia Vol- unteers. * Killed, wounded, and Report of Adjutant General of Wisconsin, 1865, page 620 (October 16th). Casualty List, File A, No. 161, S. G. O. Report of Adjutant General of Tennessee, 1866, p. 475. Report of Adjutant General of Iowa, 1864, p. 994. Official reports. Official reports, Union and Confederate. Also des- ignated Robertson's Run. Official Report of Major General Bumside. Report of Adjutant General of Massachusetts, 1863, page 804. Report of Adjutant General of Tennessee, 1865, page 525. Report of Adjutant General of Indiana, Vol. Ill, page 111. Official. Official reports. Casualty List, S. G. O. Official reports. Also designated AVarrenton Springs. Official reports. Also known as Marshall, Arrow Rock, Blackwater, and Jonesboro". Report of Adjutant General of AA'isconsin. 1865, page 590. Official. Casualty List, File F, No. 86, S. G. O. LOCALITY 1863. Oct. 14th..I Auburn, A'irginia........ i Oct. 14th.. Bristoe Station, Virginia Oct. 14th.. Salt Lick, A'irginia Oct. 15th..; Canton, Mississippi Oct. 15th..! McLean's Ford, A'irginia.......... Oct. 15th..! Hcdgcville, Virginia............. ! Oct. 15th.. Blackburn Ford, A'irginia......... Oct. Kith | Brownsville, Mississippi........... to 18th. Oct. 16th.. Cross Timbers, Missouri........... UNION TROOPS ENGAGED. Portion of the 1st Division, Second Corps, Armyof the Potomac. Second Corps, AA'arren's ; portion of the Fifth Corps, Sykes' ; assisted by the 2d Cavalrj- Division, Gregg's,—Army of the Potomac. 6th AA'est A'irginia A'olunteers......................... Portion of the Fifteenth and Seventeenth Corps, com- manded by Major General McPherson. New Jersey Brigade, Third Corps, Army of the Po- tomac. Detachments of the 1st New York and 12th Pennsyl- vania Cavalry and 116th Ohio A'oluntcers. Portion of the Second Corps, Army of the Potomac... Portion of the Fifteenth and Seventeenth Corps, Major General McPherson. Oct. 17th..; Destruction of two blockade runners in Tampa Baj-. Oct. 17th.. Clinton, Mississippi Oct. 17th.. | Rapidan, Virginia,. Oct. 17th. Oct, 18th. Oct. 18th. Ilumansvillc, Missouri. Charlestown, A'irginia.. Bcrrysville, A'irginia... Oct. 19th.. Buckland Mills, Virginia. Oct. 20th..: Barton Station, Mississippi Oct. 20th j Philadelphia, Tennessee and 22d. i Oct. 21st..| Cherokee Station, Alabama Oct. 21st. Opelousas, Louisiana Oct. 22d...! Beverly Ford and Rappahannock Cross- I iug, A'irginia. 18th Iowa A'olunteers............. Union gunboats Tahoma and Adeic Detachment of the Armj-of the Tennessee, commanded bj' Major General McPherson. 1st Division, Buford's, Cavalry Corps, Army of the Potomac. 6th Missouri Militia Cavalry......................... 9th Maryland A'olunteers............................ 34th Massachusetts A'oluntcers and 17th Indiana Battery 3d Division, Kilpatrick's Cavalry Corps, Army of the Potomac. Troops of the Army of the Tennessee, Sherman's .. 45th Ohio Mounted Infantry, 1st, llth, and 12th Ken- tucky Cavalry, and 24th Indiana Battery, commanded bj' Colonel AVolford. 1st Division, Osterhaus's, Fifteenth Corps, Army of tho Tennessee. Franklin's Division, General Banks'troops......... 2d Pennsylvania and 1st Maine Cavalry, commanded by Colonel Gregg, 1st Maine Cavalry. >i UNION LOSS. CONFED. LOSS. 11 42 20 80 37 100 24 7501 2001 601 10 20 82 401 24 REMARKS AND REFERENCES. Official. Casualty List. S. (i. O. Official Reports of Major General .Meade, U. S. A., and Lieutenant General A. P. Hill, ('. S. A. Among the casualties in . the Confederate army were Brigadier Generals H. F. Cooke, Posey, and Kirkland, wounded ; in the Union army, ISrig. General Malone, killed. Also designated Liberty Mills. Unofficial Official Report of Major General Meade. Report of Adjutant General of Illinois, Vol. Ill, page 54. Report of Adjutant General of Iowa, 1865, p. 277. Official Report of Acting- Rear-Admiral Bailey, U. S. N. Casualty List, S. G. O. Report of Adjutant General of Missouri, 1865, p. 493. Official Report of Brig. General Imboden, ('. S. A. Official Report of Brig. General Imboden, C. S. A. Report of Adjutant General of Massachusetts, 1863, page 834. Official Reports of General Stuart and Lee, C. S. A., and Major General Meade, U. S. A'. Official Report of Major General C. S. Stevenson, commanding Confederates. Official reports. Report of Adjutant General o£ Maine, 1863, p. 56. a W w o « o O Q >—< a P> f d > Pi o Oct. 22d... Oct. 23d... Oct. 24th.. Oct. 24th.. Oct. 25th.. Oct. 25th.. Oct. 25th.. Oct. *26th.. Oct. 26th.. Oct. 26th.. Oct. 27th.. Oct. 27th.. Oct. 28th. Oct. 29th. Nov. 1st.. Nov. 1st.. Nov. 2d.. Nov. 3d.. Nov. 3d.. Nov. 3d.. Nov. 4th.. Nov. 4th.. New Madrid Bend, Tennessee......... Supply train, Tullahoma, Tennessee... Bealton and Rappahannock Bridge, Va. Sweetwater, Tennessee.......... Colliersville, Tennessee......... Pine Bluff, Arkansas............ Creek Agency, Indian Territory. Cane Creek, Alabama........... Philadelphia, Tennessee......... Vincent's Cross Roads, Tishamingo Countj-, Mississippi. Brown's Feny, Tennessee............. 32d Iowa A'olunteers___ 70th Indiana A'olunteers. 1st. Division, Buford's, Cavalry Corps, Army of the Potomac. Cavalry of the Armj' of the Ohio. 5th Kansas and 1st Indiana Cavalrj'................... 1st Kansas Indian Home Guards and 2d Indiana Bat- tery. 1st Division. Fifteenth Corps, commanded by Major General Osterhaus. AA'auhatchie, Tennessee. Clarksville. Arkansas . Leiper's Ferry, Tennessee .. Cherokee Station, Alabama AA'ashington, North Carolina......... Faj-etteville, Tennessee............. Brazios De Santiago, Texas......... Centreville and Pinej- Factorj-, Tenn. Grand Coteau, Louisiana............ Colliersville, Tennessee. Lawrenceburg, Tennessee. Moscow, Tennessee....... Metly's Ford, Little Tennessee River . 1st Alabama Union Cavalrj-, commanded by Colonel G. E. Spencer. Detachments from the 5th, 6th, and 23d Kentucky, 1st, 6th, 41st, 93d, and 124th Ohio, and 6th Indiana A'olunteers, of the 2d Brigade, Hazcn's, 3d Division, Fourth Corps, Armj- of the Cumberland. Eleventh Corps, Major General O. O. Howard, and 2d Division, Geary's, Twelfth Corps, commanded by Major General Joseph Hooker. 3d AA'isconsin Cavalry. llth and 37th Kentucky and 112th Illinois Volunteers .. 1st Division of the Fifteenth Corps, commanded by Major General Osterhaus. 4th Indiana Cavalrj-. Troops of the Thirteenth Corps, commanded by Brig. General N. J. T. Dana. A mixed command, under Lieutenant Colonel Scully, 10th Tennessee Volunteers. 3d Division, McGinnis', and 4th Division, Burbridge's, of the Thirteenth Corps, commanded by Major Gen. C. C. AA'ashburn. Cavalry Brigade, Sixteenth Corps, commanded bj7 Col. Hatch, 2d Iowa Cavalry. 14th Michigan Mounted Infantry...................... Cavalry Brigade, Sixteenth Corps, commanded bj- Col. Hatch, 2d Iowa Cavalry. Cavalry of the Army of the Ohio, commanded by Gen. Sanders. 1,200 7 100 Report of Adjutant General of Iowa, 1865, p. 300. Official Report of Colonel Powell Clajton, com- manding. Official Report of General Sherman. Also desig- nated Bear Creek and Tuscunibia. Confederate official reports. Official. Also known as Bay Springs. Casualty Return, S. G. O. Official Report of Brigadier General AV. F. Smith, commanding. Official Report of Major Gen. George H. Thomas, commanding Army of the Cumberland. Casu- altj- List, S. G. O. Appendix to Part I, Medical ana Surgical History of the War, page 282. Report of Adjutant General of Wisconsin, 1865, page 620. Official reports, Union and Confederate. Unofficial telegrams. Report of Adjutant General of Indiana, A'ol. Ill, page 20. Official Report of Major General N. P. Banks. Official Report of Major General G. H. Thomas. Official Report of Major General E. O. C. Ord. Also designated as Bayou Bourbeaux and Car- rion Crow Bavou. Official Report of Major General Thomas. f Killed and wounded. Q ► Q > b td > tr1 LOCALITY Alill Point, Pocahontas Countj-, AA'est A'irginia. Kincaels, Tennessee .. Rogersville, Tennessee Droop Mountain, A'irginia. Rappahannock Station, A'irginia Kelly's Ford, A'irginia. Stevensburg, A'irginia. Clarksville, Arkansas. Muddj' Run, near Culpeper, Virginia. Bayou Sara, Mississippi.............. Natchez, Mississippi................. Roseville, Arkansas.............___ Trinity River, California............. Mill Creek Valley, West A'irginia Palmyra, Tennessee............. Huff's Ferrj', Tennessee......... Rockford, Tennessee. Marj-sville, Tennessee--- Loudon Creek, Tennessee. Lenoirs, Tennessee....... UNION LOSS. UNION TROOPS ENGAGED. llth Pcnnsj'lvania and 3d AVest A'irginia Cavalrj commanded by Brigadier General AV. AV. Averill. 7th Ohio Cavalrj-, 2d Tennessee Mounted Infantry, and 2d Illinois Batterj', coniinanded by Colonel Gar- rard, 7th Ohio Cavalrj-. 14th Pennsylvania and 2d and 5th AA'est A'irginia Cav- alry; 8th and 10th AA'est Virginia and 28th Ohio A'olunteers, and Battery B, West A'irginia Artillery, commanded by Brigadier General AV. AA'. Averill. 5th AVisconsin, 5th and 5th Alaine. 49th and 119th Penn- sylvania, and 121st New York A'olunteers, supiported bj' the remainder of the Sixth Corps, Sedgwick's, and a portion of the Fifth Corps, Army of the Poto- mac. 1st U. S. Sharpshooters, 40th New A'ork, 1st and 20th Indiana, 3d and 5th Michigan, and 110th Pennsyl- vania A'olunteers, supported by the remainder ofthe Third Corps, Major General French, Army of the Potomac. 3d Cavalrj' Division, Army ofthe Potomac, commanded by Brigadier General Kilpatrick. 3d AA'isconsin Cavalry................................ 1st Division, Cavalry Corps, Army of the Potomac... 58th U. S. Colored Troops (6th Mississippi). Two companies 2d Kansas Cavalry........ Two companies 1st Battalion California Mountaineer Infantrj-. Mounted infantry, commanded by Captain Cutter...... lilth Ohio, 107th Illinois, llth and 13th Kentucky, and 23d Michigan Vols., and 24th Michigan Battery. 1st Kentucky Cavalry and 45th Ohio Mounted Infantry, commanded by Colonel S. G. Adams, 1st Kentucky Cavalrj-. llth Kentucky Cavalry.............................. lilth Ohio Volunteers............................... Cavalry and infantry of the Army of the Ohio, cover- ing- retreat of Major General Burnside's forces on Knoxville. 3701 701 25 33 050 25 1 25 100" 100" CONFED. LOSS. 98 10 REMARKS AND REFERENCES. Official Report of Brigadier General B. F. Kellcy. Ohio in the War, A'ol. 2. page 800. Official Report of Brig. General Ransom, C. S. A. ffcial Report of Brigadier General B. F. Kelley, U. S. V. 1,629 Official Reports of Major General Meade, com- manding, and Lieutenant General Lee, C. S. A. Official Reportof Major General Meade, U. S. V., and Lieutenant General R. E. Lee, C. S. A. Report of Adjutant General of AA'isconsin, 1865, page 620. Casualty List, S. G. O. Confederate official reports. Official. Official. Official. 1 ! Official Report of Major General Thomas Official. Ohio in the AA'ar, A'ol. 2, 591. Nov. 15th.. 1 Holston River, near Knoxville, Tonn. Nov. 16th.. Nov. 16th.. Nov. 17th to Dec. 4th. Nov. 17th. Nov. 17th.. Nov. 18th.. Nov. 19th.. Nov. 23d to 25th, Nov. 24th.. Nov. 26th.. Nov. 26th.. Nov. 26th.. Nov. 25th.. Nov. 26th.. Nov. 26th.. Nov. 26th to 28th. Charles City Cross Roads, Virginia.... Campbell's Station, Tennessee......... Siege of Knoxville, Teuucssee........ Willow Creek, California............. Mount Jackson, A'irginia.............. Mustang Island, near Aranzas Pass, Texas. Carrion Crow Bayou, Louisiana....... Union City, Tennessee................ Water Proof, Louisiana............... Chattanooga, Tennessee.............. Barnwell's Island, South Carolina Bonfouca, Louisiana............. Sparta, Tennessee............... Beersheba Springs, Tennessee___ Greenville, North Carolina....... Warm Springs, North Carolina. Kingston, Tennessee........... Operations at Mine Run, A'irginia ... llth Kcntuckj', 45th Ohio, and H7th Kentucky Mounted Infantrj', of the Army of the Ohio. Cavalry expedition, commanded by Colonel West . Ninth Corps, Major General Ferrero; 2d Division, Twenty-third Corps, Brig. General Julius AVhite ; and Cavuliy, commanded by General Sanders,— Army of the Ohio, coniinanded bj' Major General A. E. Bumside. Army of the Ohio, Major General Burnsido.......... 1st California Battalion Mountaineer Infantry. 1st New Y'ork Cavalry...................... 13th and 14th Maine, 34th Iowa, and 8th Indiana Vols., and Battery F, 1st Missouri Artillery, commanded bj' Brigadier General N. J. T. Dana. 6th Missouri Cavalry................................ 2d Illinois Cavalrj-, commanded by Captain F. B. Moore. Steamer AVelcome Fourth Corps, Major General G. Granger, and Four- teenth Corps, Major General J. M. Palmer,—Armj' of the Cumberland, Major General George H. Thomas; Eleventh Corps, Major General O. 0. Howard, and Geary's Division ofthe Twelfth Corps, Major General Joseph E. Hooker ; and Fifteenth Corps, Army ot the Tennessee, Major General AV. T. Sherman. 33d U. S. Colored Troops (1st South Carolina), com- manded by Captain AVhituey. 31st Massachusetts A'olunteers and 4th Massachusetts Battery, commanded bj- Captain G. S. Darling. 1st Tennessee and 9th Pennsj-lvania Cavalrj-, com- manded by Lieut. Colonel J. P. Brownlow. Alabama and Tennessee Scouts, commanded by Cap- tain Brixbj-. 12th New A'ork Cavalry, 1st North Carolina A'olunteers, and 24th New A'ork Battciy, commanded by Captain G. W. Graham. Cavalrj- of the Armj- of the Ohio, commanded by Col. By id. First Corps, Major General John Newton; Second Corps, Major General G. K. Warren; Third Corps, Major General French ; Fifth Corps, Major General Sykes; Sixth Corps, Major General John Sedg- wick ; and 1st and 2d Divisions Cavalrj',—Army of the Potomac. 5 340 90 570* 361 6,142 10 20 Casualty last, S. G. O. Brigadier Generals AVm. P. Sanders and AA'urfiold, wounded. Official. Official Report of Brig. General J. C. Sullivan. Report of Major General N. P. Banks. Official Report of Major General U. S. Grant, com- manding. Casualtj- List, S. G. O. Appendix to Part I, Medical and Surgical Historj- of the AA'ar, page 283. In the battle of Chattanooga are included the engagements at Orchard Knob on the 23d, Lookout Mountain on the 24th, and Missionary Ridge on the 25th. Among the casualties were Brigadier Generals J. M. Corse, G. A. Smith, and Jlatthies, U. S. A'., wounded. Official. Report of Adjutant General of Massachusetts, 1863, page 965. Official Report of Major General Thomas. Official. List of casualties, S. G. O. Includes the engage- ments at Raccoon Ford, Bartlett's Mills, Robert- son's Tavern, and New Hope, and is designated Locust Grove, Payne's Tavern, and Orange Grove. Official Reports of Major General Meade, commanding Union, and Lieut. General R. E. Lee, commanding Confederate forces. Among the casualties were Brigadier Generals J. M. Jones and J. E. B. Stuart, wounded. * Killed, wounded, and missing. t Killed and wounded. Q W t> H GO > u bd P" H tr1 DATE. 1863. Nov. 27th.. Nov. 27th to 29th. Nov. 28th.. Nov. 29th.. Nov. 30th.. Dec. 1st... Dec. 2d... Dec. 3d... Dec. 4th... Dec. 4th... Dec. 6th... Dec. 7th... Dec. 7th... Dec. 7th... Dec. 8th... Dec. 8th to 21st. Dec. 10th.. Dec. 10th.. Dec. 10th.. Dec. 12th.. LOCALITY. UNION TROOPS ENGAGED. Ringgold, Grej-sville, Pea A'ine Creek, und Tuj'lor's Ridge, Georgia. Cleveland, Tennessee................. Fort Esperanza, Texas................ Louisville, Tennessee................. Fort Sanders, Knoxville, Tennessee.... Salj'ersville, Kcntuckj'................ Riplej-, Mississippi................... Walker's Ford, Clinch River, AVest A'irginia. Salisbury, Tennessee................. Niobrara, Nebraska................... Moscow Station, Mississippi........... Clinch Mountain, Tennessee.......... Natchez, Mississippi.................. Creelsboro', Kentucky................ Celina, Tennessee.................... Princeton, Arkansas.................. Averill's raid, Southwestern A'irginia... Bean's Station, Tennessee............. Morristown, Tennessee................ Moresburg, Tennessee................ Duval's Bluff, Arkansas................ Johnson's Division. Fourteenth Corps; Osterhaus's Division, Fifteenth Corps; and Geary's Division, Twelfth Corps. 2d Brigade, 2d Cavalry Division, commanded by Col. Eli Long. 8th and 18th Indiana, 33d and 99th Illinois, 23d and 34th Iowa, and 13th and 15th Maine A'olunteers, 7th Michigan and Co. F, 1st Missouri Battery,—portion of the 1st tind 2d Divisions, Thirteenth Corps 6th Illinois Cavalry............................. Armj- of the Ohio Major General A. E. Burnside. 14th Kentucky A'olunteers....................... 2d Brigade, Cavalrj- Division, Army of the Tennes- see., commanded by Colonel Hatch, 2d Iowa Cavalrj-, 5th Indiana and 14th Illinois Cavalry, 21st Ohio Bat- terj', and 65th, 116th, and 118th Indiana A'olunteers. 2d Brigade, Cavalry Division. Sixteenth Corps, com- manded by Colonel E. Hatch, 2d Iowa Cavalry. One company of the 7th Iowa Cavalry................ UNION LOSS. Cavalrj- Division, Sixteenth Corps, commanded by Brigadier General B. II. Grierson. Cavalrj' of the Army of the Ohio...... One company of the 4th Iowa Cavalry. 13th Kcntuckj- Cavalrj'............... 13th Kentucky Cavalry............... Detachment of Cavalry 2d, 3d, 4th, and 8th West A'irginia Mounted Infantry, 14th Pennsylvania and Dodson's Battalion Cavalrj-, and Battery G, West Virginia Artillery. Bond's Brigade of Wolford's Division of Shackleford's Cavalry Corps, Army of the Ohio. Garrard's Brigade of Foster's Division, Shackleford's Cavalry Corps, Army of the Ohio. Cavalry, Army of the Ohio......................... 8th Missouri Cavalry................................. 80 1751 94 CONFED. LOSS. 15 18 REMARKS AND REFERENCE 230 I Official Report of Major General U. S. Grant. 200 6 Official Report of Major General U. S. Grant. Official Report of Major General C. C. Washburne, commanding. 300 | See Siege of Knoxville, Nov. 17th. Report of Adjutant General of Kentucky, Vol. I, page 892. 28 Official. 10 13 28 200 Report of Adjutant General of Iowa, 1865, p. 144. Also designated Wolf River Bridge. Official dis- patches of Gen. S. D. Lee, C. S. A. Colonel E. Hatch, U. S. V., wounded. Report of Adjutant General of Kentucky, Vol. I, page 373. Report of Adjutant General of Kentucky, A'ol. I, page 373. Report of Adjutant General of Iowa, 1867, Vol. II, page 511. Official Report of Brig. General AA'. A\'. Averill, commanding. O W w o « o t-l o Q M o t> d w Hi o Dec. 15th.. Dec. 16th. Dec. 17th and 24th. Dec. 18th.. Dec. 19th.. Dec. 22d.. Dec. 23d.. Dec. 24th and 25th. Dec. 25th.. Dec. 25th.. Dec. 26th.. Dec. 27th and 28th. Dec. 29th and 30th Dec. 30th. Dec. 30th. 1864. Jan. 1st. Jan. 3d... Jan. 4th... Jan. 7th... Big Sewoll and Meadow Blufl", AA'est A'irginia. Bean's Station, Tennessee........ Sangster's Station, A'irginia___ Blain's Cross Roads, Tennessee. Rodney, Mississippi........... Indiantown, North Carolina Barren Fork, Indian Territory. I2th Ohio Volunteers, of General Scammon's command. Cavalry Division ofthe Army ofthe Ohio, commanded bj' Major General Shackleford. 150th New A'ork Volunteers........................ Army of the Ohio.................................. 1st Mississippi Marine Brigade, cavalry and infantry . 36th IT. S. Colored Troops (2d North Carolina) and 5th U. S. Colored Troops, commanded by Brigadier General AVild. 1st and 3d Kan«as Indian Home Guards, commanded by Colonel AV. A. Phillips. Cleveland, Tennessee................. Jacksonport, Arkansas............... Bolivar and Summeryille, Tennessee. Lafayette, Tennessee................. Legaresville, Stono Inlet, South Carolina. Port Gibson, Mississippi..............., Colliersville, Tennessee............... Charleston, Tennessee Talbot's Station and Mossy Creek, Ten- nessee. Matagorda Baj-, Texas..... St. Augustine, Florida..... Greenville, North Carolina . AA'aldron, Arkansas........ Rectortown, Virginia......, Joncsville, Virginia........ 3d Missouri Cavalry................................. 7th Hlinois Cavalry, commanded by Colonel Prince... 117th Illinois A'olunteers. U. S. gunboat Marblehead......................... Mississippi Marine Brigade of Infantry and Cavalry . Cavalry of the Army of the Tennessee.............. Detachments of infantrj' and cavalry, commanded by Colonel Laibold, 2d Missouri Volunteers, and Long's 4th Ohio Cavalry, guarding a wagon train. 1st Brigade, 2d Division, Twenty-third Corps, 1st Ten- nessee, 1st Wisconsin, and 2d and 4th Indiana Cav- alry, and 24th Indiana Batterj-, commanded by Brig. General S. D. Sturgis. Three companies of the 13th Maine, assisted by the gunboat Sciota. 10th Connecticut and 24th Massachusetts Volunteers. Detachment of the 12th New York, 23d New York Batterj-, and 1st North Carolina Volunteers, com- manded by Colonel McChesney. 2d Kansas Cavalrj-. Fort Sumner, New Mexico . Martin's Creek, Arkansas .. 1st Maryland Cavalry, Potomac Home Brigade, com- manded by Major H. A. Cole. Detachment of the 16th Illinois Cavalry and 22d Ohio Batterj-, commanded bj' Major Beers, 16th Illinois Cavalrj'. Co. B, 2d California, and Apaches and citizens..... llth Missouri Cavalry. j Killed and - 2 10 7001 1 9001 4 2 9 7 1 2 50 11 1 6 3 8 29 3 3 2 15 1 8 39 121 4 I 2 12 6 6 lOt 48 25 1 6 10 41 300 4 40 12 25 1 1 13 Casualty List, S. G. O. General Gracie, C. S. A., wounded. Official. Official. Also designated Sandy Swamp. Confederate sources. Official. Casualty return, S. G. O. Report of Adjutant General of Illinois, A'ol. II, page 537. Official. Official Report of Major General Thomas. Ohio in the AA'ar, Vol. 2, page 6. Report of Adjutant General of Maine, 1863, p. I Reports of Adjutant Generals of Massachusetts and Connecticut. Official. Partizan Life with Mosby, page 178. Also desig- nated Five Points. Ohio in the War, Vol. 2, page 883. Fight with the Navajo Indians Official. Q > Q GO b bd > H DATE. 1864. Jan. 7th.. Jan. 8th.. Jan. 9th.. Jan. 10th. Jan. 10th. Jan. 12th. Jan. 13th. Jan. 14th. Jan. 14th. Jan. 14th. Jan. 16th to 18th. Jan. 16th and 17th. Jan. 17th.. Jan. 19th.. Jan. 20th.. Jan. 20th.. Jan. 21st.. Jan. 22d.. Jan. 23d.. Jan. 24th.. Jan. 24th.. Jan. 25th.. Jan. 26th.. Jan. 27th.. UNION LOSS. LOCALITY. UNION TROOPS ENGAGED. Madisonville, Louisiana......... Petersburgh, West A'irginia..... Turman's Ferrj-, Kentucky...... Loudon Heights, A'irginia....... Strawberry Plains, Tennessee ... Maj-field, Kcntuckj'............. Mossy Creek, Tennessee........ Middleton, Tennessee........... Bcalton, A'irginia............... Terrisville, Cosby Creek, Tennessee .. Grand Gulf, Mississippi............... Dandridge, Tennessee................ 39th Kentucky A'oluntcers........................... 1st Maryland Potomac Home Brigade Cavalrj-, com- manded bj- Major II. A. Cole. Cavalry......................................... 58th Illinois A'oluntcers........................... Cavalrj-, commanded bj- Colonel McCook......... 35th Iowa Volunteers............................ One companj- of the 9th Massachusetts Volunteers. Detachments of the 15th Pcnnsj-lvania and 10th Ohio Cavalry, commanded bj- Colonel W. J. Palmer, 15th Pennsylvania Cavalrj'. Cavalry and infantry of the Mississiiipi Marine Brigade. Cavalry Division, Army of the Ohio, commanded by Brigadier General Sturgis, and infantry of the Fourth Corps. Lewisburgh, Arkansas................ j Detachment of the 2d Arkansas Cavalry, commanded by Captain D. Hamilton. Branchvillc, near Pine Bluff, Arkansas..; 5th Kansas Cavalrj', commanded by Colonel Powell Clayton. 17 3 150 Island No. 76, Mississippi Tracy City, Tennessee--- Near Dalton, Georgia. Armstrong Ferry, Tennessee.......... Rolling Prairie, Arkansas............. Baker Springs, Caddo Gap, Arkansas... Tazewell, Tennessee..................• Athens, Alabama... Florence, Alabama Cameron, Virginia. Battery E, 2d Colored Light Artillery.......... Detachment of the 20th Connecticut A'olunteers 28th Kentucky Mounted Infantry and 4th Michigan Cavalry, commanded by Colonel AV. P. Boone. llth Missouri Cavalrj-...... 2d and 6th Kansas Cavalry 34th Kentucky and 116th and 118th Indiana A'olunteers, llth Tennessee Cavalry, and llth Michigan Battery. Troops commanded by. Colonel A. O. Miller, 72d In- diana A'olunteers. Train on the (trange and Alexandria Railroad........ CONFED. LOSS. 20 10 15 10 30 30 100 REMARKS AND REFERENCES. Official. Official Report of Brigadier General J. C. Sullivan. Partizan Lite with Mosby, page 180. Report of Adjutant General of Massachusetts, 1864. page 295. Ohio in the War, Vol. 2, page 816. Official. Casualty List, File F, No. 234, S. G. O. Also designated Ivy Ford. Official. Official Report of Major General G. H. Thomas. Official Report of Major General G. H. Thomas. Official. Official. Report of Adjutant General of Kentucky, Vol. II. page 345. Official reports. Official Report of Major General G. H. Thomas. O W W o O f o Q i—i O- ►" f Jan. 27th. Jan. 27th.. Jan. 28th.. Jan. 28th.. Jan. 29th.. Jan. 29th.. Jan.---- Feb. 1 st, 2d and od. Feb. 1st.. Feb. 1st.. Feb. 1st to Mar. 8th. Feb. 3d.. Feb. 3d.. Feb. 3d to Mar. 5th. Feb. 4th.. Feb.'4th.. Feb. 4th.. Fair Gardens, near Seviersville, Ten- nessee. cott's Mills Road, near Knoxville, Ten- nessee. Tunnel Hill, Georgia Oregon Mountains..................... Medley, near Williamsport, West Vir- ginia. Cumberland Gap, Tennessee . Canon de Chelly............. Bachelor Creek, Newport Barracks, and New Berne, North Carolina. Smithfield, A'irginia.. Waldron, Arkansas................... New Creek Valley, AA'est Virginia..... Expedition up the Yazoo, Mississippi... Cavalry division, Army of the Ohio, commanded by Brigadier General S. D. Sturgis. 13th Kentucky and 23d Michigan Volunteers........... Rccennoisance of part of the Fourteenth Corps, Army of the Cumberland. 1st California Cavalry............................... 23d Illinois. 2d Maryland Potomac Home Brigado, and 1st and 14th AVest Virginia A'olunteers, and 4th West Virginia and Ringgold's (Pa.) Cavalry. Nationals, commanded by Colonel Kit Cars Lebanon, Alabama.................... Detachment from the Army of the Cumberland Liverpool Heights, Mississippi......... Patterson Creek, West Virginia........ Springfield, West Virginia............ Expedition from Vicksburg to Meridian, Mississippi. Rolling Prairie, Missouri. Hot Springs, Arkansas... 132d New A'ork, 9th A'ermont, 17th Massachusetts, and 2d North Carolina A'olunteers, 12th New York Cav- alrj-, and 3d New A'ork Artilleij-, commanded by Brigadier General I. AA'. Palmer. Detachments from the 3d Pennsylvania Artillery, 20th New York Cavalry, 99th New York and 21st Con- necticut A'oluntcers, and a detachment of seamen from the U. S. steamer Minnesota, on the gunboat " Smith Briggs." 2d Kansas Cavalry.................................. One company of infantry............................ llth Illinois, 47th U. S. Colored Troops (8th Louisiana), 3d U. S. Colored Cavalry (1st Mississippi), and a por- tion of Rear-Admiral Porter's fleet. llth Hlinois Volunteers and 47th U. S. Colored Troops (8th Louisiana). Champion Hills, Baker's Creek, Raj'- niond, and Bolton Depot, Mississippi. Moorefield, West Virginia. Clinton and Jackson, Mississippi. Cavalry, commanded by Lieut. Colonel Thompson--- A'ep.teh's and A. J. Smith's Divisions of the Sixteenth Corps, Hurlburt's: Legaett's, and Crocker's Divis- ions ofthe Seventeenth Corps MoPherson's; with the 5th and llth Illinois, 4th Iowa, 10th Missouri, and Foster's Ohio Battalion of Cavalrj'. 8th Missouri Militia Cavalry. 3d Missouri Cavalry......... 10th Missouri, 4th Iowa, 5th and llth Illinois, and Foster's Battalion Ohio Cavalrj-, and a portion ofthe Seventeenth Corps. Portion of the troops of the Department of West Vir- ginia, commanded by Colonel J. A. Mulligan, 23d Illinois Volunteers. Cavalry and a portion ofthe Seventeenth Corps, Major General Sherman's forces. lOOt 601 401 Official. Also designated French Broad and Kel- ly's Ford. Report of Adjutant General of Michigan, 1864, page 181. Official Report of Major General Geo. H. Thomas. List of casualties, File A, No. 451, S. G. O. The Nationals, commanded by Colonel J. AV. Snyder, were guarding a wagon train. Engagements with Indians; 23 killed and 150 wounded. Official reports, Union and Confederate. Casualty List, File A, No. 432, S. G.O. Appendix to Part I, Medical and Surgical History ofthe AA'ar, page 239. Official reports. Casualty List, File A, No. 414, S. G. O. Land forces commanded by Colonel J. H. Coates, llth Illinois. Official Report of Major Genera] G. H. Thomas. Ohio in the AVar, Vol. 2, page 294. Casualty List, File A, No. 414, S. G. O. See ex- pedition up the Yazoo, February 1 st. Official Report of Major General W. T. Sherman, commanding. Casualty List, File A, No. 414, S. G. O. Official. Official. See expedition to Meridian, Mississippi, Feb. 3d. Also designated Big Black River. See expedition to Meridian, February 3d. t Killed and wounded. Q Q W *=* i—i M Si w > U bd > H M W LOCALITY. UNION TROOPS ENGAGED. Qualltown, North Carolina. Cape Girardeau, Missouri.. Wyatt's, Mississippi....... Bolivar, Tenncsseo..... Morton's Ford, A'irginia . Barnett's Ford, Virginia. A'idalia, Louisiana...... Morton, Mississippi . Donaldsonville, Louisiana.............. 4th Wisconsin Cavalry Detachment of the 14th Illinois Cavalry, commanded by Major Davis. 2d Missouri Militia Cavalry. 114th Illinois Volunteers ... Detachment of the 7th Indiana Cavalry............ Reconnoissance by a part of the Second Corps, Army of the Potomac. 1st Division Cavalrj', Army of the Potomac, com- manded by Brigadier General Merritt. 6th IT. S. Heavy Artillery (2d Mississippi), 64th U. S. Colored Troops (7th Louisiana), and 30th Missouri A'olunteers. Cavalry of Major General Sherman's forces. Near Point Washington, Florida Morgan's Mills, Spring River, White County, Arkansas. Barber's Place, South Fork, St. Mary's River, Florida. Smith's raids from Germantown, Ten- nessee, co-operating with Sherman's expedition to Meridian. Rock House, Wayne County, West Virginia. Caddo Gap and Scott's Farm, Arkansas Lake City, Florida.................... Decatur, Mississippi......... Chunky Station, Mississippi Vicksburg, Mississippi...... Detachment ofthe 7th Vermont Volunteers, command- ed by Lieutenant Ross. Detachments of the llth Missouri and 1st Nebraska Cavalry, and 4th Arkansas Infantrj'. 40th Massachusetts Mounted Volunteers and Independ- ent Battalion Massachusetts Cavalrj', commanded by Colonel Guy V. Henry, 40th Massachusetts Mounted Volunteers. 4th Missouri, 2d New Jersey, 7th Indiana, 19th Penn- sylvania, 2d Iowa, 2d, 3d, 6th, 7th, aud 9th Illinois, 3d Tennessee, 4th U. S., and 5th Kentucky Cavalrj', 72d Indiana Mounted Infantry, and other regiments composing Smith's and Grierson's Cavalry Divisions. 14th Kentucky Infantry, commanded by Col. Gallup. 2d Kansas Cavalry................................... 40th Massachusetts Volunteers and Independent Bat- talion Massachusetts Cavalry, commanded by Col. Guy V. Henry. • One regiment of the Sixteenth Corps, guarding a wagon train. 20th, 29th, 31st, 45th, and 124th Illinois Volunteers, Seventeenth Corps, commanded by General Force. 52d U. S. Colored Troops (2d Mississippi)............. UNION LOSS. 25 12 3 201 201 CONFED. LOSS. 12 100 50 REMARKS AND REFERENCES. Official Report of Major General Grant. Also known as Deep Creek. Major General A'auce, of the Confederate armj-, captured. Report of Adjutant General of Illinois, A'ol. II, page 516. Casualty List, S. G. O. Casualty Return, S. G. O. Official. See expedition to Meridian, Mississippi, February 3d. Report of Adjutant General of Vermont, 1864, page 189. Official Report of Lieutenant Colonel Stephens, llth Missouri Cavalry, commanding. Official Report of Brigadier General Seymour. Casualty List, S. G. O. Appendix to Part I, Medical and Surgical History of the AVar, p. 243. Official Report of Brigadier General AA'. S. Smith, commanding. Casualty List, S. G. O., File F, page 251. Official. Casualty List, S. G. O. Official Report of Brig. General F. Seymour, commanding. See Sherman's expedition to Meridian, Mississippi, February 3d. See Sherman's expedition to Meridian, Mississippi, February 3d. Official. a W w o % o M O Q M o GO d w ►o o Feb. 13th.. Feb. 14th.. Feb. 14th.. Feb. 14th.. Feb. 14th.. Feb. 14th and 15th. Feb. 16th. Feb. 17th.. Feb. 17th.. Feb. 19th.. Feb. 19th.. Feb. 20th.. Feb. 20th.. Feb. 20th. Feb. 21st. Feb. 22d. Feb. 22d. Feb. 22d. Feb. 22d. Feb. 22d. Feb. 22d. Feb. 22d. Feb. 22d. Tunnel Hill, Mississippi. Ross Landing, Grand Lake, Arkansas.. Meridian, Mississippi................... Gainesville, Florida............. Brentsville, A'irginia............ Waterproof, Louisiana.......... Lauderdale Springs, Mississippi Marion, Mississippi............. Loss of the Housatonic in Charleston Harbor, South Carolina. Grosse Tete Bayou, Louisiana......... AVaugh's Farm, near Batesville, Inde- pendence County, Arkansas. Holston River, Tennessee Olustee, Florida......... Prairie Station, Mississippi....... AVest Point, Mississippi.......... Powel's River Bridge, Tennessee. Cavalrj- advance of Major General Sherman's forces, commanded by Colonel E. F. AVinslow, 4th Iowa Cavahy. 51st U. S. Colored Troops (1st Mississippi)___ Occupied by Major General Sherman's forces. 40th Massachusetts Volunteers, commanded by Captain G. E. Marshall. 13th Pennsylvania Cavalry, commanded by Major J. II. Larrimer, 5th Pennsylvania Reserves. 49th IT. S. Colored Troops (llth Louisiana) and the gunboat Forest Rose. 32d AVisconsin Volunteers and an Indiana regiment... Portion of the Seventeenth Corps.................... 4th Wisconsin Cavalry. llth Missouri Cavalry and 4th Arkansas Infantry, commanded by Captain Wm. Castle, llth Missouri Cavalrj-. 4th Tennessee Volunteers............................ 47th, 48th, and 115th New York, 7th Connecticut, 7th New Hampshire, and 40th Massachusetts Volunteers, 1st Massachusetts Cavalry, 54th Massachusetts Col- ored Troops, 1st North Carolina Colored Troops, 8th U. S. Colored Troops, 1st and 3d U. S. Artillery, and 3d Rhode Island Artillerj-. Cumberland Gap, Tennessee......... Mulberry Gap, Tennessee............ Okalona and Mount IvjT, Mississippi .. Drainesville, Virginia................ Luna Landing, Arkansas.............. Willmarsh Island, South Carolina ___ Johnson's Mills, White County, Tenn.. Two companies of the 34th Kentucky Infantry. One company of the 91st Indiana Volunteers... 9th Tennessee Cavalry....................... Brigadier Generals W. S. Smith's and B. F. Grierson's Cavalrj' Divisions. Detachment of the 2d Massachusetts Cavalry, com- manded bj' Captain J. S. Reed. 1st Mississippi Marine Brigade (Missouri Volunteers) . 85th Pennsylvania and 4th New Hampshire Volunteers Detachment o the 5th Tennessee Cavalry............ 131 100 7 5 4 1 400 See Sherman's expedition to Meridian, Mississippi, February 3d. Report of Adjutant General of j Iowa, 1864, page 966. See Sherman's expedition to Meridian, Mississippi, February 3d. Official Report of Brigadier General F. Seymour, commanding. See Sherman's expedition to Meridian, Mississippi, February 3d. See Sherman's expedition to Meridian, Mississippi, February 3d. Official Report of Rear-Admiral J. A. Dahlgren. Report of Adjutant General of Wisconsin, 1865, page 635. Official. Report of Adjutant General of Tennessee, 1865, page 98. Appendix to Part I, Medical and Surgical History of the War, page 243. Casualty List, S. G. O. Official Report of Brigadier General F. Seymour, commanding. Also designated Ocean Pond and Silver Lake. See Smith's raid in Mississippi, February 10th. See Smith's raid in Mississippi, February 10th. Report of Adjutant General of Kentucky, Vol. II, page 345. Report of Adjutant General of Indiana, Vol. in, page 117. Confederate statements. Also known as Wj-er- man's Mills. Smith's raid in Mississippi, February 1st, 1864. Also designated Ivy Hills. Report of Adjutant General of Massaohusetts, 1864, page 946. Partizan Life with Mosby, page 203. Report of Adjutant General of Tennessee, 1866, p. 442. Prisoners killed by Champ Ferguson's guerillas. * Killed, wounded, and missing, t Killed and wounded. Q > Q W M CO O W >■ DATE 1864. Feb. 27th and 28th. Feb. 25th to 27th. Feb. 28th to Mar. 4th. Feb. 28th. Feb. 28th.. Feb. 29th. Feb 29th.. Mar. 1st... Alar. 1st... Mar. 1st... Mar. 2d... Mar. 2d... Mar. 3d... Mar. 4th... Mar. 5th... Mar. 5th... Mar. 5th... Mar. 6th... Mar. 7th... Mar. 9th... Mar. 10th.. LOCALITY. Calf Killer Creek, Tennessee. Near Cunton, Mississippi..... Buzzard Roost and Tunnel Hill, Rocky Face Ridge, Georgia. Kilpatrick's raid from Stevensburg to Richmond, A'irginia. Dukedom, Kentucky............... Near Yazoo City, Mississippi....... New Berne, North Carolina........ Taylorsville, South Anna River, A'a. Stanardsville and Burton's Ford, Rapid- an, A'irginia. Brooks' Turnpike, Richmond fortifica- tions, Virginia. Atlees, Bidnella Cross Roads, A'irginia. Near AYalkertown, Virginia........... Harrisonburg, Louisiana............... Tunstall Station, Virginia........ Rodnej-, Mississippi.............. Panther Spri ngs, Tennessee...... Yazoo City, Mississippi........... Coleman's, Mississippi. Flint Creek, Arkansas. Decatur, Alabama--- Suffolk, Virginia--- Cabletown, Virginia. UNION TROOPS ENGAGED. 5th Tennessee Cavalrj- Foraging detachments, one of the 3d Iowa and another of the 32d Iowa A'olunteers. Fourth and Fourteenth Corps and Cavalry Corps, Army of the Cumberland. Division of cavalry, Army of the Potomac. 7th Tennessee Cavalry................... 3d U. S. Colored Cavalry (1st Mississippi). 6th New A'ork Cavalry . 1st. 2d, 5th, and 6th U. S., 6th Pennsylvania, 1st New A'ork, and 1st New Jcrsej' Cavalrj', commanded by Brigadier General Custer. Cavalry of the Army of the Potomac.................. Cavalry of the Army of the Potomac . 2d New York Cavalry, commanded by Colonel Ulric Dahlgicn. Mississippi squadron, commanded by Rear-Admiral Porter. 7th Michigan and 1st Vermont Cavalry............... Cavalrj- and infantry of the Mississippi Marine Brigade. One company of the 3d Tennessee................... 3d IT. S. Colored Cavalry (1st Mississippi), 47th IT. S. Colored Troops (8th Louisiana), and the llth Illinois A'olunteers, commanded bj' Colonel J. H. Coates, 9th Illinois A'olunteers. Mississippi Marine Brigade. I4th Kansas Cavalry....... Troops of the Armj- of the Tennessee, commanded by Brigadier General Dodge. 2d U. S. Colored Cavalry, commanded by Colonel G. W. Cole. 1st New York A'eteran Cavalrj-........................ UNION LOSS. 6 272 89 20 300" 30 Q CONFED. LOSS. 25 35 120 25 300" REMARKS AND REFERENCES. Report of Adjutant General of Tennessee, 1865, page 442. Report of Adjutant General of Iowa, 1864. Casualty List, S. G. O. Official Report of Major General G. H. Thomas, commanding. Appen- dix to Part I, Medical and Surgical History of the AVar, page, 297. Casualty List. S. G. O. Appendix to Part I, Med- ical aiid Surgical Historj-of the AA'ar, page 79. Official. See expedition up the Yazoo, Feb. 1st. See Kilpatrick's raid, February 28th. Casualty List, S. G. O. See Kilpatrick's raid, February 28th, 1864. See Kilpatrick's raid, February 28th, 1864. See Kilpatrick's raid, February 28th, 1864. Col. Dahlgren killed. See Kilpatrick's raid, February 28th, 1864. Official. Casualty List, File A, No. 414, S. G. O. See ex- pedition up the Yazoo. Official. Official. Official. Partizan Life with Mosby, page 206. Mar. 13th.. Mar. 14th.. Mar. 14th.. Mar. 15th.. Mar. 16th.. Mar. 17th.. Mar. 18th.. Mar. 18th.. Mar. 20th.. Mar. 21st.. Mar. 24th. Mar. 25th. Mar. 26th. Mar. 28th. Mar. 28th. Mar. 29th. Mar. 30th. Mar. 30th. Mar. 31st. Mar. 31st.. April 1st.. April 1st.. Carrolton Store, Virginia........ Cheek's Cross Roads, Tennessee. Fort De Rusr.y, Louisiana....... Clarendon, Arkansas... Fort Pillow, Tennessee. Manchester, Tennessee. Monticello, Arkansas......... Calf Killer River, Tennessee. Bersheba Springs. Tennessee. Henderson Hills, Louisiana... Union City, Kentucky.............. Fort Anderson, Paducah, Kcntuckj-. Longview, Arkansas............... Danville, Arkansas___ Arkadelphia, Arkansas. Charleston, Illinois. Bolivar, Tennessee............ Mount Elba, Arkansas........ Grosse Tete Baj'ou, Louisiana. Natchitoches, Louisiana....... Roach's Plantation, neai^Snydersville, Mississippi. Near the Rappahannock, A'irginia...... Fitzhugh's Woods, Augusta, Arkansas. 1st New York Mounted Rifles and llth Pennsj-lvania Cavalrj-. Cavalry, commanded by Colonel Israel Garrard, 7th Ohio Cavalrj-. Detachments of tho Sixteenth and Seventeenth Army Corps, coniinanded by Brig. General A. J. Smith, and .Mississippi squadron, commanded by Rear- Admiral Porter. 6th Missouri Cavalry. 5th Tennessee Cavalrj', commanded by Colonel AV. B. Stokes. rth Missouri Cavalry. 5th Tennessee Cavalry, commanded by Colonel AV. B. Stokes. 5th Tennessee Cavaby, commanded bj' Captains Black- burn and Waters. Detachment of the Kith Corps and Cavalry of the 19th Corps, commanded by Brigadier General .Mower. 7th Tennessee Cavalry, commanded by Lieutenant Colonel J. R. Hawkins. 16th Kentucky CNvalry, 122d Illinois Infantry, and 8th U. R. Colored Heavy Artillery (1st Kentucky), com- manded by Colonel S. G. Hicks, 401b Illinois. 5th Kansas and 7th Missouri Cavalry, and 28th Wiscon- sin A'olunteers, commanded bj- Col. Powell Clayton. 2d Kansas Cavalry.................................. Advance cavalry, Seventh Corps, Major General Fred. Steele, commanding. Portion of the 54th Illinois Volunteers, commanded by Colonel G. M. Mitchell. 6th Tennessee Cavalry. 7th Missouri and 5th Kansas Cavalry, and 28th Wiscon- sin A'olunteers, commanded by Col. Powell Clayton. Detachment of the 118th Illinois Volunteers. Cavalry of the 19th Coips, commanded by Brigadier General A. L. Lee. 3d U. S. Colored Cavalry (1st Mississippi)......... Patrol of the 1st Connecticut Cavalry............. 3d Minnesota Volunteers and 8th Missouri Cavalry. * Killed, wounded, and missin Official. Casualty List, File A, No. 425, S. G. O Official. Report of Adjutant General of Tennessee, 1866, page 442. Report of Adjutant General of Tennessee, 1865, page 442. Casualty List, S. G. O. Official Report of Major General N. P. Banks, commanding Red River expedition. Also designated Baj-ou Rapides. Official Report of N. B. Forrest, commanding Confederates. Post captured. Official Report of N. B. Forrest, commanding. Brigadier General A. P. Thompson, C. S. A., was killed. Official. Report of Adjutant General of Hlinois, Vol. II, page 76. The regiment, while re assembling from veteran furlough, was attacked by a mob of Cop- perheads. Report of Adjutant General of Tennessee, 1866, page 475. Casualty Return, S. G. O. Report of Adjutant General of Wisconsin, 1865, page 429. Report of Adjutant General of Illinois, Vol. II, page 545. Official Report of Major General N. P. Banks, com- manding Red River expedition. Official Also designated Brook's Plantation. Casu- alty Return, S. G. O. Report of Adjutant General of Connecticut, 1864, page 409. Official Report of Colonel C. C. Andrews, 3d Minne- sota Volunteers, commanding. DATE. 1864. LOCALITY. April 2d.. April 2d.. April 2d.. April 2d.. April '2d.. April 3d.. April 4th.. April 4th to 6th. April 5th.. April 5th.. Antoine, Arkansas. Spoonville, Terre Noire Creek, Arkansas Crump's Hill, Louisiana. Cleveland, Tennessee. Pensacola, Florida___ Okalona, Arkansas. Campti, Louisiana. Elkin's Ford, Little Missouri Arkansas. Roseville, Arkansas. Stone's Farm, Arkansas. April 6th. April 7th. April 7th.. April 7th.. April 8th.. April 8th.. April 8th.. Quicksand Creek, Kentucky. Wilson's Farm, Louisiana... Harnej' Lake Valley, Oregon.......... Plains' Store, near Port Hudson, Louisi- ana. Pembescott Bayou, near Osceola, Arkan- sas. Wolf River, Tennessee....... Sabine Cross Roads, Louisiana. UNION TROOPS ENGAGED. 13th Illinois and 1st Iowa Cavalry. 29th Iowa, 50th Indiana, and 9th Wisconsin Volunteers, and 1st Missouri Cavalry, commanded by Brigadier General Rice. 14th New A'ork, 2d Louisiana, 2d Illinois, and 16th Mis- souri Cavalry, and 5th U. S. Colored Artillery, com- manded by Brigadier General A. L. Lee. 1st AVisconsin Cavalry............................... One company of the 14th New York Cavalry, com- manded by Captain Schmidt. 1st Missouri and 13th Illinois Cavalrj-, and 27th Wiscon- sin, 40th Iowa, 77th Ohio, and 43d'llIinois Volunteers, of the 1st and 3d Divisions. Seventh Corps, com- manded by Colonel A. Engleman, 43d Illinois. 2d and 18th New York and 3d Rhode Island Cavalry, 35th Iowa and 5th Minnesota Volunteers, commanded by Col. O. 1'. Gooding, OtU Massachusetts Cavalry. 43d Indiana, 29th and 36th Iowa Volunteers, Battery E, 2d Missouri Light Artillery, and 1st Iowa Cavalrj',— 2d Brigade, 3d Division, Seventh Corps. Seventy-five men of the 2d and 6th Kansas Cavalry... Twenty-six men of the 6th Kansas Cavalry, com- manded bj- Lieutenant McKibben. Co. I, 14th Kentucky Volunteers, commanded by Capt. Reuben Patrick. Advance Cavalrj- of Nineteenth Corps, commanded by Brigadier General A. L. Lee. 1st Oregon Cavalry................................. Detachment of 118th Hlinois and 21st New York Bat- tery, and 3d Illinois Cavalry. Battery I, 2d Missouri Light Artillery.............___ Cavalry commanded by Brig. Gen. B. H. Grierson.... Cavalry Division, commanded by Brigadier General A. L. Lee ; 3d and 4th Divisions, Thirteenth Corps, com- manded by Brigadier General Ransom; 1st Division, Nineteenth Corps, commanded by Brigadier General W. H. Emory,—Army of the Department of the Gulf, Major General N. P. Banks, commanding. UNION LOSS. CONFED. LOSS. i 5 •6 at •a e a o feb a r3 *d o M •6 O) •d a 3 o si a S3 REMARKS AND REFERENCES. Engagement during Steele's expedition co-opera-ting with Banks. Engagement during Steele's expedition co-opera-ting with Genera) Banks' Red River expedition. Casualty List, (5. G- O. Official report of Major General Banks, command-ing Red River expedition. Also designated ! Piney Woods. j Official. i Engagement during Steele's expedition co-opera-ting- with General Banks' Red River expedition. Casualty List, S. G. O. Official Report of Major General N. P. Banks, com-manding Red River expedition. Engagement during Steele's campaign in Arkansas. Official Report of Colonel W. E. McLean, 43d Indiana, commanding. Official. Engagement with guerrillas. Official. Eleven of the detachment, including Assistant Surgeon S. A. Fairchilds, were taken prisoners and killed by guerrillas. Unofficial. Casualty List, S. G. O. Official Report of Major General N. P. Banks, commanding Red River expedition. Official. Report of Adjutant General of Illinois, Vol. II, page 545 Official. Casualty List, File A, No. 279, S. G. O. Appendix to Part I, Medical and Surgical History of the War, page 335. Also designated Mansfield and Pleasant. Grove. Among the casualties in the Confederate army were Major Gen. A. Mouton and Brigadier General M. M. Parsons, killed. In the Union army, Major General Franklin and Brigadier General Ransom were wounded. 10 35 20 loot 25 60 12 10 16 10 5 19 11 3 74 18 33 11 10 11 6 11 3 18 15 12 30 25 10 15 7 40 3 100 14 39 9 3 6 1 4 4 7 8 900 2 2 200 1,800 300 1,200 April 9th.. Pleasant Hills, Louisiana. Prairie D'Ann, Arkansas Little Cacapon, Virginia. Fort Pillow, Tennessee . Fremont's Orchard, near Denver, Colo- rado Territory. Pleasant Hill Landing, Louisiana...... Indian Baj', Arkansas................. Florence, Alabama.................... Cleveland, Tennessee................. Moscow, Arkansas.................... Paintsville, Kentucky................. Smithfield, Virginia................... Half Mount, Magoffin County Kentucky Dutch Mills, Arkansas................ Bristoe Station, Virginia............... Liberty Post Office, Arkansas.......... Occupation of Camden, Arkansas...... King's River, Carroll County, Arkansas Scullyville, Indian Territory.......... Plymouth, North Carolina............. Cavalry Division, commanded by Brigadier General A. L. Lee j 1st and 3d Divisions, Sixteenth Corps, commanded by Brigadier General A. J. Smith ; and Ist Division, Nineteenth Corps, commauded by Major General Franklin. 1st Arkansas, 18th, 29th, :13d, 3(i(h, and40th Iowa, 50th Indiana, 43d Illinois, 27th AA'isconsin, and 12th Kan- sas A'olunteers; 2d and 3d Missouri, 13th Illinois, 2d, (ith, and 14th Kansas, and 1st Iowu Cavalry, and Battery A, 3d Illinois and 2d Indiana Artillery,—3d Division, Seventh Corps. Co. K, 54th Pennsylvania Volunteers.................. llth IT! S. Colored Troops (also designated 6th U. S. Colored Heavy Artilleiy and 1st Alabama), Battery F, 2d U. S. Colored Light Artillerj', and Bradford's Battalion of 13th Tennessee Cavalrj',—about 60U men. Two companies of the 1st Colorado Cavalry........... Ironclads Osage and Lexington, of the Mississippi squadron, Rear-Admiral Porter commanding, and troops of the Seventeenth Corps on transports, T. Kilbj' Smith, commanding. 56th U. S. Colored Troops (3d Arkansas)............. Detachment of the 9th Ohio Cavalry.................. 1st Wisconsin Cavalry................■-.............. 18th Iowa A'olunteers, 2d Indiana Battery, and 6th Kansas Cavalrj-,—rear-guard of the 3d Division of the Seventh Corps. Kentucky Volunteers, commanded by Colonel G. W. Gallup, Mth Kentucky. 9th New Jersey, 23d and 25th Massachusetts, and 118th New York Volunteers. Kentucky Volunteers, commanded bj- Colonel G. W. Gallup, 14th Kentucky. 6th Kansas Cavalry.................................. 13th Pennsylvania Cavalry........................... 29th Iowa, 50th Indiana and 9th AVisconsin Volunteers,— advance of the 3d Division, Seventh Corps. Advance of the Seventh Corps. 2d Arkansas Cavalry......... 3d Kansas Indian Home Guards. 85th New York, 103d Pennsylvania, and 16th Connecti- cut Volunteers, commanded by Brigadier General II. W. Wessells, assisted by the Navy under Lieut. Commander Flusser. 350 700 1,500 1,200 200 f Casualty List, File A, No. 279, 8. G. O. Official Report of Major General N. P. Banks, command- ing Army of the Red Kiver expedition. Appen- dix to Part I, Medical and Surgical History of the War, page 335. Report of Adjutant General of Iowa, 1864, p. 1261. Official reports. Casualty List, S. G. O. An en- gagement during Steele s campaign in Arkansas, co-operating with Banks' Red River expedition. Casualty List, S. G. O. Official Report of the U. S. Senate investigating committee. Official Report of Major General N. B. Forrest, commanding Confederates. Official Report of Major General N. P. Banks, com- manding- Red River expedition. Also desig- nated Blair s Landing. The Confederate Gen. Thomas Green was killed. Official. Ohio in the War, Vol. 2, page 811. Official. Casualty List, S.G. O. Engagement during Steele's campaign in Arkansas. Report of Adjutant General of Kentucky, Vol. II, page 425. Report of Adjutant General of Massachusetts, 1864, page 646. Also designated Cherry Grove. Report of Adjutant General of Kentucky, Vol. II, page 425. Skirmish during Steele's campaign in Arkansas. Skirmish during Steele's Arkansas campaign. Re- port of Adjutant General of Iowa, 1864, p. 1189. Casualty List. S. G. O., File A, 619. General F. Steele's forces, co-operating with Major General Banks' Red River expedition. Report of Adjutant General of Arkansas. Official Report of Major General John J. Peck. In- cludes the engagements at Forts Gray, AVessels, and Williams. Lieutenant Commander C. W. Flusser, U. S. N., was killed. Killed, wounded, and missing, t Killed and weunded. Q Q M CO b bd > H f LOCALITY Decatur, Alabama. Poison Springs, eight miles from Cam- den, Arkansas. Boykcn's Mills, South Carolina . Pound Gap, Kentucky......... Natchitoches, Louisiana........ AA'atcrproof, Louisiana................ Cotton Plant, Cache River, Arkansas... Red Bone, Mississippi................. Near Tunica Bend, Red River, La..... Swan Lake, Arkansas................. Moneti's Bluff, Cane River, Louisiana. April 23d Cloutcrsville, Louisiana. and 24th. Nickajack Trace, Georgia. Jaeksonport, Arkansas....... Red River, Louisiana........ AVautauga Bridge, Tonncssoo Marks' Mills, Arkansas. Moro Creek, Arkansas . Alexandria, Louisiana . Offett's Knob, Missouri. Princeton, Arkansas--- Snia Hills, Missouri. UNION TROOPS ENGAGED. 25th AA'isconsin A'oluntcers........................... Forage train, guarded by the 18th Iowa Volunteers; 79th U. S. Colored Troops (2d Kansas), and 6th Kansas Cavalrj', Col. J. M. AA'illiams, commanding. 54th Massachusetts U. S. Colored Troops.............. 45th Kentucky Volunteers............................ 4th Brigade, Cavalrj- Division, Nineteenth Corps...... 63d U. S. Colored Troops (9th Louisiana)............. 8th Missouri Cavalrj-................................, 2d Wisconsin Cavalry................................ Three companies of the 3d Rhode Island Cavalry, on transports. 5th Kansas Cavalry.................................. Cavalry Division and 3d Britrade, 1st Division of the Nineteenth Corps, and 3d Division, Thirteenth Corps, commanded bj' Brigadier General H. W. Birge. Portion of the Thirteenth, Seventeenth, and Nineteenth Corps, commanded by Brig-. General T. K. Smith. Detachment ofthe 92d Illinois Volunteers, commanded by Captain Scovill. 1st Nebraska Cavalrj'................................ U. S. gunboats Cricket and Fort Hindman............. 10th Michigan Cavalrj' of the Twenty-third Corps..... 36th Iowa, 77th Ohio, and 43d Indiana Volunteers; Battery E, 2d Missouri Light Artillerj', and 1st Indi- ana and 7th Missouri Cavalry,—escort to a wagon train. 33d and 40th Iowa A'olunteers, and 5th Kansas, 2d and 4th Missouri, and 1st Iowa Cavalrj-. 14th New York and 6th Missouri Cavalry............, 1st Missouri Militia Cavalry......................... 40th Iowa and 43d Illinois Volunteers, 3d Illinois Bat- tery, and 6th Kansas Cavalry. 2d Colorado Cavalry............................--- UNION LOSS. CONFED. LOSS. 3 100 160 1501 9 250 14 3 100 20 110 228 400 * REMARKS AND REFERENCES. Report of Adjutant General of AVisconsin, 1865, page 381. Official. Engagement during- Steele's campaign in Arkansas. Casualty List, S. G. O. Engagement during Banks' Red River expedition. Official. Official. Official. Report of Adjutant General of Rhode Island, 1805, page 463. Official. Casualty List, File A, Nos. 279 and 419, S. G. O. Official Report of Major General N. I'. Banks, commanding Red River expedition. Official. Engagement during the Red River ex- pedition. Appendix to Part I, Medical and Sur- gical History of the AVar, page 336. Report of Adjutant General of Illinois. Vol. II, page 551. "Of the men taken prisoners, 12 were shot down and 6 died of wounds." Official. Official Report of Rear-Admiral Porter. Casualty List, S. G. O. Also designated Carter's Station. Official Report of Lieut. Colonel Drake, 36th Iowa, commanding. Engagement during Steele's cam- paign in Arkansas. Official. Engagement during Steele's campaign in Arkansas. Casualty List, File A, No. 279, S. G. O. Skirmish during the Red River expedition. Official. Official Report of Colonel A. Engelmann, 43d Illi- nois A'olunteers. commanding. Official. 3 < to o o t-l o o M Q t> go d > o April 30th. May 1st... Ma j- 1st... May 1st to 4th. May 1st... May 1st to 8th. May 2d.... May 2d.... May 3d.... May 3d.... May 3d..., Jenkins' Ferry, Saline River, Arkansas. Jacksonville, Florida.........-•- Hudnot's Plantation, Louisiana . Ashwood Landing, Louisiana. Clinton, Louisiana Near Alexandria, Louisiana . Memphis, Tennessee.................. Governor Moore's Plantation, Louisiana. Cedar Bluffs, Colorado Territory Bolivar, Tennessee............. 77th Ohio, 4th, 18th, 29th, 33d, 36th, and 40th Iowa, 1st Arkansas, l"Jth Kansas, 9th and 27th AVisconsin, and 43d Illinois A'olunteers; 79th (1st Kansas) and 83d (2d Kansas) U. S. Colored Troops; Battery A, 3d Illinois and 2d Indiana Battery; and 1st Iowa, 2d, (ith and 14th Kansas, 1st and 2d Missouri, and 13th Illinois Cavalry,—composing 3d Division of the Seventh Corps. 7th U. S. Colored Troops....... Cavalry of the Nineteenth Corpi 64th U. S. Colored Troops. Portions of the cavalry of the Thirteenth and Nine- teenth Corps. 7th Kansas Cavalry................................. Foraging expedition, composed ofthe 83d Ohio A'olun- teers and the 3d Rhode Island Cavalry, of Major General Banks'forces. Red Clay, Georgia. May 3d___ Baton Rouge, Louisi May 3d... Transport City Belle, near Snaggy Point, Red River, Louisiana. May 3d.. May 4th.. May 4th to" 13th. Richland, Arkansas................ Doubtful Ctnon, Arizona Territory. Yazoo City expedition, Mississippi..... One company of ths 1st Colorado Cavalry...... Cavalry, commanded by General S. D. Sturgis. 1st Division Cavalry, McCook's, Army of the Cum- berland. 4th AA'isconsin Cavalry............................. 120th Ohio Volunteers and 73d U. S. Colored Troops. 2d Arkansas Cavalry............................. Detachment of the 5th California Volunteers and 1st California Cavalry. 3d U. S. Colored Cavalry, llth, 72d, and 76th Illinois A'olunteers, 5th Illinois Cavalrj', and 7th Ohio Bat- tery, Brigadier General McArthur, commanding. 4th Kautz's cavalry raid from Suffolk to City 5th and llth Pennsj-lvania, 3d New York, and 1st to 12th ! Point, Virginia. " District of Columbia Cavalry, and 8th New York Battery, Cavalry Division, Army of the James. May 5th... May 5th... May 5th... Mav 5th... Ram Albemarle, Roanoke River, North Carolina. Dunn's Bayou, Red River, Louisiana .. U. S. gunboats Ceres, Commodore Hull. Mattabesett, Sassacus, Seymour, AVyalusing, Miami, and White- head, commanded by Captain Melanchthon Smith. U. S. steamer Covington, gunboat Signal, and trans- port AVarner, with the 56th Ohio Volunteers on board. Wall Bridge, Virginia.................. Cavalry Division, Army of the James, Brig. General Kautz. Craig's Meeting House, A'irginia. sion Cavalry, Wilson's, Army of the Potomac. * Killed, wounded, and missing 200 1 10 5 955 300 800 1 20 2 20 i 23 1 2 1 67 21 25 100 70 10 1 10* 225 20 1 5 6 20 1 10 20 5 35 26 65 57 150 10* ........ 10 50 Casualty List, S. G. O. Engagement during Steele's campaign in Arkansas, co-operating with Ranks' Red River expedition. In this engage- ment Brigadier General S. A. Rice, U. S. V., was mortally wounded. Official. Report of Adjutant General of Massachusetts, 1864, page 749. Official. Ohio in the War, Vol. 2, page 270. Engagement during the return of Major General Banks' Red River expedition. Official. Ohio in the War, A'ol. 2. page 482. Report of Ad- jutant General of Rhode Island, 1865, page 463. Report of Adjutant General of Missouri, 1864, page 182. Official. Official Report of Major General N. P. Banks. Ohio in the War, Vol. 2, page 617. Report of Adjutant General of Arkansas. Official Report of Lieutenant H. H. Stevens, 5th California, commanding. Casualty Lists, S. G. O. See Benton, May 7th, and A'aughn, May 12th. Official reports. See AA'all's Bridge, May 5th, Stoney Creek Station. May 7th, Jarrett's Station and White's Bridge, May 9th. Official Report of Acting Rear-Admiral S. P. Lee. Official Report of Major General N. P. Banks. See Kautz's cavalry raid, May 4th to 12th. Casualty List. S. G. O. Included in the Wilder- ness. May 5th to 7th. i Killed and wounded. Q fcl CO > U bd P> f DATE. 1864. LOCALITV. May 5th : AA'ilderness, A'irginia___ to 7th. May 5th to 9th. Rocky Face Ridge, Georgia. May (ith. May (ith. May 7th. May (ith and 7th. James River, near City Point, Virgini Princeton, AA'est A'irginia............ Benton, Mississippi.................. Richmond and Petersburg Railroad, near Port AA'althal and Chester Station, A'a. May 7th... Baj-ou La Mourie, Louisiana May 7th... Tunnel Hill. Georgia........ May 7th... UNION TROOPS ENGAGED. Second Corps, Major General W. S. Hancock; Fifth Corps, Major General G. K. AVarren ; Sixth Corps, Major General John Sedgwick ; Ninth Corps, .Major General A. E. Burnside ; and Cavalry Corps. Major General P. H. Shei idan. — Army of the I'otomac. Major General G. G. Meade. Fourth Corps, Major General O. O. Howard; Four- teenth Corps, Major General J. M. Palmer; Twen- tieth Corps, Major General J. Hooker,—Army of the Cumberland, Major General G. H. Thomas: Fif- teenth Corps, Major General J. A. Logan; Sixteenth Corps, Major General C. C. Dodge.—Army ofthe Tennessee, Major General J. B. McPherson; and Twenty-third Corps, Army of the Ohio, .Major Gen. J.M. Schoiield;—Army of the Military Division of the Mississippi, .Major General AA'. T. Sherman. UNION LOSS. CONFED. LOSS. 3,288 2, 309 9,278 12, 185 Gunboat Commodore Jones............ Advance of General Crook's command. llth, 72d, and 76th Illinois A'olunteers, and 7th Ohio Batteiy, commanded by General McArthur. Portion of the Tenth and Eighteenth Corps, Army of the James, Major General B. F. Butler, commanding. Portion of the Sixteenth Corps........................ Fourth Corps, Major General O. O. Howard, and Cav- alry, Army of the Cumberland, Major Gen. Thomas. Mill Creek and Dug Gaps,- Georgia.....; Twentieth Corps. Major General Joseph Hooker, Ar of the Cumberland, Major General Thomas. May 7th... Stoney Creek Station, AA'eldon Railroad. A'irginia. May 8th. ..J Todd's Tavern, A'irginia .. May 8th. to" 18th. Spottsjlvania Court-House, A'irginia... 5th and llth Pennsylvania, 3d New A'ork, and 1st Dis- trict Columbia Cavalrj-, and 8th New York Batterj-, commanded by Brigadier General A. V. Kautz. 2d Division, Cavalry Corps, Brigadier General Gregg, Armj- of the Potomac. Second Corps, Major General AA'. S. Hancock; Fifth Corps, Major General G. K. Warren; Sixth Corps, Major General H. G. AVright; Ninth Corps, Major General A. E. Burnside; and Cavalrj-Corps, Major General P. II. Sheridan,—Army of the I'otomac, Major General G. G. Meade. 40 2,146 2,031 256 31 150 7, 956 11,731 6, 784 3, 893 ,000 6, 00(1 3, 400 REMARKS AND REFERENCE Official Report of Lieutenant General U. S. Grant. Casualty List, S. G. O. Appendix to Part I, Medical and Surgical History ofthe AVar. p. 149. Among the casualties in (Ik; Union army were Brigadier Generals James S. AA'adsworth, Alex. Hays, and A. S.Webb, killed, and Brig. Generals Getty and Carroll, wounded; in the Confeder- ate armj-, Generals J. M. Jones and Pickett, killed, aiid Generals Longstreet, Pegram, Staf- ord, Hunter, and Jennings, wounded. Includes the engagements at Tunnel Hill, Mill Creek Gap, Buzzard Roost. Snake Creek Gap, and near Dalton. Official Report of Major Gen. AV. T. Sherman, IT. S. A'., and Lieut. General J. E. Johnston, C. S. A. Casualty List, S. G. (). Appendix to Part I, Medical and Surgical His- tory of the AA'ar, page 299. 50 5,000 . Official report. Report of Adjutant General of Illinois, A'ol. II, pages 210 and 236. Casualty List, S. G. O. Official reports. 50* I Engagement during the return of Banks' Red River expedition. See Rooky Face Ridge, May 5th to 9th. See Rocky Face Ridge, May 5th to 9th. See Kautz's raid, May 5th to 12th. 70 List of casualties, S. G. O. Included in Spottsjl- vania. 3, 000 Appendix to Part I, Medical and Surgical History of the AVar, page 149. Casualty List, S. G. (.). Includes the engagements on the Fredericksburg Road, Laurel Hill, and Ny River. Among the casualties in the Union army were Major Gen. J. Sedgwick, Brigadier Generals J. C. Rice, J. J. Owens, and T. G. Stevenson, killed; Brigadier Generals Robertson. Bartlett, Morris, and Bax- ter, wounded. Of the Confederates. Generals Daniels and Ferrin were killed, Hayes and AA'alker, wounded, and Major Gen. Ed. Johnson and Brigadier General G. H. Stewart, captured. d w o May 8th... May 8th... May 8th... May 9th... May 9th to* 13th. May 9th. May 9th. May 9th. May 9th. May 9th and 10th. May 9th and 10th. Mav 9th and 10th. May 9th.. May 10th.. May 10th.. May llth.. May llth.. May 12th. May 12th. May 12th to 16th. May 12th to 17th. Jeffersonville, A'irginia................ Buzzard Roost Gap, Georgia.......... Snake Crook Gap, Georgia............. Dal ton, Georgia...................... Sheridan's cavalrj-raid, A'irginia....... Jarrett's Station, AA'eldon Railroad. A'a.. AA'hite's Bridge, Nottaway Creek, A'a... A'arnell's Station, G eorgia............. Childsburg. A'irginia................... Swift Creek, A'irginia.................. Cloj'd's Mountain and New River Bridgi A'irginia. Cove Mountain, near AA'jthcville, A'a.. Beaver Dam Station, North Anna, A'a. Ground Squirrel Church and Bridge South Anna, Virginia. Dardanelle, Arkansas................ Ashland, A'irginia.................... s Yellow Tavern, near Richmond, A'a... Smith's Station, Indian Territorj-..... Vaughn, Mississippi.................. Fort Darling, Drury's Bluff, A'irginia.. Kautz's raid on the Petersburg and Lj-nchburg Railroad, A'irginia. Cavalry of the Army of AA'est A'irginia, Brigadier General A\\ AW Averill, commanding. Fourth Corps, Major General O. O. Howard, and Cav- alrj', Army ofthe Cumberland, Major Gen. Thomas. Fifteenth Corps, Major General John A. Logan, Army of the Tennessee,'Major General Mel'lierson. Twenty-third Corps, Army of the Ohio, Major Genera] Scho'field. 1st Division, Merritt's. and 2d Division. Gregg's, (lay- airy Corps, Major General Sheridan's, Arm.v of the I'otomac. llth Pennsylvania and 8th New A'ork Battery, com- manded hj- Colonel W. B. Spear. 3d New A'ork and 1st District Columbia Cavalrj', and 8th New York Battery, of the Army of the Jaines. 1st Division, McCook's, Cavalty ofthe Army ofthe Cumberland. 6th Ohio aud 1st New Jersey, holding the rear of the cavalrj- on Sheridan's raid. Tenth Corps. Major General Q. A. Gillmore. and Eight- eenth Corps. Major General AA'. F. Smith,—Army of the James, Major General B. F. Butler. 12th, 23d, 36th, and 34th Ohio, 9th, llth, 14th, and 15th AVest A'irginia A'olunteers. and 3d and 4th Pennsyl- vania Reserves, of the Army of AVest A'irginia. 14th Pennsylvania, 1st. 2d, and 3d AA'est A'irginia, and 34th Ohio Mounted A'olunteers. 1st Division, Merritt's, Cavalry Corps, Major General Sheridan, of the Armj' of the Potomac. 1st Division, Merritt's, Cavalry Corps, Major General Sheridan, of the Army of the Potomac. 6th Kansas Cavalry.................................. 1st Massachusetts Cavalrj' ofthe 2d Division, Gregg's, Cavalrj- Corps. 1st Division, Brig. General Mcrritt, and 3d Division. Brig. General AA'ilson, Cavalrj- Corps, Major General Sheridan, Armj- of the Potomac. 1st Nebraska Battalion Cavalry....... llth, 72d, and 76th Illinois A'oluntcers Tenth Corps, Major General Q. A. Gillmore, and Eighteenth Corps, Major General AV. F. Smith,— Armj- of A'irginia and North Carolina, Major General B. F*. Butler. Cavalrj- of the Army of the James, Brigadier General A. A''. Kautz. * Killed, wounded, and missing 28 7 t Killed und wounded. Also designated Abb's A'alley. See Rockj- Face Ridge, Maj- 5th to 9th. See Rocky Face Ridge, May 5th to 9th. ... See Rocky Face Ridge, May 5th to 9th. ..... Official reports. List of casualties, S. G. O. Ap- pendix to Parti, Medical and Surgical History I of the AA'ar, page 179. 40 i See Kautz's raid, May 5th to 12th. .....! See Kautz's raid, May 5th to 12th. ..... Ohio in the AA'ar. Casualty List. S. G. O. 500 . Casualty List, S. G. O. Official reports. Also known as Arrowfield Church. Official Report of Brigadier General George Crook. commanding. Casualty List, S. G. O. General A. G. Jenkins, commanding the Confederates. i was killed. Appendix to Part I. Medi-jal and Surgical Historj-of the AA'ar, page 227. Official Report of Brig. General AA'. AA*. Averill. commanding. Also designated Grassj- Lick. Casualty List, S. G. O. Engagement during Sher- idan's raid, May 9th to 13th. Casualty List. S. C. O. Engagement during Sher- idan's raid. -May 9th to 13th. Casualty List. S. G. < >. Engagement during Sher- idan's raid, Maj- 9th to 13th. Casualtj-List, S. G. O. Engagement during Sher- idan's cavalrj- raid. Major General J. E. B. Stuart, commanding the Confederate cavalrj-, was killed, and Major General J. B. Gordon, C. S. A., wounded. Official. Engagement during- Brigadier General McArthur' expedition to Yazoo Citj'. 100 Casualtj- List. S. G. O. Includes the engagements at AA'ierbottom Church, Proctor's, and Palmer's Creek. List of casualties, S. G. O. DATE. 1864. LOCALITY. UNION TROOPS ENGAGED. May 12th.. Meadow Bridge, Chickahominj- River, | A'irginia. May 13th to Kith. Resaca, Georgia Maj- 13th.. Pulaski, Tennessee...... May 13th.. Tilton, Tennessee....... Maj' 13th.. Point Lookout, A'irginia. May 14th to 16th. May 14th.. May 15th.. May 15th.. May 15th.. May 15th.. May 16th.. May 16th.. May 16th.. May 16th.. May 16th to 20th. May 16th., May 16th to'30th. Mansura, Louisiana. ftood's Hill, A'irginia. 1st Division, Merritt's, and 3d Division, AA'ilson's, Cav- alty Corps, Armj- of the Potomac. Fourth Corps, Major General Howard ; Fourteenth Corps, Major General Palmer; Twentieth Corps, Major General Hooker; and Cavalrj-,—Armj- of the Cumberland, Major General Thomas : Fifteenth Corps, .Major General Logan, and Sixteenth Corps, Major General Dodge,—Army of the Tennessee, Major General McPherson: Twentj'-third Corps, Armj- of the Ohio, Major General J. M. Schofield. lilth U. S. Colored Troops (3d Alabama) 1st Division. McCook's, Cavalry of the Armj- of the Cumberland. Detachment of the 36th U. S. Colored Troops and sea- men from the Potomac flotilla. 3d Division, Sixteenth Corps, portion of cavalrj- di- vision, Nineteenth Corps. Portion ofthe Army of AA'est A'irginia, commanded bj' Colonel A. Moore, 28th Ohio. Mount Pleasant Landing, Louisiana. New Market, Virginia..........,— Ley's Ferrj', Georgia................... Tanner's Bridge, near Rome, Georgia... Rome Cross Roads, Georgia............ Ashepoo River, South Carolina......... Pond Creek, Pike County, Kentucky--- Clear Creek, Missouri.................. Fredericksburg Road, Virginia......... 67th U. S. Colored Troops........................... Portion of the Army of AA'est A'irginia, under command of Major General F. Sigel. Portion of the Sixteenth Corps, Army of the Tennes- see. 2d Division Cavalry, Army of the Cumberland....... Sixteenth Corps, Major Gener.al Dodge, Army of the Tennessee, Major General McPherson. 34th U. S. Colored Troops.......................... 39th Kentucky A'oluntcers.......................... Two companies of the 15th Kansas Cavalrj'......... Tyler's Division, Fifth Corps, Army of the Potomac Smoky Hill, Colorado Territory........' One companj' of 1st Colorado Cavalry, and McLain's Colorado Batterj-. Bermuda Hundred, Virginia. Tenth Corps, Major General Q. A. Gillmore, and Eighteenth Corps, Major General AA'. F. Smith,— Army of the James, Major General B. F. Butler. UNION LOSS. CONFED. LOSS. 600 2,147 3 120 200 5 560 1,000 30" 1 240 85 1,500 1,000 50' 3,000* REMARKS AND REFERENCES. Casualtj- List, S. G. O. idan's cavalrj- raid. Engagement during Sher- Casualtv Lists. S. G. O. Appendix to Part I, Medi- cal and Surgical History of the AVar. page 299. Official Reports of General AV. T. Sherman, com- manding Union forces, and J. E. Johnston, com- manding Confederate forces. Also designated Sugar Valley and Oostcnaula. Among the casu- alties were Major General Kilpatrick, command- ing the 3d Cavalry Division, wounded, and Brig. General B. G. AVadkins, C. S. A., killed. Official. Included in Resaca, May 13th. Official Report of Commander F. A. Parker, U.S.N. Casualty List, File A, No. 279, S. G. O. Official Report of Major General N. P. Banks, command- ing Red River expedition. Also known as Avoy- elle's Prairie, Morreausvillc, and Murksvillo. Official reports. Official. Casualty List, File A, Nos. 181 and 326, S. G. O. Appendix to Parti, Medical and Surgical His- tory of the AVar, page 227. Casualty List, S. G. O. Included in Resaca, May 13th to 16th. Casualtj'List, S. G. O. Report of Adjutant Gen- eral of Michigan, 1864, page 76. Casualty List, S. G. O. Official. Report of Adjutant General of Kentucky. Official. Included in Spottsylvania, Maj- 8th. Official. Official Report of Major General Grant. Major General AA'alker, C.S.A., was severely wounded. O w W o o t-1 o 2 o ► May 16th.. May 17th and 18th. May 17th.. May 18th.. May 18th.. May 18th.. May 18th.. May 19th.. May 19th.. May 19th to 22d. May 20th.. May 20th.. May 21st... May 21st... May22d... May 23d to 27th. May 23d... May 24th.. May 24th.. May 24th.. May 24th.. Belcher's Mills, A'irginia.............. Adairsville, G eorgia.................. Madison Station, Alabama............ Rome, Georgia....................... Kingston, Georgia..................... Bayou De Glaize, Louisiana........... Crooked River, Oregon................ Faj-etteville, Arkansas................ Welaka aud Saunders, Florida......... Cassville, Georgia..................... Downer's Bridge, Virginia............. Milford Station, Virginia.............. Snia Hills, Missouri.................. Mount Pleasant, Mississippi............ Old River, Louisiana.................. North Anna River, Virginia............ Capture of steam-tug Columbine, at Horse Lauding, St. John's River, Florida. Hollj' Springs, Mississippi............. Kingston, Georgia..................... Wilson's AA'harf Landing, A'irginia...... Nashville, Tennessee................... 3d New York, 5th and llth Pennsylvania, and 1st Dis- trict Columbia Cavalrj-, of the Armj- ofthe James. Fourth Corps, Howard's, Armj- of Ihe Cumberland___ 3d Division, Fifteenth Corps, Armj- of the Tennessee., 2d Division, Davis's; Fourteenth Corps, Palmer's; and Cavalrj',—Armj' of the Cumberland. 2d Division Cavalrj', Armj' of the Cumberland....... 1st and 3d Division of the Sixteenth Corps, portion of the Seventeenth Corps, and Cavalrj- of the Ni..... teenth Corps, Major General A. J. .Smith, command- ing. 1st Oregon Cavalrj'.................................. 6th Kansas Cavalrj-.................................. Detachment of the 17th Connecticut A'olunteers....... Twentieth Corps, Major General Hooker, Army of the Cumberland. 5th New A'ork Cavalrj-, advance of the 1st Cavalry Division. 1st Division Cavalry, Army of the Potomac... -....... 2d Colorado Cavalry................................ 4th Missouri Cavalrj-................................. 6th Missouri Cavalrj-................................. Second Corps, Major General AV. S. Hancock; Fifth Corps, Major General G. K. AA'arren, and Ninth Corps, Major General A. E. Burnside,—Armj- of the Poto- mac, Major General G. G. Meade. 35th U. S. Colored Troops, and sailors on the Columbine. 4th Missouri Cavalrj-................................. 50th Ohio and 14th Kentuckj- A'olunteers, and 2d Kcn- tuckj- Cavalrj-. 1st District of Columbia and 10th U. S. Colored Troops, and Battery IS, U. S. Colored Artillery, commanded by Brigadier General E. A. AA'ild. 15th U. S. Colored Troops............................ * Killed, wounded, and missing 2,000 1001 Casualty List, File A. No. 139, S. G. O. Engage- ment during Kautz's raid on the Lynchburg Railroad. Casualty List, S.G. O. Official reports, Union and Confederate. Includes the engagements at the Graves House and Calhoun. Casualty Return, S. G. O. Ca-ualty List, S. G. O. Casualty List, S. G. O. Official Report of Major General N. P. Banks. Engagement during the return ofthe Red River expedition. Also known as Old Oaks, A'ellow Bayou, Simmsport, and Calhoun Station. Official. Official. Report of Adjutant General of Connecticut, 1865, page 329. Official Reports of Lieutenant General J. E. John- son, C. S. A., and Major Genera! AA'. T. Sherman, U. S. A. Casualtj- List, S. G. O. Official. Official. Casualty List, File A, No. 279, S. G. O. Also designated Jericho Ford and Taylor's Bridge. Casualtj- List. S. G. O. Appendix to Part I. Medical and Surgical History ofthe AA'ar, p. 158. Official report. Official. Ohio in the AA'ar, A'ol. 2, page 307. Official Report of Major General Benj. F. Butler. Casualtj- List, S. G. O. Official. t Killed and wounded. Q t> Q ts H CO td H H DATE. 1804. LOCALITY May 25th to J unc 4th. May 25th.. May 26th.. May 26th.. May 26tb.. May 27th.. Muv 26th and 27th. May 27th.. May 28th May 28th.. May 28th.. May 28th.. May 28th aud 29th, May 29th to 31st. May 30th. May 30th. May 30th. Dallas, (I core UNION TROOPS ENGAGED. Cassyille Station, Georgia Burned Church, Georgia Lane's Prairie, Morris County, Missouri-. Torpedo explosion on Bachelor's Creek, North Carolina. San Carlos River, California............ Decatur, Court-land Road, Alabama..... Ilanovei-ton, Panmnkey River, A'irginia. Hawcs Shop, Tolopotomy Creek, A'ir- ginia. Little Rock, Arkansas.......... Pleasant Hill, Missouri......... Jacksonville, Florida........... Moulton, Alabama............. Tolopotomy. A'irginia.......... Hanover Court-IIouse, A'irginia. Ashland, Virginia.............. Old Church, A'irginia........... Fourth Corps, Major General < 1. O. Howard; Fourteenth Corps, Major General J.M. Palmer; Twentieth Corps, Major General Joseph E. Hooker; and Cavalrj-.— Army ofthe Cumberland. Major General George H. Thomas: Twenty-third Corps, Army of the Ohio, Major Gen. .). M." Seholield ; Fifteenth Corps, Major General J. A. Logan; Sixteenth Corps, Major Gen, (!. M. Dodge, and Seventeenth Corps, Major General F. P. Blair, — Armj' of the Tennessee, Major General J. B. McPherson ;—Armj-of the Military Division of the Mississippi, Major General AA'. T. Sherman. 1st and llth Kentucky Cavalrj', guarding wagon train.. Cavalry of the 1st Division, McCook's, Army of the Cumberland. Two companies 2d AA'isconsin Cavalry............... 132d and 158th New York and 58th Pennsj-lvania A'ol- unteers. Companj- K, 5th California Infantrj-................... 1st, 3d, and 4th Ohio Cavalry, 2d Brigade, 2d Division. Cavalrj' Corps, and 3d Brigade, 4th Division, Six- teenth Corps, coniinanded by Colonel Eli Long. 1st Division, Torbctt's, and 2d Division, Gregg's,—Cav- alrj'Corps, Armj'of the Potomac, Major General P. Sheridan. 1st Division, Torbctt's, and 2d Division, Gregg's,—Cav- alrj- Corps, Major General P. 11. Sheridan, Armj- of the Potomac. 57th U. S. Colored Troops............................ 2d Colorado Cavalry......... ....................... 7th U. S. Colored Troops............................. 1st. 3d, and 4th Ohio Cavalrj'. 2d Cavalry Division, Armj- of the Cumberland, coniinanded by Colonel Eli Long. Second Corps. Hancock's, and Fifth Corps, AA'arren's, Armj' of the I'otomac. 3d Division, Wilson's, Cavalry Corps, Armj- of the Potomac. 3d Division, AA'ilson's, Cavalry Corps, Army of the Potomac. 1st Division, Torbctt's, Cavalrj- Corps, Army of the Potomac. UNION LOSS. CONFED. LOSS. feu .5 I 2,400* REMARKS AND REFERENCES. 30 100 30 74 3,000 Oflicial Report of Major General AV. T. Sherman U. S. A., and Lieutenant General J. E. Johnson C. S. A. Appendix to Part I, Medical and Sur gical History of the AA'ar, page 299. Also des ignated New Hope Church. Burned Hickory Pumpkin A'ine Creek, and Altoona Hills. Maj General 11. T. AA'alker, C. S. A., killed. 2 Official Report of Lieut. General Johnson, C. S. A. 47 | Adjutant General's Report, 1864, page 591. Casualty List, File A, No. 435. Official. Casualty List, S. G. O. 5 Official reports. Casualty List, S. G. O. 400" Casualtj- Lists, S. G. O. Official reports. Also designated Salem Church. Official. Official. Official. Casualty List, S. G. O. Casualty List, S. G. (). Losses included in North Anna, May 24th. Casualty List, S. G. (). Casualty List, S. G. O. Casualty List, S. G. O. H O o f o a i—i o > d o Cold Harbor. A'irginia. Bermuda Hundred, Virginia........... Engagements at Gaines's Mills, Salem Church, and Hawe's Shop, A'irginia.. Searcy, Arkansas..................... Panther Gap, AA'est A'irginia........... Ackworth, Georgia................... Buffalo Gap, AA'est A'irginia............ Piedmont, A'irginia.................... Lake Chicot, Arkansas. June 6th... Greenland Gap Road, near Moorefield, West A'irginia. Ripley, Mississippi.................... Point of Rocks, Maryland... Kenesaw Mountain, Georgia. Mount Sterling, Kentucky. Lafayette, Tennessee...... Frankfort, Kentucky...... Lexington, West Virginia. Second Corps, Major General AA'. S. Hancock; Fifth Corps, Major General O.K. AA'arren ; Sixth Corps, Major General H. G. Wright; Ninth Corps, Major General A. E. Burnside, and Cavalry Corps, Major General 1". II. Sheridan, — Army of the Potomac, and Eighteenth Corps, Major General Smith, Army of the James. Tenth Corps, Major General Q. A. Gillmore, ofthe Army of A'irginia and North Carolina, .Major General B. F. Butler. Cavalry of the Armj' of the Potomac____ Detachment of the 8th Missouri Cavalry. General Hayes' Brigade of the 2d Division, Crook's, of the Army of AA'est A'irginia. Cavalry of the 2d Division, McCook's, Army of the Cumberland. General Hayes' Brigade of the 2d Division, Crook's, of the Army of AA'est A'irginia. Cavalrj- and Infantry of the Armj- of AA'est A'irginia, commanded by Major General David Hunter Sixteenth Corps, commanded by Major General A. J. Smith. 22d Pennsylvania Cavalry. Cavalry advance of Major General S. D. Sturgis' com- mand. 2dU. S. Colored Cavalry............................. Fourth Corps, Major General O. O. Howard; Fourteenth Corps, Major General J. M. Palmer; and Twentieth Corps, Major General Joseph E. Hooker,—Armj- of (he Cumberland.. Major General George H. Thomas : Fifteenth Corps, Major General John A. Logan ; Six- teenth Corps, Major Gen. G. M. Dodge; and Seven- teenth Corps, Major General F. P. Blair,—Army of the Tennessee, Major General James B. McPherson : Twenty-third Corps, Army ofthe Ohio, Major Gen. J. M. Schofield :—Army of the Military Division of the Mississippi, commanded by Major General AA'. T. Sherman. Cavalry of the Division of Kentucky, commanded by General Burbridge. 7th Kansas Cavalrj'............................... Enrolled Kentucky Militia and citizens............. 2d Division, Crook's, Army of AA'est A'irginia, Major General David Hunter. Killed, wounded, and missin 1,905 10, 570 100 2,450 1,200 500 100 2 25* 25* 130 40 650 70 12 70 460 1,450 1,060 100* 1,370 35 1 i 6,500 150 800 50 1,10 t 200 3,500 250 3 18 5 6 Appendix to Part I, Medical and Surgical History of the AVar, page 150. Official Report of Major General U. S. Grant. Casualty List, S. O. O. Among the casualties was Brigadier Generals G. E. Doles and Keitt, C. >S. A., and Brookes and Byrnes, U. S. V., killed. Brig. Generals Tj'ler, Stannard, and Johnson, U. S. V., and Kirkland, Finnegan, Law, and Lane, C. S. A., wounded. Casualty List, S. G. O. Included in Cold Harbor, June 1st to 12th. Ohio in the War, Vol. 2, pages 224 and 507. Report of Adjutant General of AVisconsin, 1865, page 591. Ohio in the AVar, A'ol. 2, page 224. Official Report of Major General IT. S. Grant. Casu- alty List, File A, No. 609, S. G. O. Appendix to Part I, Medical and Surgical History of the War, page 228. Also known as Mount Crawford. Gen. W. E. Jones, commanding confederate forces, killed. Casualty List, File A, No. 419, S. G. O. Official reports. Also designated Old River Lake, Ditch Bayou, Columbia and Fish Bayou. Casualty Return, S. G. O. Engagement during expedition to Guntown, Miss., June 5th to 10th Official. Casualty List, S. G. O. Appendix to Part I, Medi- cal and Surgical History of the AA'ar. page 299. Also designated Lost Mountain, Nose's Creek, Marietta, and Big Shantj-. Includes the engage- ments at Pine Mountain, June 14th ; Pine Knob, June 19th ; Golgotha, June 16th; Gulp's House, June 22d; and the general assault, June 27th; the cavalrj' engagements at McAfee Cross Roads, Lattemore's Mills, June 20th, and Powder Springs, June 20th. Among the casualties were Lieut. General Polk. O. 8. A, and Brigadier Gen. C. G. Harkcr and McCook, U. S. A'., killed. Casualty List, S.G.O. Attack on Morgan's raiders. Morgan's raid. t Killed and wounded. Q t> Q W H CO > a bd i-3 DATE. 1864. June 10th.. June 10th.. June 10th.. June 10th.. June 10th.. LOCALITY Cane Creek, Alabama. Lexington, Kentucky . Princeton, Kcntuckj'. Petersburg, Virginia. Brice's Cross Roads sissippi. near Guntown, Mis- June 10th. June 10th. June 10th. June 10th and llth. June llth.. June llth.. June llth. June llth and 12th. June 12th.. June 12th.. June 13th.. June 13th.. June 14th.. June 14th.. June 14 th.. Corinth, Mississippi ... Cynthiana, Kentucky. Kellar's Bridge, Licking River, Kentucky Old Church, Virginia................... Wilson's Landing, Virginia. Cynthiana, Kentucky...... Riplcj', Mississippi. Trevillian Station, Central Railroad, A'ir- ginia. McAfee's Cross Roads, Georgia. Kingsville, Missouri............ AA'hite Oak Swamp Bridge, Charles City Cross Roads, A'irginia................. White Post, West Virginia............. Pine Mountain, Georgia................ Lexington, La Fayette County, Missouri. Buchanan, near Lexington, Virginia--- UNION TROOPS ENGAGED. 106th Ohio Volunteers. 4th Kentucky Cavalry. Cavalry, Brigadier General A. V. Kautz, and portion of the Tenth Corps, Major General Q. A. Gillmore, of the Army of the James. 4th Missouri, 2d New Jersey, 19th Pennsylvania, 7th and 9th Illinois, 7th Indiana, 3d and 4th Iowa, and 10th Kansas Cavalry, Brigadier Gen. B. H. Grierson; 9th Minnesota. 81st, 95th, 108th, 113th, 114th, and 120th Illinois, 72d and 95th Ohio, and 93d Indiana A'olunteers ; 1st Illinois, (ith Indiana, and Co. E, 2d Illi- nois Batteries ; 59th (1st Tennessee) and 55th (1st Ala- bama), U. S. Colored Troops, and Battery F, 2d U. S. Colored Artillery. 2d New Jersey Cavalry... 168th Ohio (100 days' men) 171st Ohio (100 days' men), commanded by Brigadier General Hobson. 3d Division, Wilson's, Cavalry Corps, Army of the Potomac. 1st U. S. Colored Cavalry............................ Cavalry of the Division of Kentucky, commanded by General Burbridge. 3d and 4th Iowa, 2d New Jersey, and 4th Missouri Cav- alry. 1st Division, Merritt's, and 2d Division, Gregg's, Cav- alry Corps, Major General Philip Sheridan,—Army of the Potomac. Cavalry of the Army of the Cumberland......... Scouting party of the 1st Missouri Militia Cavalry. 3d Division, Wilson's, Cavalry Corps, and 2d Division, Crawford's, Fifth Corps,—Army of the Potomac. 6th West Virginia Cavalry.......................... Detachment of the 1st Missouri Militia Cavalry. Advance of the Army of West Virginia........ UNION LOSS. 223 394 1,623 85 12 50 280 700 150' 160 CONFED. LOSS. 131 475 300 t 400 370 REMARKS AND REFERENCES. Skirmish with guerrillas. Ohio in the AA'ar, A'ol. 2, page 575. Casualty List, S. G. O. Engagement during Mor- gan's raid. Casualty List, S. G. O. Official reports. Official Report of Major General S. D. Sturgis commanding. Engagement during the Guntown expedition. Captured by Morgan's raiders. Ohio iu the AA'ar, Vol. 2, page 698. Captured by Morgan's raiders. Ohio in the AA'ar, Vol. 2, page 701. Casualty List, S. G. O. Included in Cold Harbor. Casualty List, S. G. O. Attacks on Morgan's raiders. Report of Adjutant General of Iowa, 1864, page 952. Official Report of Major General S. D. Sturgis. Casualty List, S. G. O. Official reports. Brigadier General Rosser, C. S. A., wounded. Included in Kenesaw Mountain, June 9th to 30th. Report of Adjutant General of Missouri, 1865, page 448. Casualty List, S. G O. Also designated Riddle's Shop. See Kenesaw Mountain, June 9th to 30th. Report of Adjutant General of Missouri, 1865, page 448. Major General Hunter, commanding. Q W w o o t-" o Q i-t a l> tr< d K o *1 June 15th.. Samaria Church, Malvern Hill, A'irginia. Moscow, Tennessee.................... Bajlor's Farm, A'irginia................ Siege of Petersburg, A'irginia........... 3d Division, AA'ilson's, Cavalrj- Corps, Armj' of the ! 25 I'otomac. 55th U. S. Colored Troops (1st Alabama)............. 3d Division, blinks', Tenth Corps, Armj'of the James. Petersburg, A'irginia. Tenth Corps, Major General 0. A. Gillmore ; Eighteenth Corps, Major'General AV. V. Smith,—Army of the .Tames, Miijur General B. F. Butler : Second Corps, Major General AV. S. Hancock; Fifth Corps, Major General G. K. AA'arrcn ; Sixth Corps. Major General II. G. AV right; and Ninth Corps. Maj. General A. E. Burnside,—Armj' of the I'otomac, Major General G. G. Meade. June 16th.. AA'est Point, Arkansas.............. June 16th.. Otter Creek, near Liberty, A'irginia. AVier Bottom Church, A'irginia...... Golgotha, Georgia................. AA'althal, Virginia........ Pierson's Farm, Virginia. Nose's Creek, Georgia--- Lynchburg, Virginia..... 9th Iowa Cavalry..................................... Advance ofthe Armj- of AA'est Virginia, Major General D. Hunter. 2d Division, Foster's, Tenth Corps, Army ofthe James. Twentieth Corps..................................... 1st Division, Terry's, Tenth Corps, Army of the James. 36th U. S. Colored Troops............................ 1st Division, Sullivan's, 2d Division, Crook's, and Aver- ill's and Duffle's Cavalrj-,—Armj- of AA'est Virginia, commanded bj' Major General D. Hunter. Pine Knob, Georgia. Kearsarge and Alabama, off Cherbourg, France. White House, Virginia................ Liberty, A'irginia........ Powder Spring, Georgia. U. S. steamer Kearsarge . Brigade oi Union troops, commanded by Brigadier General Abercrombie. 2d Division, Averill's, Cavalry, Army of West Va. Cavalry of the Army of the Cumberland.......... Lattemore's Mills, Noonday Creek, Ga. Trenches in front of Petersburg........ Salem, Virginia...... Pine Bluff, Arkansas. Naval engagement on the James River, near Dutch Gap. AA'hite House Landing, Virginia Buford's Gap, Virginia......... Cavalry of the Army of the Cumberland.............. Fifth and Ninth Corps, Army of the Potomac, and Tenth and Eighteenth Corps, Armj- of the James. Averill's Cavalry, 2d Division, Army of West Va. 27th Wisconsin.................................. Portion of the 1st and 2d Divisions, Cavalry Corps, Army of the Potomac. 23d Ohio Volunteers, of the Army of West Virginia... * Killed, wounded, and missing, 1,298 7,474 15 lOt Casualty List, S. G. O. Official. See Petersburg, June 15th to 19th. Appendix to Part I, Medical and Surgical History of the AVar, page 1(14. Casualty List,, S. G. O. Official Report of Major General U. S. Grant. Includes the engagements at Baj-lor's Farm, June 15th; AA'althal and AA'ier Bottom Church, June 16th. .... Official. i;5 j Report of Adjutant General of AA'est A'irginia. See Petersburg, June 15th to 19th. Casualty List, S. G. 0. Included in Kenesaw Mountain. See Petersburg, June 15th to 19th. Official. Included in Kenesaw Mountain, June 9th to 30th. Casualty List, File A, No. 324, S. G. O. Included in Kenesaw Mountain, June 9th to 30th. Official Report of Captain John A. Winslow, U. S. Navy, commanding the Kearsarge. Included in Kenesaw Mountain, June 9th to 30th. Included in Kenesaw Mountain, June 9th to 30th. Official Report of Lieutenant General U. S. Grant. Appendix to Part I, Medical and Surgical His- tory of the AA'ar, page 164. Generals Chamber- lain and Egan, U. S. V., wounded. Casualty List, S. G. O. Appendix to Part I. Med- ical and Surgical Historj- of the AA'ar, p. 180. o > Q H M > b bd > »-3 i-3 t Killed and wounded. DATE. 1864. June 22(1.. June 22d to .'.Oth. June 22d. June 22d.. June 22d and 23d. June 23d.. June 23d.. June 23d.. June 24th.. June 24th.. LOCALITY. AA'hitc River, Arkansas. AA'ilson's raid on the AA'eldon Railroad, A'irginia. Gulp's House, Georgia....... Ream's Station, A'irginia..... AA'eldon Railroad, Virginia--- Nottoway Court-House, A'irginia. Colliersville, Mississippi......... Jones' Bridge, A'irginia.......... Samaria Church, A'irginia. June 24th. June 25th.. June 25th to S. 9th. June 27th.. AA'hitc River, Arkansas............... Staunton Bridge, A'irginia............. La Fajette, Macon Countj', Tennessee.. Point Pleasant, Louisiana............. Clarendon, St. Charles River, Arkansas. Kenesaw Mountain (general assault)... Juno 27th.. Charlestown, AA'est Virginia. June 28th.. j Stoney Creek, A'irginia...... June 29th.. Ream's Station, A'irginia--- UNION TROOPS ENGAGED. Three companies of the 12th Iowa, and U. S. steamer Lexington. Cavalry of the Army of the James, Brigadier General A. A'. Kautz, and 3d Cavalry Division, Army of the Potomac, Major General AA'iison, commanding. Kautz's Cavalrj', Army of the James, 3d Division, Cav- alry, Army of the Potomac, Major General AVilson. Second Corps, Birney, Sixth Corps, AA'right, and the 1st Division, Gibbons, of the Fifth Corps,—Army of the Potomac, Major General George G. Meade. 3d Cavalry Divison, Wilson's, Army of the Potomac.. Train on the Charlestown and Mississippi Railroad___ 1st. Division, Torbctt's, and 2d Division, Gregg's, Cav- alry Corps. Army of the Potomac, and 28th U. S. Colored Troops. 1st Division, Torbctt's. and 2d Division, Gregg's, Cav- alrj- Corps, Armj- of the Potomac. U. S. steamer Queen City and gunboats.............. 3d Division, AA'ilson's, Cavalrj- Corps, Armj- of the Potomac, and Kautz's Cavalrj-, Armj- of the James. UNION LOSS. 40 64th U.S. Colored Troops............................ llth Missouri, Oth Iowa, and 3d Michigan Cavalrj-. J26th Illinois A'olunteers, and Battery D, 2d Missouri Artillery. Fourth Corps, Major General O.O. Howard; Fourteenth Corps. Major General J. M. Palmer; Twentieth Corps. Major Gen. Joseph E. Hooker, and Cavalrj-,—Arinj' ofthe Cumberland. Major General Geo. H. Thomas ; Fifteenth Corps. Major General John A.Logan; Six- teenth Corps, Major Gen. G. M. Dodge; and Seven- teenth Corps. Major General F. P. Blair,—Armj' of the Tennessee. Major General James B. McPherson : Twenty-third Corps, and Cavalry,—Armj' of the Ohio, Major General J. M. Schofiel'd. 1st Division, Army of West A'irginia.................. Cavalrj', Army ofthe James, Kautz's. and 3d Division, Cavalry, AA'ilson's, Army of the Potomac. Cavalrj'. Armj' ofthe James, Kautz's, and 3d Division, Cavalrj-, AA'ilson's, Army of the Potomac. 4 265 52 190 40 3,000t 2 700 5 100 200 CONFED. LOSS. 15 3 3001 50 200j 200 6001 200 REMARKS AND REFERENCES. Report of Adjutant General of Iowa. 1864. p. 1079. Official Report of Ensign 11. Booby, U. S. N. Casualty Lists, S.G.O. Appendix to Part I, Med- ical and Surgical History of the AVar, page 104. Included in Kenesaw Mountain, June 9th to 30th. Casualty List, S. G. O. AA'ilson's raid, June 22d to 30th. Also designated AA'illiams' Farm, Davis' Farm, and Jerusalem Plank Road. Official Report of Lieut. General U. S. Grant. Casualty List. S.G.O. Appendix to Medical and Surgical Historj' of the AA'ar, page 104. 200 Casualty List, S. G. O. AA'ilson's raid . don Railroad, June 22d to 30th. the AA'el- Army and Navj- Journal, A'ol. I, page 786. Casualty List, S. G. O. Appendix to Part I, Med- ical and Surgical History of the AVar, page 180. Casualty List, S. G. < >. Appendix to Part I, Med- ical and Surgical Historj' of the AA'ar, page 180. Army and Navy Journal, Vol. I, page 786. Casualty List, S. G. O. AA'ilson's raid on the AA'el- don Railroad, June 22d to 30th. Report of Adjutant General of Iowa, 1867, A'ol. II, page 561. Also known as Pikesville and Saint Charles. Casualty Lists. S. G. O. Appendix to Part I, Med- ical and Surgical Historj' of the AA'ar, page 301. Included in Kenesaw Mountain. June 9th to 30th. Generals Harker and McCook, U. S. A"., killed. Casualty List, S. G. O. Casualty List. S. G. O. See AA'ilson's raid on the AA'eldon Railroad, June 22d to 30th. Casualty List. S. G. O. Sec AYilson's raid on the AA'eldon Railroad, June 22d to 30th. O W W o o o Q i—i a > en d > Pi Kj O La Faj-ette, Geoif Juh- 1st Front of Petersburg, A'irginia. to 31st. Pine 1311111, Arkansas.. Saulsburj-, Mississippi. Juiy 2d... July 2d... July 2d... July 2d to 5th. July 3d... July 3d... July 3d to 9th. July 3d... Fort Johnson, James'Island, South Caro- lina. Nickajack Creek, G eorgia............. Platte City, Missouri...... North Mountain, A'irginia . Expedition from Vicksburg to Jackson, Mississippi. Leetown, Virginia___ July 3d... Hammack's Mills, NorthRiver, West A'a July 4th... j Searcj-, Arkat sas...... July 4th... Vicksburg, Mississippi. July 4th... Clay County, Missouri-. July 4th... July 4th.. Clinton, Mississippi. Point of Rocks, Maryland. July 4th i Coleman's Plantation, near Port Gibson, and 5th. I Mississippi. July 5th Smith's expedition from La Grange, Tennessee, to Tupelo, Mississippi. John's Island, South Carolina.......... Hagerstown, Pleasant Valley, Maryland Jackson, Mississippi................... to 18th. July 5th to 7th. July 5th.. July 5th and 6th. July 6th. July 6th. July 4th to 7th. Little Blue, Missouri......... Mount Zion Church, Virginia. Bolivar and Maryland Heights, Virginia. 4th and 6th Kentucky Cavalry....................... Second, Fifth, and Ninth Corps, Armj' ofthe Potomac. Major Gen. G. (!. Meade, and Tenth and Eighteenth Corps, Army of the James, -Major Gen. 1!. !•'. Under. 64th U. S. Colored Troops........................... 3d Iowa Cavalrj-..................................... Troops of the Department of the South............... Armj- of the Cumberland, Alajor General George II. Thomas; Army of the Tennessee, Major General J. B. McPherson,—Grand Army of the Mississippi, Major General AA'. T. Sherman. 9th Missouri Militia Cavalry...........'............... Outpost of the 135th Ohio National Guards, of Sigel's command. Troops of the 1st Division, Seventeenth Corps, com- manded by Major General Dennis. 1st New A'ork Cavalrj- and 10th West A'irginia Volun- teers, commanded bj- Major General Sigel. 153d Ohio National Guards........................... Detachment of the 3d Arkansas Cavalry.............. 48th U. S. Colored Troops (10th Louisiana)............ 9th Missouri Militia Cavalrj-.......................... 2d AA'isconsin Cavalrj-, advance of the 1st Division, Seventeenth Corps, commanded by Major General Dennis. Marj'land Potomac Home Brigade.................... 52d U. S. Colored Troops (2d Mississippi) and Missis- sippi Marine Brigade. 1st and 3d Divisions, Sixteenth Corps, Major General J. A. Mower; Cavalry Brigade, Brig. General B. H. Grierson; and one brigade U. S. Colored Troops. Troops of the Department of the South, Major General Foster. 1st Marjland Cavalrj-, Potomac Home Brigade, com- manded hj- Major Cole. 2d Wisconsin, 5th and llth Illinois, and 3d IT. S. Col- ored Cavalry, and 46th, 76th, and 79th Illinois Volun- teers, of the 1st Division, Seventeenth Corps. 2d Colorado Cavalrj'................................ 2d Massachusetts Cavalry............................ Reserve Division ofthe Army of West Virginia, Major General Sigel, commanding. * Killed, wounded, and missinf A Report of Adjutant General of Kentucky, Vol. I page 41,5. The losses at the crater. July 30th, and Deep Bot- tom, July 27th, not included. Casualty Lists, S. G. O. Official. Report of Adjutant General of Iowa, 1864, p. 955. Casualty Return, S. G. O. Appendix to Part I, Medical and Surgical Historj' of the AA'ar, page 30L. Casualty List, S. G. O. Official reports. Also known as Smyrna and A'ining Station. Official. Ohio in the War, A'ol. 2, page 664. The Confederate General Gholson was wounded. Casualty List, File A, No. 429, S. G. O. Ohio in the AA'ar, A'ol. 2, page 684. Official Report of Major General Steele. Official. Official. Engagement during Dennis's expedition to Jackson, Mississippi. Casualty List, File A, No. 429, S. G. O. Official. Official Report of Major General A. J. Smith, com- manding expedition. Casualty Lists, S. G. O. Official. - Casualty List, File A, No. 429, S. G. O. Engagement during the return of Major General Dennis's expedition from A'icksburg to Jackson, Mississippi. Partizan Life with Mosbj-, page 24y. Report of Adjutant General of Massachusetts. Casualty List, File A, No. 429, S. G. O. DATE. 1864. July Oth to" 10th. July 7th.. July 7th.. July 7th.. July 7th.. July 9th.. July llth to 22d. July llth. July 12th. July 12th. July 12th.. July 13th to" 15th. July 14th Ozark, Missouri. and 15th July 14th.. j Ten Islands, Coosa River, Alabama. July Mth..j Farr's Mills, Montgomery County, Ark.. July 15th..! Stone's Ferry, Tallapoosa River, Ala--- LOCALITY. Chattahoochie River, Georgia.......... Hngar's Mountain and Middleton, Marj-- land. Clinton, Mississippi.................... Solomon's G tip, Frederick City, Maryland. Riplej-, Mississippi.................... Monocacj-, Maryland................... Rosseau's raid in Alabama and Georgia... Pontotoc, Mississippi................... Fort Stevens, Washington, D. C........ Petit Jean, Arkansas River, Arkansas..- Lee's Mills, near Ream's Station. Va___ Tupelo, Mississippi.................... July Kith and 17th. Grand Gulf, Port Gibson, Mississippi. July 17th.. 1 Snicker's Gap, A'irginia............. UNION TROOPS ENGAGED. Army of the Ohio. Major Gen. J. M. Schofield ; Army of'the Tennessee, Major General J. B. McPherson; Armj' of the Cumberland, Major General George H. Thomas,—Armj- of the Military Division of the Mississippi, Major General AA'. T. Sherman. 8th Illinois Cavalrj' and Alexander's Baltimore Batterj'. llth Illinois and 2d AA'isconsin Cavalry, and Batteiy of the 2d Illinois Artillery. 8th Illinois Cavalrj', 3d Marj-land Potomac Home Bri- gade, and Alexander's Baltimore Batterj-. 2d Iowa Cavalrj-..................................... 1st and 2d Brigades of the 3d Division, Sixth Corps. Major General J. B. Ricketts, and detachment of the Eight Corps, Brigadier General E. B. Tyler. 8th Indiana, 5th Iowa, 9th Ohio, 2d Kentucky, and 4th Tennessee Cavalry, and Batterj- E, 1st Michigan Artillery. 8th AA'isconsin, 5th Minnesota, and llth Missouri A'ol- unteers. and 2d Iowa Cavalrj-, of Major General A. J. Smith's forces. 1st rfnd 2d Divisions. Sixth Corps, Twenty-second Corps, convalescents, Marines, Home Guards, and citizens, commanded bj- Major General Augur. One company of the 3d Arkansas Cavalry............. 2d Division, Gregg's, Cavalry Corps, Army of the Potomac. 1st and 3d Divisions, Sixteenth Corps, Major General J. A. Mower; Cavalry, Brigadier General B. H. Grierson; and a Brigade of Colored Troops, Major General A. J. Smith, commanding. 14th Kansas Cavalry.....................-........ 8th Indiana and 5th Iowa Cavalry. A battalion of the 4th Arkansas Cavalry. 72d and 76th Illinois A'olunteers, 2d AA'isconsin Cavalrj-, and 53d U. S. Colored Troops, of the Seventeenth Corps, Major General Slocum. Army of AA'est Virginia, Major General Crook...... UNION LOSS. CONFED. LOSS. 80 54 85 20 579 1,290 319 400 563 REMARKS AND REFERENCES. Casualty Lists. S. G. O. Appendix to Part I. Medi- cal and Surgical History ofthe \A"ar, page 301. Official reports. Official Report of Colonel Clendcnin. 500* 25" 22 Engagement during the return of Dennis's expedi- tion from Vicksburg to Jackson, Mississippi. Official Report of Major General Lew AA'allaco. Report of Adjutant General of Iowa, 1864, p. 933. Engagement during Smith's expedition to Tupelo, July 5th to 18th. Casualty List, File A, No. 603, S. G. O. Official Report of Major General Lew AVallace, com- manding. Casualtj- List, S. G. O. Includes engagements at Ten Islands, July 14th; Stone's Ferry, 15th; | Auburn, 18th ; and Chewa Station, 20th. Engagement during Smith's expedition to Tupelo. July 5th to 18th. Casualty Return, File F, No. 106, S. G. O. Official Report of Major General F. Steele. Casualty List, S. G. O. Casualty List, File A, No. 202, S. G. O. Official reports. Includes the engagements at Harrisburg, July 13th, and Old Town Creek, July 15th. Oflicial. Also designated Jackson's Ford. Engagement during- Rosseau's raid, July llth to 22d. Official Report of Major General F. Steele. Engagement during Rosseau's raid in Alabama and Georgia, Julj- llth to 22d. Report of Adjutant General of Illinois, A'ol. II, page 210. O W w o o f o Q M a > t-1 d > Pi «1 O July 17th.. July 18th.. July 18th.. July 18th.. July 18th.. Fredericksburg, Missouri Auburn, Georgia....... Chewa Station, Montgomery and AA'est Point Railroad, Georgia. Snicker's Ferry, Island Ford, Shenan- doah River, A'irginia. Ashby's Gap, Virgini July 19th.. Darksville, A'irginia. Jiuy 20th.. AA'inchcster, A'irginia. July 20th.. Peach-Tree Creek, Georgia July 21st. July 21st. July22d.. 2d Colorado Cavalry............................, 9th Ohio and 4th Tennessee Cavalrj'............... 8th Indiana, 5th Iowa, and 4th Tenuessoe Cavalry Deep Bottom, A'irginia.............. Henderson, Kentucky............... Atlanta, Georgia (Hood's first sortie) Armj- of AA'est A'irginia, Major General Crook, and a portion of the Sixth Corps, Major General Wright. Cavalry ofthe Armj' of AA'est A'irginia, Brigadier Gen. Duffle. Portion of the Armj- of AA'est A'irginia, coniinanded by General Averill. 2d Cavalry Division, Army of AA'est A'irginia, com- manded by Brigadier General Averill. Fourth Corps, MajorGeneral O. O. Howard; Fourteenth Corps, Major General .1. M. Palmer; and Twentieth Corps', Major General Joseph E. Hooker.-Army of the Cumberland, Major General George If. Thomas, of the Army of the .Military Division of the Missis- sippi, MajorGeneral AA'. T. Sherman. 1st Division, Tenth Corps, Army of the James....... July 22d... A'idalia, Louisiana . I July22d..J Decatur, Georgia .. July23d... Kernstown, Virginia . July 24th.. Winchester, Virginia. July 24th.. Steamer Clara Bell, Carrolton Landing, Caroline Bend, Mississiiipi. July 25th..' Courtland, Alabama.................. luly 26th.. Wallace's Ferry, Big Creek, Arkansas . July 26th. July 26th to' 31st. July 26th to 31st. Fifteenth Corps, Major General Logan; Sixteenth Corps, Major General Dodge; and Seventeenth Corps, Major General Blair,—Armj- of the Tennes- see. Major General McPherson, ofthe Army ofthe Military Division of the Mississippi, Major General AV. T. 'Sherman. 6th U. S. Colored Heavy Artillerj' (2d Mississippi)... 2d Brigade, 4th Division, Sixteenth Corps, Army of the Tennessee, Colonel Sprague, commanding. Cavaby of the Armj- of West A'irginia.............. Portion of the Army of AA'est Virginia, commanded by General Crook. 6th Michigan Artillery. 18th Michigan and 32d Wisconsin Volunteers. Des Arc, Arkansas................ Stoneman's raid to Macon, Georgia. McCook's raid to Lovejoy Station, Ga... July 26'h.. St. Mary's Trestle, Florida . 15th Illinois Cavalry, Co.E. 2d IT. S. Colored Artillery, and tiuth (1st Iowa) and 56th (3d Arkansas) U.S. Colored Troops, commanded bj' Colonel AA'. S. Brooks, 56th II. S. Colored Troops". llth Missouri Cavalry............................... Stoneman's and G Army of the Cun nrard's Cavalrj' Divisions of the l.erlaiid. 1st AA'isconsin, 5th and 8th Iowa, 2d and 8th Indiana, 1st and 4th Tennessee, and 4th Kentucky Cavalry. 75th Ohio Mounted Infantry 100 200" 1,410 2,141 Engagement during Rosseau's raid in Alabama and Georgia, July llth to 22d. Engagement during Rosseau's raid in Alabama and Georgia, July llth to 22d. Official reports. Casualtj- Returns, S. G. O. 200 Casualty List. S. G. O. General Dilly. C. S. A. was wounded. Also designated Stevenson': Depot and Carter's Farm. 2,500 1,183 1,000 2,482 4,000 Casualty List, S. G. O. Appendix to Part I, Medi eal and Surgical History of the AA'ar, page 301 Official Reports of Generals Sherman and John- ston. Brigadier Generals \A'. S. Featherstone A. L. Long. J. J. Pettis, and G. M. Stevens C. S. A., were killed. Official reports. Casualty Returns, S. G. O. Official Report of Major General AA'. T. Sherman. Appendix to Part 1. Medical and Surgical His- tory of the AA'ar. Casualty List. S. G. 0. Major General J. B. McPherson and Brigadier General L. Greathouse, ofthe Union army, were killed. 1,200* lOOt lOOt 900 500 Major General AA'. H. T. AA'alker, C. S. A., was killed. Casualty List. File A.t S. G. O. Casualtj- Lirt. S. G. O. Official. Official Report of Major General F. Steele. Official. Includes engag-ements at Macon, Julj- 30th, and Hillsboro' on the 31st. Official reports. Official Report of Major General .Sherman. In- cludes engagements iit Campbelltown on the28th, Lovejoy's Station on the 29th. and Newnan and vicinitj- on the 31st. Ohio in the AA'ar. A'ol. 2, page 437. Killed, wounded, and missing, t Killed and wounded. > Q H ca > td > H tr1 M DATE. i864. LOCALITY. UNION TROOPS ENGAGED. July 27th..1 Mtizztud Prairie. Fort Smith, Arkansas. July 27th and 28th. July 27th. July 28th. July 28th. July 28th. July 28th. July 28th. July 28th. July 28th to Sep. 2d. Deeji Bottom, Newmarket, and Malver Hill, A'irginia. AA'hiteside, Black Creek, Florida...... Tah-kaho-kuty, Dakota Territory..... Atchafalaj-a River, Louisiana.......... AA'est Point, Arkansas................. Ezra Chapel, Atlanta,Ga. (second sortie) Campbelltown, Georgia ... Flat Shoals, Georgia...... Siege of Atlanta, Georgia. Two hundred men of the 6th Kansas Cavalrj'. 1st Division. Tenth Corps, and Cavalry. Armj- of the James; Second Corps, Major General Hancock, and 1st Division, Torbctt's, and 2d Division, Gregg's, Cavalry Corps, Major General Sheridan, Armj- of the Potomac, Major General G. G. Meade. 35th U. S. Colored Troops (1st North Carolina)....... 8th Minnesota Mounted Infantry, 6th and 7th Iowa, and Dakota and Brackett's Minnesota Cavalry, com- manded by Brigadier General A. Sully. Portion of the Nineteenth Corps..................... llth Missouri Fifteenth Corps. Major General Logan; Sixteenth Corps, Major General Dodge; Seventeenth Corps, Major Gen. Blair,—Armj- of the Tennessee, Major General O. O. Howard. Portion of McCook's Cavalry, ofthe Army ofthe Cum- berland. Portion of General Garrard's Cavalrj', of the Army of the Cumberland. Inly 30th..! Mine explosion at Petersburg, A'irginia. Fort Smith, Arkansas................. July 29th to 31st. July 29th and 30th. July 29th.. July 30th.. July 30th.. July 30th.. July 30th.. July 30th.. Armj- of the Cumberland, Major Gen. G. II. Thomas ; Army of the Tennessee, Major Gen. <).(). Howard; and Army of the Ohio. Major Gen. J. M. Sohofield,— of the Army of the Military Division of the Missis- sippi, Major General AA'. T. Sherman. The attacking column was composed of the Ninth Corps, MajorGeneral Burnside. supported by the Eighteenth Corps, with the Second and Fifth Coips in reserve. Lovejoj- Station, Georgia... Clear Springs, Maryland ... New nan, Georgia.......... Chambcrsburg, Pennsylvania. Macon, Georgia.............. Cavalrj- of the Armj- of the Cumberland, commanded bj' General McCook. 12th and 14th Pennsj'lvania Cavalry.................. Cavalrj- of the Armj' of the Cumberland, commanded by General McCook. .................. Cavalrj-of the Army ot the Cumberland, commanded bj" General Stonemau. Lee's Mills, A'irginia................... Davis's Brigade, 2d Cavalry Division. Armj- of the Potomac. Lebanon. Kcntuckj-....................! One company of the 12th Ohio Cavalry.............. UNION LOSS. 419 17 279 152 CONFED. #o-:S. 1,679 3,000 RE.AIARKS AND REFERENCES. 1,000 171 200 Casualtj- Return. S. G. O. Official Report of Major General F. Steele. Casualtj- Lists, S. G. O. Appendix to Part I, Medi- cal and Surgical Historj- of the AA'ar, page 165. Engagement with Indians ; 125 Indians killed. Official Report of Major General John Pope. Report of Adjutant General of AA'isconsin, 1805, page 442. Official Report of Major General Sherman. Ap- pendix to Pitrt I, Medical and Surgical Historj' of the AVar, page 299. Casualty Lists, S. G. O. Skirmish during McCook's raids, July 26th to 30th. Engagement during Stoneman's raid, Julj' 26th to 31st. Losses include those of Utoy Creek, August 5th. Casualty Returns, S. G. O. Appendix to Part I, Medical and Surgical History of the AA'ar, p. 299. Official reports. Casualtj- List, S. G. Appendix to Part I, Medical and Surgical Historj- ofthe AA'ar, page 165. Of- ficial Reports of Major General Grant. Report of Adjutant General of Indiana, A'ol. Ill, page 389. Engagement during McCook's raid, July 26th to 31st. Four Years in the Saddle, page 208. Engagement during McCook's raid, Julv 26th to 31st. Burned bj- orderof Brig. Gen. McCausland, C. S. A. See Stoneman's raid to Macon, July 26th to 31st, Casualty List, S. G.O. Ohio in the AA'ar, Vol. 2, page 823. a W w o « o t-1 o Q M o ► 0 > Pi o Hillshoro', Geort Rolla, Missouri...................... Trenches before Petersburg, A'irginia . Cumberland, Maiyland............___ Green Springs Depot, AA'est A'irginia, near Oldtown, Maiyland. Osceola, Arkansas......... Elkshute, Missouri......... New Creek, AA'est A'irginia . Cavalry of the Army of the Cumberland, commanded bj' General Stoncnian. 5th Missouri Militia Cavalry. Second, Fifth, and Ninth Corps, Army ofthe Pote and Eighteenth Corps, Army of the James. Command of Brigadier General 11. F. Kelly... 153d ()hio A'olunteers......................... 2d and 3d Militia and 1st and 6th Missouri Cavalry. Forts Gaines and Morgan, Mobile liar- j U. S. steamships Brooklyn, Octorora, Hartford,< Issipoe, bor, Alabama. I Itasca, Oneida, Galena, Metaconiet. Richmond, IVirt Royal, Lackawanna. Seminole, Monongahela, and Tccninseh, commanded by Admiral Farragut, and Thirteenth Army Corps, Major General Granger. Utoy Creek, Georgia. Cowskin, Missouri. .. Decatur, Georgia......... Donaldsonville, Louisiana. Cabin Point, A'irginia..... Plaquemine, Louisiana___ Armies of the Cumberland, Tennessee, and Ohio. 8th Missouri Militia Cavalry. 2d Division Cavalry, Army of the Cumberland . llth New A'ork Cavalry....................... 1st U. S. Colored Cavalry..................... Moorefield, A'irginia... Tallahatchie River, Mississippi___ Fort Gaines, Alabama Two Hills Bad Lands, Little Missouri River, Dakota Territory. Explosion of ammunition at City Point, A'irginia. U. S. steamer Empress, Mississippi Berryville Pike, A'irginia.......... Sulphur Springs Bridge and AA'hite Post, Virginia. 4th AA'isconsin Cavalry and llth (14th Rhode Island) Heavy Artillery. 14th Pennsj-lvania. 8th Ohio, 1st and 3d AA'est A'irginia, and 1st New- A'ork Cavalrj', coniinanded bj' Brigadier General Averill. Cavalrj-, Brigadier General Hatch, and infantry,,Major General Mower, of the Sixteenth Corps, commanded bj- Major General A. J. Smith. U. S. fleet, commanded by Admiral Farragut.......... 8th Minnesota A'olunteers and 2d Minnesota, 6th and 7th Iowa, Bruokett's Battalion Minnesota, and 1st Battalion Dakota Cavalry. Reserve Brigade and 1st Cavalry Division, Major Gen. Torbett, Arm j- of the Potomac. 1st and 3d Divisionsand Reserve Brigade,CavalryCorps, Major General Torbett, Army of the Potomac. Van Buren, Crawford Countj-, Arkansas.! 2d and 6th Kansas Cavalry. 484 30 3 50 170 2,344 100 f See Stoneman's raid to Macon. July 26th to 31st. Also designated Sunshine Church. Official. Official reports. List of casualties, S. G. O. .....' Also designated Flock's Mills. ..... Casualty Returns, S. G. O. Four Years in the Saddle, Gilrnor, page 221. 25 Official Report of Col. J. L. Burris, commanding. 28 Official Report of Col. J. L. Burris, commanding. ..... Four Years in the Saddle, Gilmor, page 221. Official Report of Rear-Admiral D. G. Farragut, commanding the west gulf blockading squadron, j Besides those killed, over 100 were drowned by the sinking of the Tecumseh. The Confederate | Admiral Buchanan was wounded, and Commo- dore Craven. U. S.N., drowned. Fort Gaines sur- rendered Aug. 8th and Fort Morgan Aug, 23d. Casualty List. S. G. O. Included in the siege of Atlanta, July 28th to Sept. 2d. Casualtj- List, S. G. O. Official. Also designated Indian Citj- A'illage. 400 i Casualty List. S. G. O. Four Years in the Saddle, Gilmor, page 225. Report of Adjutant Genera] of Missouri, 1865, p. 381. See Mobile Harbor, August 5th to 23d. Official Report of Major General John Pope. En gagement with Indians ; 100 Indians killed. Official Report of Major General Sheridan. Casu- alty List, S. G. O. Official report of Major General Sheridan. Casu ality List, S.G.O. f Killed and wounded. Q > Q M H CO > f> H f DATE. 1864. Aug. 12th.. Aug. 12th.. Aug. 13th.. Aug. 14th.. LOG A LIT V. Abbeville and Oxford, Mississippi Little Blue, Dakota Territory___ Near Snicker's Gap, A'irginia..... Gravel Hill, A'irginia............. Aug 14th ' Strawberry Plains, Deep Bottom Run, A'irginia. Hurricane Creek, Mississippi... to 18th. Aug . 14th.. Aug . 14th to 16th. Aug . 15th.. Aug 16th.. Dalton, Georgia...................... Fisher's Hill, near Strasburg, A'irginia. Smoky Hill Crossing, Kansas.......... UNION TROOPS ENGAGED. Aug. 16th.. Crooked Run, Front Royal, A'irginia... Aug. 17th.., Gainesville, Florida...........'........ Aug. 17th.. Cleveland, Tennessee---'............. Aug. 17th..j AA'inchester, Virginia.. Aug-. 18th.. Decatur, Alabama. Aug. 181h, I Six-Mile House. AA'eldon Railroad, A'a.. 19th, and i 21st. Aug-. 18th.. Fairburn, Georgia........... Aug. 19th.. Snicker's Gap Pike. Virginia. Block-House No. 4, Nashville and Chat- tanooga Railroad, Tennessee. Aug. 19th.. Martinsburg, A'irginia. Cavaby, Brigadier General Hatch, and infantry, Major General Mower, of the Sixteenth Corps, Major Gen. A. J. Smith. Detachment of the 7th Iowa Cavalrj-................, 144th and 149th Ohio A'olunteers (one hundred daj-s' men), guarding a supplj- train. 2d Division, Major General Gregg, Cavalry, Armj' of the Potomac. 2d Cavalrj' Division, Gregg's; Second Corps, Major General Hancock,—Army of the Potomac, Major General Meade ; and Tenth Corps, Major General Birnej',—Army of the James, Major General Butler. Cavalry, Hatch's, and infantrj', Mower's, of the Six- teenth Corps, commanded bj' Major General A. J. Smith. 2d Missouri A'olunteers and 14th U. S. Colored Troops, commanded bj' Colonel Siebold, 2d Missouri A'ols. 1st Cavalrj- Division. Armj-of the Potomac, and Sixth and Eighth Corps. Detachments of the 7th Iowa and U. S. Cavalrj-....... 1st and 2d Brigades, lstCavaliy Division, Armj'of the Potomac, commanded bj' General Merritt. 75th Ohio Mounted Infantry.......................... 6th Ohio Heavy Artillery............................ 3d Division Cavalry, AA'ilson's, Army of the Potomac, and the New Jersey Brigade, Sixth Corps. 2d Division Cavalrj-, Armj'of the Cumberland, and 1st U. S. Colored Heavy Artilleiy. Kautz's Cavalry and the 2d Cavalrj- Division, Gregg's, Fifth Coips, Major General G. K. AA'arren, and Ninth Corps, Major General J. G.Parke—Armj-of tl e Potomac. Cavalrj-, Armj- of the Cumberland................... Detachment of the 5th Michigan Cavalry............. One company of the 115th Ohio A'olunteers............ One companj' of cavalrj' of Averill's command........ UNION LOSS. CONFED. LOSS. 10 18 1,755 1,155 251 200 1,400 102 250 3,176 1,000 2,000 .2, 000 REMARKS AND REFERENCES. leport of Adjutant General of Missouri, lHii page 149. Report of Adjutant General of Iowa. 1865. p. 144. Engagement with Indians; 12 Indians killed. Ohio in the AVar, A'ol. 2, page 680. Partizan Life with jAIosbj', page 276. Casualty List, S.G.O. Casualty List, S. G.O. Appendix to Part I, Med- ical and Surgical History of the AVar, page 173. General Girard, U.S.A., and General Chaplin, U. S. V., were killed. Report of Adjutant General of Missouri, 1865, page 103. Casualty List, S. G. O. Official Report of Major General Sheridan. Report of Adjutant General of Iowa, 1865, p. 143. Engagement with Indians. Casualty List, S. G. O. Oflicial Report of Major General Sheridan. Ohio in the AA'ar, A'ol. 2, page 437. Ohio in the AVar, Vol. 2, page 912. Casualty List, S. G. O. Official Report of Major General Sheridan. Casualty List, S. G. O. Casualtj- List, S. G.-O. Appendix to Part I, Medi- cal and Surgical Historj- of the AA'ar, page 173. Brig. Generals Saunders and Lamar, C. S. A., killed, and Generals Claigman, Barton, Finne- gan, and Anderson, C. S. A., were wounded. Casualtj- List, S.G.O. '■All the prisoners who were taken, and all the wounded who had fallen bj- the way, were put to death." Partizan Life with Mosby, page 282. Ohio in the AVar, Vol. 2, page 602. a W W o o o o Q f> Aug. 18th I Kilpatrick's raid on the Atlanta Rail- to 22d. j road. Aug. 19th..| Red Oak, Georgia..................... Aug. 19th Jonesboro', Georgia............... and 20th. Aug. 19th.. Pine Bluff, Tennessee River, Tenn. Aug. 20th.. i Lovejoj- Station, Georgia......... Aug. 21st.. | Summit Point, A'irginia........... Aug. 21st.. Aug. 21st.. Duval's Bluff, Arka-i Memphis, Tennessee Cavalrj- of the Armj- of the Cumberland. Cavalrj' of the Armj' of the Cumberland. 2d Division Cavalry, Army of the Cumberland....... Detachment of Co. B, 83d Illinois Mounted Infantry.... Cavalrj', Army of the Cumberland.................... 1st Division, Merritt's, and 3d Division, AVilson's, Cav- alry Corps, and Sixth Corps. Major General Wright, of the Army of the Middle Military Division, Major General Sheridan. Aug. 21st ! College Hill, Mississippi and 22d. Aug. 22d. Aug. 22d. Aug. 23d. Canton, Kentuckj-..... Rodgersville, Tennessee Fort Morgan, Alabama. Aug. 23d..! Abbeville, Mississippi. llth Missouri Cavalry................................ Detachments of the 8th Iowa, 108th and 113th Illinois, 39th, 40th, and 41st AA'isconsin A'olunteers, 61st (2d Tennessee) U. S. Colored Troops, 3d and 4th Iowa Cavalrj-, and Batterj- G, 1st Missouri Light Artillery. 4th Iowa and llth and 21st Missouri A'olunteers, and 3d Iowa and 12th Missouri Cavalry, of the Sixteenth Corps. Naval forces under Admiral Farragut................. 10th Missouri, 14th Iowa, 5th and 7th Minnesota, and 8th AA'isconsin A'olunteers, of Major General A. J. Smith's command. Bermuda Hundred, A'irginia............ Tenth Corps, Army of the James, Major Gen. Butler .. Aug. 21th and 25th. Aug. 24th.. | Fort Smith, Ar-kansas Aug. 24th Aug. 24th.. Aug. 25th.. Aug. 25th.. Aug. 25th.. Aug. 25th.. Aug. 26th.. Jones's Hay Station and Ashley Station, Long Prairie, Arkansas. Halltown, Virg llth U. S. Colored Troops.................. 9th Iowa and 8th and llth Missouri Cavalry . Smithfield and Shepherdstown, A'irginia. Ream's Station, A'irginia............... Conee Creek, Clinton, Louisiana........ Sacramento Mountain, New Mexico---- Bull Bayou, Arkansas................. Portion of the Eighth Corps, Army of the Shenandoah, Major General Crook. 1st Division, Merritt's, and 3d Division, Wilson's, Cav- alry, Army of the Potomac. Second Corps, Major General W. S. Hancock, and 2d Division of Cavalry, Gregg's, of the Army of the Potomac, Major General George G. Meade. Portion of the Cavalry of the Department of the Gulf, commanded bj' General Lee. 1st New Mexico Cavalry............................ 2 100 13 41 37 61 546 16 100 9th Kansas and 3d Wisconsin Cavalry.............. * Killed, wounded, and missing, t Killed and wounded. lOOt Includes engagements at' Red Oak on the lfith and Jonesboro' and Lovejoy Station on the 20th. Casualty List. S. G. O. Engagement during Kil- patrick's raid, August 18th to -J2d. Casualty List, S. G. O. Engagement during Kil- patrick's raid, August 18th to iJ'-id. Casualty List, File A. No. 416, S. G. O. Killed and mutilated bj' guerillas. Casualtj- List. S. G. O. Kilpatrick's raid, August 18th to 22d. Casualty List. S. G. O. Official Report of Major General Sheridan. In.-hides the engagements of the 1st Cavalry Division at Berryville 3d Cavalrj' Division at Sumn.it, and Sixth Corps at Flowing Springs. Official. Report of Adjutant General of Iowa. 1864, p. 1062. Also designated Oxford Hill and Hurricane Creek. See Mobile Harbor, August 5th to 23d. Casualty Return, FileF, No. 230, S.G. O. Report ol Adjutant General of Iowa, 1867, page 502. Casualty List. S. G. O. Official Report of Major General Sheridan. Casualty List. S. G. O. Official Report of Major General P. H. Sheridan. Also called Kearneys- ville. Casualty List, S. G. O. Appendix to Part I, Medi- cal and Surgical Historj- of the AA'ar. page L75. Oflicial Report of Major General U. S. Grant. Report of Adjutant General of AA'isconsin, 1864, pages 635 and 653. Report of Adjutant General of AA'isconsin, 1864, page 622. DATE. I.-64. LOCALITY. Aug. 20th Hulltown, A'irginia and 27th. Aug. 27th. Owensboro',' Kentucky Aug. 27th i Holly Springs, Mississippi......... and 28th. Aug. 28th..! Fort Cottonwood, Nevada Territory. Aug. 28th. Aug. 29th.. Aug. 29th. Aug. 29th.. Aug. 29th and 30th. Aug. 31st mil Sep. 1st. Howard Countj-. Missour Ghent, Kcntuckj-....... Smithfield, A'irginia..... AA'ormlej-'s Gap, A'irginia.............. Arthur's Swamp, A'irginia............. Block-house, No. 5, Nashville and Chat- tanooga Railroad, Tennessee. Jonesboro', Georgia. Mnj-5thto Campaign in Northern Georgia, from Sept. 8th. Chattanooga to Atlanta. Sept. 1st ' Rosseau's pursuit of Wheeler in Tenn.. to 8th. Sept. 1st Trenches before Petersburg--- to Oct. 30th. | Sept. 1st... Lavergne, Tennessee.......... Sept. 2d..., Occupation of Atlanta, Georgia. Sept. 2d.. opt. 2d lo 6th. Franklin, Tennessee..... Lovejoy Station, Georgia. UNION TROOPS ENGAGED. 1st and 2d Divisions, Eighth Corps, Army of AA'est A'irginia, Major Gen. (','. Crook, of the Army of the Middle Military Division, Major Gen. P. II. Sheridan. 108th U. S. Colored Troops........................... 1 Ith Iowa A'olunteers, llth U. S. Colored Troops (1st Alabama Artillery), and 10th Missouri Cava'ry. 7th low a Cavalry . Company E, of the 4th Missouri Militia Cavalry....... 117th U. S. Colored Troops........................... 1st Division, Torbctt's, Cavalry Corps, and 3d Division, Rickett's, of the Sixth Corps, Army of the Potomac. Detachment commanded by Capt. Blazer, 91st Ohio 2d Division, Gregg's, of the Cavalry Corps, Armj- of the Potomac. 115th Ohio A'olunteers................................ Cavalry and Davis's Division, Fourteenth Corps, Major General J. M. Palmer,—Army of the Cumberland, Major General George H. Thomas: Fifteenth Corps, MajorGeneral J. A. Logan; Sixteenth Corps, Major General G. M. Dodge; and Seventeenth Corps, Maj. General F. P. Blair—Army of the Tennessee. Maj. General O. O. Howard ;—of the Army of the Military Division ofthe Mississippi, Maj. Gen. AA'. T. Shcrmau. Armies of the Cumberland, Tennessee, and Ohio...... 1st and 4th Tennessee, 2d Michigan, 1st AA'isconsin, 8th Iowa, 2d and 8th Indiana, and (ith Kentucky Cavalrj', coniinanded by General Rosseau. Army of the Potomac................................ Cavalry commanded by General L. H. Rosseau Twentieth Corps, Major General Slocum, Army of the Cumberland. Cavalry commanded by General L. II. Rosseau Twenty-third Corps, Army of the Ohio, Major General ■I. M. Seholiehl, and Fourth Corps, Armj' of the Cumberland, Major General George II. Thomas.— Armj- of the Military Division of the Mississippi, Major General AA'. T. Sherman. UNION LOSS CONFED. LOS> REMARKS AND REFERENCES. 100* Appendix to Part I, Medical and Surgical History of the AA'ar, page 224. Casualty List, S. G. O.' 1,149 26,129 30 822 5,786 812 200* 60* Report of Adjutant General of Iowa, 1865. Fight with Indians. Report of Adjutant General of Missouri, 1865, page 474. Official Report of Major General P. H. Sheridan. Casualty List. S.ti.O. Surgeon AV. II. Rullison. Medical Director, was killed. Casualty List, S. G. O. .......| Official Report of Major General G. II. Thomas. Ohio in the AA'ar, Vol. 2, page 602. 2, 000 i Casualty List, S. G. O. Appendix to Part I, Medi- cal and Surgical History of the AA'ar, page 299. Official Report of Major General AV. T. Sherman. The Confederate Brigadier Generals Anderson, Cunnnings, and Patten were killed. Appendix to Part I, Medical and Surgical History of the AVar, page 302. Casualty List, S. li. O." 300 * 1,000 Casualty List, File A, No. 416, S. G. O. General Kelly, C. S. A., was wounded. Casualtj- Lists, S. G. O. Included in Rosseau's pursuit of AA'heeler, Sept. 1st to 8th. Appendix to Part I, Medical and Surgical History of the AVar, page 309. Official Report of Major General AA'. T. Sherman. Included in Rosseau's pursuit of AA'heeler, Sept. 1st to 8th. Casualty List, S. G. O. Appendix to Part 1, Medi- cal and Surgical Historj- of the AA'ar, page 302. Official reports. a W Pi o « o f o Q M a > f co d > o Sept. 2d... Sept. 3d... Sept. 3d and 4th. Sept. 3d.. Sept. 4th.. Sept. 5th.. Sept. 6th... Sept. 7th.. Sept. 7th.. Sept. 10th. Sept. 13th. Sept, Sept. 16th and 18th. Sept. 16th. Sept. 17th.. Sept. 17th. Sept. 17th to 20th. Sept. 18th. Sept. 18th. Sept. 19th. Big Shanty, Georgia................. Murfreesboro', Tennessee.............. Berryville, Virginia................... Darkesville, A'irginia................. Greenville, Tennessee................. Campbellville, Tennessee............. Searcj-, Arkansas..................... Readj-ville, Tennessee................ Dutch Gap, A'irginia.................. Capture of Fort Hell, Jerusalem Plank Road, A'irginia. Lock's Ford, Opcquan, A'irginia....... Near Pine Bluff, Arkansas............. Fort Gibson, Indian Territory......... Sycamore Church, A'irginia............ Fairfax Station, A'irginia............. Belcher's Mills, Virginia............... Doniphan and Black River, Missouri... Martinsburg, Virginia................. Fort Cottonwood, Nevada Territory___ Opequan, AVinchester, A'irginia........ Sept. 19th. Cabin Creek, Indian Territory. 9th Ohio Cavalry on a railroad train. 100th U. S. Colored Troops......... 1st Cavalry Division, Major General Torbett, Army of the Potomac; Eighth Corps, Army of AA'cstern A'irgi- nia, MajorGeneral G. Crook, and'Nineteenth Corps, Major General Emory,—Army of the Middle Military Division, MajorGeneral P. 11. Sheridan. 3d Cavalry Division, Armj' of the Potomac............ 9th and 13th Tennessee, and 10th Michigan Cavalry, commanded by General Gillem. Cavalry commanded bj' General L. II. Ros Detachment of the 9th Iowa Cavalry......... Detachment of the 9th Pennsj-lvania Cavalry. 4th U. S. Colored Troops.................... 99th Pennsj-lvania, 2d U. S. Sharp-Shooters, and 20th Indiana A'olunteers. 2d Brigade, Brigadier General Mcintosh. 3d Division, AA'ilson's, Cavalry Corps, Major General Torbett's,— Armj- of the Middle .Military Division, Major Gen. P. IL Sheridan. Two companies of the 1st Indiana Cavalry. 79th U. S. Colored Troops (1st Kansas) and 2d Kansas Cavalrj-. 1st District of Columbia and 13th Pennsylvania Cavalrj', guarding cattle. 13th and 16th New York Cavalry..................... Kautz's Cavalrj- of the Army of the James, and the 2d Cavalry Division, Gregg s, Armj' ofthe Potomac. One company of the 3d Missouri Militia Cavalrj'....... 2d Division of Cavalry, Averill's, of the Army of West Virginia, Middle Military Division. 7th Iowa Cavalry................................... Eighth Corps, MajorGeneral G.Crook, and 2d Division, Cavalry, Brigadier General Averill, of the Army of AA'est Virginia; Sixth Corps, Major General IL G. AA'right, and 1st and 3d Divisions, Cavalrj-, Major General F. 11. Toihctt, Armj- of the Potomac; 1st and 2d Divisions, Nineteenth Corps, Major General Emorj-.—Army of the Middle Military Division Major General P. II. Sheridan. 2d, 6th, and 14th Kansas Cavalry, and 1st and 2d Kansas Indian Home Guards. 50* 7 25 100 70 50* 60 i 75 3,719 48 400 s Ohio in the AVar, Vol. 2, page 813. Official. Casualty List, S. G. O. Official Report of Major General P. H. Sheridan. Casualty List, S. G. O. Report of Adjutant General of Tennessee, 1866, page 637. The Confederate General John Morgan, was killed. Included in Rosseau's pursuit of Wheeler, Sept. 1st to 8th. Report of Adjutant General of Iowa. 1867, p. 562. 90 161 3, 0001 2,500 Casualty Lists, S. G. O. Official Report of Afajor General P. II. Sheridan. Casualty Lists, S. G O. Report of Adjutant General of Indiana, A'ol. U, page 278. Report of Adhitant General of Maine. 1864, p. 297. Partizan Life with Mosby. Appendix to Part I, Medical and Surgical History of the AA'ar, page 196. Report of Adjutant General of Missouri, 1865. Page 467. Casualty List. S. G. O. Report of Adjutant General of Iowa, 1865, p. 143. Casualty List, S. G. O. Appendix to Part I. Medi- cal and Surgical Historj- of the AA'ar, page 223. Official Report of Atajor General P. H. Sheridan. Also designated Belle Grove. Among the casu- alties in the Union army were Brigadier General D. A. Russell and Colonel James A. Mulligan, killed, and Brigadier Generals Mcintosh. Upton, and Chapman, wounded. In the Confederate army, Major General Rhodes. Brigadier Generals Gordon and Goodwin, were killed, and Fitz-Hugh Lee, Terrj-, Johnson, and AA'harton. wounded. ' Killed, wounded, and missing, t Killed and wounded. UNION LOSS. DATE. 1864. Sept. 21st. Sept. 22d LOCALITY. Front Royal Pike, A'irginia. Fisher's Hill, A'irginia...... UNION TROOPS ENGAGED. Sept. 23d.. Athens, Alabama..... Sept. 23d..' Rockport, Missouri___ Sept. 23d. J Blaekwuter, Jlissouri . Sept. 24th. Luraj-, A'irginia....... Sept. 24th. Fayette, Missouri..... Sept. 24th. i Bull's Gap, Tennessee Sept. 24th ' Price's invasion of Jlissouri. to Oct. 28th. 3d Division, AA'ilson's, Cavalrj- Corps, of the Armj- of the Potomac. Sixth Corps, Major General II. ft. AA'right ; 1st and 2d Divisions, Cavalry, Major General F. H. Torbett, of the Army ofthe Potomac ; Eighth Corps, Major Gen. G. Crook, of the Army of AA'est Virginia ; 1st and 2d Divisions, Nineteenth Corps, Maj. General Emory,— Army of the Middle Military Division, Major Gen. P. II. Sheridan. 106th, 110th, and 114th U. S. Colored Troops, 3d Ten- nessee Cavalry, garrisoning the Post, and 18tb Mich- igan and 102d Ohio A'olunteers, reinforcements. Sept. 25th . Sept. 25th.. Sulphur Branch Trestle, Alabama. Johnsonville, Tennessee.. Sept. 25th.- Henderson, Kentucky--- Sept. 26th... A'ache Grass, Arkansas.. Sept. 26th | Fort Davidson, Pilot Knob, Missouri. and 27th. ' Sept. 26th. Brown's Gap, A'irginia..... Sept. 26th.. Richland, Tennessee....... Sept. 27th. AA'cyer's Cave, A'irginia ... 3d Missouri Militia Cavalry. One battalion of the 1st Missouri Militia Cavalry. 1st Division, Merritt's, Cavalrj- Corps, Army of the Potomac. 9th Missouri Militia Cavalry. Cavalry and Mounted Infantrj', commanded by Gen. Amnion. Missouri Militia Cavalry and Cavalry of General A. J. Smith's command, commanded by Gen. Pleasanton; Kai sas Militia and Cavalrj- of the Armj- of the Border, commanded by General Curtis. lilth II. S. Colored Troops (3d Tennessee), and 9th Indiana Cavalry. 13th U. S. Colored Troops. 118th U. S. Colored Troops 14th Kansas Cavalry...... CONFED. LOSS. REMARKS AND REFERENCES. !30t Official Report of M: commanding Ariny sion. or General P. II. Sheridan. if the Middle Military Divi- 1,100 Casualty List. S. G. O. Appendix to Part I, Medi- cal aiid Surgical History of the AA'ar. page 223. Official Report of Maior'Oelieral P. H. Sheridan. Also designated AA'ocdstock. Official Reportsof Generals G. II. Thomas, U. S. A., and N. !!. Forrest, (.'. S. A. \ '........................ Official. ..... Report of Adjutant General of Missouri, 1865, page 448. 74 ; Official Report of Major General P. II. Sheridan. commanding Armj- of the Middle Military Divi- sion. Report of Adjutant General of Missouri. 180. page 512. 47th and 50th Missouri, and 14th Iowa A'olunteers, 2d and 3d Missouri Cavalry, and Batterj- II, 2d Missouri Light Artillery. 1st Division of Cavalry, of (he Army of the Potomac, - and 2d Division, Cavalry, of the Army of AA'est A'a. 4 100 lilth U. S. Colored Troops (3d Alabama)..... 2d Division. Cavalry. Army of West Virginia. Ohio in the AA'ar, Vol. 2, page 609. Official Reports of Major General AV. S. Rosecrans. See engagements at Pilot Knob, Sept. 2(ith ; Cen- tralia, Sept. 27th; Leesburg, Sept. 30th ; Os-igo, Oct. (ith; Jefferson City, Oct. "ith; Boono.-ville. Oct. 9th; Glasgow and'Sedalia. Oct. j5th; Lex- ington, Oct. lilth; Little Blue, Oct. 21st; Inde- pendence. Oct. 22d; Big Blue. Oct. 23d; Little Osage, Oct. 25th ; and New -tenia, Oct. 28th. Official Report of Major General G. II. Thomas. Official. 1,500 j........| Official Report of Brigadier General T. Swing, commanding. Also designated Ironton. 30* Official Report of Major General Sheridan. Sept. 27th.. Sept. 27th.. Sept. 27th.. Sept. 27th.. Sept. 27th.. Sept. 27th. Sept. 28th. Sept. 28th. Sept. 28th to 30th. Pulaski, Tennessee.................. Massacre on North Missouri Railroad. Massacre at Ccntralia. Missouri...... Carter's Station, AA'atauga River, Ark Marianna, Florida . Fort Rice, Dakota Territory......... Clarksville, Arkansas............... AA'ajnesboro', A'irginia.............. New Market Heights, Virginia....... Cavalry commanded by Major General Rosseau........ Furloughed soldiers.................................. Three companies of the 39th Missouri A'oluntcers...... Cavalrj- and Mounted Infantry, commanded bj- Gen. Amnion. 82d U. S. Colored Troops, 7th A'ermont A'olunteers, and 2d Maine Cavalrj-, commanded bj' Brigadier General A. Asboth. Detachment of the (ith Iowa Cavalrj-.................. 3d AA'isconsin Cavalry................................ Hd Division, AA'ilson's, Cavalry Corps, of the Army of the I'otomac. Tenth Corps, MajorGeneral Birney; Eighteenth Corps, AlajorGener.il Ord; and Cavalry, Brigadier General Kautz,—of the Armj' of the James, Major General B. F. Butler. Sept. 28th. Fort Sedgwick, Jerusalem Plank Road, 3d Division, Ninth Corps. \ Virginia. Sept. 29th. Sept. 29th and 30th. Sept. 30th to Oct. 1st. Sept. 30th to Oct. 1st. Oct. 1st and 2d. Oct. 1st... Centreville, Tennessee........... Leesburg and Harrison. Missouri. Preble's Farm, Poplar Springs Church, A'irginia. Arthur's Swamp, A'irginia. Athens, Alabama......... Huntsville, Alabama...... 2d Tennessee Mounted Infantrj-....................... 2d Missouri Militia Cavalry, Battery H, 2d Missouri Light Artilleiy, and 14th Iowa A'olunteers. 1st Division, AA'ilcox's, Fifth Corps, and 2d Division, Potter's, of the Ninth Corps. 2d Cavalry Division, Greg'g's, of the Army of the Potomac. Franklin, Missouri. Oct. 1st—' Reconnoissance on Charles City Cross Roads, A'irginia. Oct. 1st Yellow Tavern, AA'eldon Railroad, Va.. to 5th. j Oct. , 1st I Sweetwater, Noses, and Powder Spring to 3d. Creeks, Georgia. Oct. 2d... Oct. 2d... 73d Indiana A'olunteers............................... Detachments of the 12th and 13th Indiana Cavalry..... Enrolled Missouri Militia, commanded bj- Col. Wolfe... Spear's Cavalry Brigade, and Terry's Brigade, Tenth Corps, Armj- of the James. 3d Division, Second Corps, ofthe Army of the Potomac. Kilpatrick's Cavalrj', of the Army of the Cumberland.. AA'ajmesboro', Virginia................. Portion of the 1st Division, Merritt's, and 3d Division, Custer's, Cavalry Cu'-ps, Army of the Potomac. Saltville, A'irginia. Gladesville, Pound Gap, Virginia... llth and 13th Kentucky, 12th Ohio, llth Michigan, and 5th and (ith U. S. Colored Cavalry, and 26th, 30th, 35th, 37th, 39th, 40th, and 45th Kentucky Mounted Infantrj-. I st Kentucky Cavalry and 3d Kentucky Mounted In- fantry. * Killed, wounded, and 22 122 2 32 5 81 400 2, 029 2,000* 10 25 141 788 60 1,756 100 800 100 50 * 104 54 190 18 71 21 Official Report of Major General Thomas. Official Report of Major General Rosecrans. Official Report of .Major General Rosecrans. Ohio in the War, A'ol. 2, page 609. Official Report of Major General E. R. S. Canbj-. Brigadier General Asboth, wounded. Engagements with Indians. Official Report of Major General Sheridan, com- manding Armj'of the Middle Military Division. Casualty List, S. O. O. Appendix to Part I. Medi- cal and Surgical Historj- of the AA'ar, page 175. Official Report cf Major General U. S. Grant. Also designated Chapin's Farm. Laurel Hill, and Forts Harrison and Gilmore. Among the casu- alties were General Burnham, killed, and Kajor Generals Ord and Stannard, wounded. Report of Adjutant General of Tennessee, Official Report of Major General T. Ewing. Casualtj- List. S. G. O. Appendix to Part I, Medi- cal and Surgical History of the AA'ar. page 175. Official Report of Major General U. S. Grant. Casualty List, S. G. O. Official Report of Major General Thomas. Report of Adjutant General of Indiana, A'ol. Ill, page 207. Official Report of Major General Rosecrans. Armj- and Navj' Journal, A'ol. I, page 99. Casualty List, S. G. O. Official Report of Major General Sherman. Official Report of Major General S. G. Burbridge, commanding. Appendix to Part 1. Medical and Surgical LMstory of the AA'ar, page 228. Official Report of Major General S. G. Burbridge. tKilled and wounded. Q > Q H OQ > b bd O t-3 H tr DATE. 1864. LOCALITY. Oct. 4th Oct. 5th Oct. 5th Oct. 5th Oct. (ith Oct. Oct. (ith Oct. (itli UNION TROOPS ENGAGED. Near Memphis, Tennessee..............' One company of the 7th Indiana Cavalry Jackson, Louisiana................ Allatoona, Georgia................ UNION LOSS. 23d AA'isconsin A'olunteers, 1st Texas, and 1st Louisiana Cavalry, and 2d and 4th Massachusetts Batteries. Fort Adams, Louisiana...... Florence, Alabama......... North Shenandoah, A'irginia. Prince's Place, Osage River, Cole Co., Missouri. 7th. 12th, 50th, 57th, and 93d Illinois, 39th Iowa, 4th Minnesota, and 18th AA'isconsin A'olunteers, and 12th AA'isconsin Batterj'. 2d Wisconsin and 3d IT. S. Colored Cavalry........... 4 142 10 352 21° CONFED. LOSS. 60th Illinois A'olunteers and 8th Iowa and 6th Tennes see Cavalry. 8th Ohio Cavalr Wondvillo, Mississippi. New Market, A'irginia.. Darbjtown Roads, near New Market Heights, A'irginia. 1st, 7th, and 9th Missouri Militia Cavalrj-, commanded bj- Colonel Philips. 3d Division, Custer's, Cavalry of the Army of the Potomac. Tenth Corps, Major General Birney, and Cavalry, ', 50 Brigadier General Kautz. of the Armj- ofthe James, Major General B. F. Butler. Oct. 7th... Moreau Bottom, near Jefferson City, ! Missouri Militia, Cavalrj-, Artillery, and Infantrj-, corn- Missouri. J mantled by Generals Fisk, Brown, McNeil, and San- born. Reconnoissance to the Boydtown Plank Rotid, A'irginia. Tom's Brook, Virginia................. Fifth and Ninth Corps of the Army of the Potomac. 1st Division, Merritt's, and 3d Division, Custer's, Cav- alry Corps. Torbctt's, ofthe Armj-of the Potomac,— Middle Militaiy Division, Major General Sheridan. California, Missouri....................i 4th and 7th Missouri Militia Cavalry and Batteries H and L, 2d Missouri Artillery. Oct. 9th to llth. Oct. 10th., Oct. 10th.. Oct. llth.. Oct. llth.. Oct. llth.. Boonsville, Missouri. 1st, 4th, 5th, 6th, and 7th Missouri Militia Cavalrj-, 15th Missouri and 17th Illinois Cavalry, and Batterj' H, 2d Missouri Light Artillerj-, commanded bj- Gen. Sanborn. South Tunnel, Tennessee . East Point, Mississippi___ Fort Donelson, Tennessee. Stonj- Creek Station, Virginia Narrows, Georgia............ 40th U. S. Colored Troops............... 61st U. S. Colored Troops (2d Tennessee) Portion of the 4th U. S. Colored Heavy Artillery, commanded bj- Colonel Weaver. 13th Pennsylvania Cavalry.......................... Garrard's Cavalrj- Division, Army of the Cumberland. 56 150 1,000 100} 47 411 350 180 REMARKS AND REFERENCES. Report of Adjutant General of Indiana,Vol. Ill, page 218. Official Report of Major General Canby. Casualtj- List, File A, S.G.O. Official reports. Brigadier General J. M. Corse, commanding the Nationals, was wounded. Official Dispatch of Major General Sheridan. Official Report of Major General Rosecrans. Official Report of Major General Canby. Confederate reports. Official Reports of Major General Grant. Among the casualties were General Gregg. C. S. A.. killed, and Bratton wounded. Colonel Spear, U. S. A'., was wounded. Official Report of Major General Rosecrans. Casualty List, S. G. O. Official Report of Major General Sheridan. Also designated Fisher's Hill, Strasburg. and AA'ood- stock. Appendix to Part I, Medical and Surgi- cal Historj- of the AA'ar, page 225. Report of Adjutant General of Missouri, 1865, p. 474. Official Report of .Major Gen. Rosecrans. Official Report of Major General Rosecrans. Official. Official. Official. Official Report of Major General Sherman. Q W O o t-1 o Q Q > > o Greenville, Tennessee Resaca, Georgia...... Reconnoissance to Strasburg, A'irginia Tilton, Georgia.. Dalton, Georgia. Garrison, commanded by Colonel AA'caver. 1st and 2d Divisions, Nineteenth Corps, Major General Emory, and 1st and 2d Divisions, Army of AA'est A'irginia, Major General Crook,—Army of the Mid- dle Military Division. Troops commanded by Colonel Johnson, 44th U. S. Colored Troops. Buzzard Roost Block-House, Georgia___ One company of the 115th Illinois Volunteers Reconnoissance, Darbytown Road, A'a. Baj-ou Biddell, Louisia Glasgow, Missouri--- 1st and 3d Divisions, Tenth Corps, Major General Terry, and Kautz's Cavalry Division, ofthe Army of the James. 52dU. S. Colored Troops (2d Mississippi)............. 43d Missouri A'olunteers, detachments of the 17th Illinois, 9th Missouri Militia, and 13th Missouri Cavalry, and 62d U. S. Colored Troops (1st Missouri), eoimnanded by Colonel Harding. Portion of the Armj' of Tennessee......... 1st and 7th Missouri Militia Cavalry....... I st Division, Fifteenth Corps.............. Detachment of the 1st Connecticut Cavalry. Oct. 20th Oct. 21st.. Oct. 21st Snake Creek Gap, Georgia ..:....... Sedalia, Missouri................... Ship's Gap, Taj-lor's Ridge, Georgia. Cedar Run Church, A'irginia......... Pierce's Point, Blackwater, Florida.....: 19th Iowa Volunteers and 2d Maine and 1st Florida Cavalry. Lexington, Missouri...... Cedar Creek, Virginia--- 3d Wisconsin and 5th, llth. 15th, and 16th Kansas Cavalry, commanded by General Blunt, of General Curtis's Army. 1st Division, Merritt's, and 3d Division, Custer's, Cav- alry Corps, Major General Torbett, and Sixth Corps, Major General'AA'right, ofthe Army of the Potomac; Eighth Corps. Crook's, and Cavalry, of the Army of AA'est A'irginia; and 1st and 2d Divisions, Nine- teenth Corps. Major General Emoiy,—Armj- of the Middle Military Division, Major Gen. Sheridan. Fort Leavenworth, Kansas. Little River, Tennessee Harrodsburgh, Kentucky. Little Blue, Missouri..... Cavalry and a portion of the Fifteenth Corps. 5th U. S. Colored Cavalry.................. 2d Colorado, 3d AA'isconsin, 5th, llth, 15th, and Kith Kansas Cavalry, and one brigade of Kansas militia of General Curtis's Army, 2d and 5th Missouri Militia, and two battalions of the 2d Missouri Artil- lery,—advance of General Pleasanton's Cavalry. 400 GO 56 3,516 501 1,891 3, OOOt Official Reports of Major Generals Sherman and Thomas. Official Report of General Sheridan. Brevet Brig. General G. D. Wells was killed. Official. Official Report of Major General Thomas. Report of Adjutant General of Illinois, A'ol. II, page 524. Official Report of Major General Grant. Official Report of Major General Rosecrans. Re- port of Adhitant general of Missouri, 1865, p. 383. Casualty Return, File F, No. 158, S. G. O. Official Report of Major General Sherman. ..... Official Report of Major General Rosecrans. 40 i Official Report of Major General Sherman. Official Report of Major General Torbett. Report of Adjutant General of Iowa, 1865, p. 285. 1,200 Official Report of Major General Rosecrans. Official Report of Major General Sheridan, Ap- pendix to Part I. Medical and Surgical History of the AA'ar, page 225. Casualty List, S. G. O. Also designated Middletown. A'mong the casu- alties in the Union army were Brigadier Gen- erals Bidwell and Thorburu, killed ; Major Generals AA'right, Ricketts. and Grover. and Acting Brigadier Generals Kitchen. MeKenzie, Penrose. Hamlin, Devius, Duval, and Lowell, wounded. In the Confederate army Major Gen. Ranueur was killed, and Major Ge'nerals Battle and Connor, wounded. Casualty Return, S. G. O. Official. Official. Official Report of Major General Rosecrans. Re- port of Adjutant General of Kansas. Two en- gagements, one between Geueral Price's van- guard and General Curtis's troops, and the other between General Price's rear and the advance of General Pleasanton. t Killed and wounded. a Q Q M H CO bd > H f UNION LOSs DATE. 1864. < )ct. 2-.'d . Oct. 2Cd . Oct. 23d.. Oct. 23d.. Oct. 23d.. Oct. 24th. (let. 25th. Oct. 26th to 29th. Oct. 27th. Oct. 27th and 28th. Oct. 28th aud 50th. Oct. 28th.. Oct. 28th.. Oct. 28th.. Oct. 28th. Oct. 29th. Oct. 30th. Oct. 30th. et nflfli LOCALITY Independence, Missouri AA'hitc River. Arkansas................ Gunboat attack on the Union batteries on the James River, A'irginia. Hurricane Creek, Mississippi.......... Princeton, Arkansas..............___ Westport, Big Blue, Missouri......... Cold water Grove, Osage . Missouri---- Mine Creek. Maria Des Oj-gncs, and Little Osage River, Kansas.' Milton, Blackwater, Florida............ Decatur. Alabama..................... UNION TROOPS ENGAGED. * 2d Colorado and 5th. 7th. llth, 15th. and Kith Kansas Cavalry, and Kansas Militia, of General Curtis's com- mand, and Ist, 2d. 4th. (ith, 7th, 8th, and 9th Missouri Militia Cavalj-, J 3th Missouri, 3d lowii, and 17th Illinois Cavalrj-, of General Pleasauton's command. 53d U. S. Colored Troops............................ I st Iowa and 9th Kansas Cavalry 3d Missouri Cavalry............. Missouri Militia Cavalry, and Cavalrj- of General A. J. Smith's command, commanded bj- Major General A. Pleasanton, and Cavalrj- and Kansas Militia of the Army ofthe Border, commanded by General Curtis. Kansas Cavalrj-, of Gen. Curtis's Armj' ofthe Border.. Cavalry of Generals Pleasanton's and Curtis's armies -. Hatcher's Run, South-Side Railroad, A'irginia. Fair Oaks, near Richmond, A'irginia--- Ncwtonia. Missouri................... Fort Heiman, Tennessee................ Destruction of the rebel ram Albemarle. Fayettcville, Arkansas................. Morristown, Tennessee................. Beverly, AVest A'irginia ..»............ Muscle Shoals, Raccoon Ford, Alabama. Ladija, Terrapin Creek, Alabama....... Near Brownsville. Arkansas............ J Vih Iowa-A'olunteers and 2d Maine Cavalrj-........... 1.8th Michigan, 102d Ohio, and 68th Indiana A'oluntcers, and 14th U. S. Colored Troops. 2d Cavalrj- Division, Gregg's; 2d and 3d Divisions, Second Corps, Major General Hancock; Fifth Corps, Major General AA'arren; and Ninth Corps, Major General Parke,—Army of the Potomac, Major Gen. Meade. Tenth Corps, MajorGeneral Terry; Eighteenth Corps. Major General AA'eitzel; and Cavalrj', Brig-. General Kautz,—Armj'of the James, Major General Butler, Cavalry of the Army of the Border, commanded bj- Gen. Blunt. Union gunboats Thirteen men, commanded by Lieut. AA'. B, Cushing, U. S. N. 1st Arkansas Cavalry................... Cavalry, commanded by General Gillem. 8th Ohio Cavalrj-....................... 1st Brigade, 1st Cavalrj- Division, Army of the Cum- berland. Garrard's Division of Cavalry ofthe Armj-of the Cum- berland. 7th Iowa and llth Missouri Cavalrj-.................. 10 156 120 45 ,047 783 1C0 699 CONFED. LO'-^S. 100 200 250 100 § 240 RE.AIARKS AND REFERENCES. Official Report of Major General Rosecrans. Two engagements, one between Price's advance and Curtis's troops, and the other between Price's rear-guard and Pleasanton's advance. Official. Official. Casualty List, File A, No. 525, ti. G. O. Official Report of Major General Rosecrans. Official Report of Major General Rosecrans. Pur- suit of Price's forces. Official Report of Lieutenant Colonel Sparling. Official Report of Major General Thomas. Official Report of Major General Grant. Appen- dix to Part I, Medical and Surgical History of the AA'ar, page 176. Casualty List, S. G.' (). Also designated Boydtown Road, Vaughn Road, and Burgess Farm. Official Report of Major General U. S. Grant. Casualtj- List, S. G. O. Official Report of Major General Rosecrans. Pur- suit of Price's forces. Official. Official report. Report of Adjutant General of Arkansas. • Ohio in the AVar, A'ol. 2, page 806. Report of Adjutant General of Iowa, 1667, p. 553. Report of Adjutant General of Iowa, 1867, p. 563. Oct. 31st...! Plymouth, North Carolina... Nov. 1st... Nov. 1st to 4th. Nov. 3d... Nov. 4 th and 5th. Nov. 5th and (ith. Nov. 5th. Nov. 9th. Black River, Louisiana--- Union Station, Tennessee A'era Cruz, Arkansas--- Johnsonville, Tennessee. Big Pigeon River, Tennessee Fort Sedgwick, A'irginia Atlanta, Georgia........ U.S. steamers Commodore Hull, Shamrock, Otsego. AVyalusing, and Taoony. 6th U. S. Colored Heavy Artillery................... 10th Missouri Cavalry............................... Nov. 9th...: Shoal Creek, Alabama | Nov. 12th.. Nov. 13th.. Nov. 14th to 28th. Nov. 15th. Nov. 16th. Newtown, Ninevah, and Cedar Springs, A'irginia. Bull's Gap, Morristown, Tennessee...... One company of the 4(ith Missouri Vols, (six-months'). llth Tennessee Cavalrj', 43d AVisconsin A'olunteers, and 12th U. S. Colored Troops. 3d North Carolina Mounted Infantry, Colonel Kirk--- Second Corps, Army of the Potomac.................. 2d Division, Twentieth Corps, Army of the Cumber- land. 5th Division, Cavalry, Brigadier General Hatch, of General Thomas' Army. 1st Division, Merritt's, and 3d Division, Custer's, Cav- alry of the Army of the Potomac, and 2d Division, Powell's, Cavalry of the Army of AVest A'irginia. 8th, 9th, and 13th Tennessee Cavalry, commanded by General Gillem. Cow Creek, Kansas................... Clinton and Liberty Creek, Louisiana ... Lovejoy Station, Jonesboro', Georgia ... Nov. 16th.. Bear Creek Station, Georgia. Nov. 17th.. Nov. 17th.. Nov. 18th.. Nov. 19th. Nov. 20th i Nov. 21st. Nov. 22d. Nov. 22d. Chester Station, Bermuda Hundred, Va. Aberdeen and Butler Creek, Alabama . Myerstown, Virginia................ Bayou La Fouche, or Ash Baj-ou, La. Macon, Georgia..................... 54th U. S. Colored Troops (2d Arkansas) and 3d Kan- sas Indian Home Guards. Expedition commanded by General A. L. Lee.....'--- 1st Brigade, 3d Division, Cavalry, Kilpatrick's, of the Army of the Cumberland. 2d Brigade, 3d Division, Cavalry, Kilpatrick's, of the Army of the Cumberland. 209th Pennsylvania Volunteers 2d Iowa Cavalry.............. Liberty and Jackson, Louisiana . Rolling Fork, Mississippi. Griswoldville, Georgia... Nov. 22d..l Clinton, Georgia. Detachment, commanded by Captain R. Blazer, 91st Ohio. llth Wisconsin Volunteers and 93d U. S. Colored Troops. 10th Ohio and 9th Pennsylvania Cavalry, 92d Illinois Mounted Infantry, and 10th AVisconsin Battery, ot the 3d Division Cavalry,—Army of the Cumberland. 4th Wisconsin Cavalry and 1st Wisconsin Batterj-...... 200 3d U. S. Colored Cavalry (1st Mississippi)............. AA'alcott's Brigade, 1st Division, Fifteenth Corps, and 1st Brigade, 3d Division of Cavalry,—Army of the Tennessee. Advance of the Fifteenth Corps................... * Killed, wounded, and missing. $ AA'ounded and missing, 200 Official Report of Commodore W. II. Macomb, U. S.N. Official. Official. Official. Official Report of Major General Thomas. Casualty Return, S. G. O. Also known as Fort Hell. Official Report of Brig. General A. S. AVilliams. Official Report of Major General Thomas. Official Report of Major General Torbett. List of casualties, S G. O. Appendix to Part I, Aledical and Surgical History of the War, page 326. Official Report of Major General Thomas. Report of Adjutant General of AA'isconsin, 1863. page 636. Official Report of Brigadier General Kilpatrick. Official Report of Brigadier General Kilpatrick. Report of Adjutant General of Iowa, 1864. p. 1323. Partizan Life with Mosby, page 267. Report of Adjutant General of Wisconsin, 1863, page 188. Official Report of Brigadier General Kilpatrick. 400 Report of Adjutant General of Wisconsin, 1865, page 636. Official Report of Afajor General Sherman. Gen. AA'alcott, U. S. A'., and Gen. Anderson, C. S. A., were wounded. / LOCALITY. Rood's Hill, A'irginia... Law renceburg, Tonnes Bent's Old Fork, Texas............... Oampbcllvillc and Lynnville, Tenn... Columbia, Duck Run, Tennessee...... Ball's Ferry, Oconee River, Georgia... Pawnee Forks, Kansas................ St. A'rain's Old Fort, Now Mexico..... Madison Station, Alabama............. Sandersvillo, Georgia................. Sylvan Grove, Georgia. Big Black River Bridge, Mississippi Central Railroad. Waynesboro", Thomas Station, and Buck Head Cheek. Fort Kelly, New Creek, AA'est Spring Hill, Tennessee....... Big Sandy, Colorado Territory.. Franklin, Tonnesseo............ Honey Hill, Broad Rivor, South Carolina. UNION TROOPS ENGAGED. 1st and 3d Divisions, Cavalry Corps, Army of the Potomac, and 2d Division of (' ivalry of the Army of AVest Virginia, Major General Torbett. 5th Division, Cavalry, ofthe Military Division of the Mississippi, Brigadier General Hatch. 1st California Cavalrj'................................ 5th Division, Cavalry, Brigadier General Hatch....... Capron's Brigade, 1st Division, Cavalry, and Fourth and Twenty-third Corps of General Thomas's Army. 1st Alabama Cavalry, advance of the Army of the Tennessee, Major General O. O. Howard. One company of the 1st Colorado Cavalry..... One company of the 1st New Mexico Cavalry. 101st II. S. Colored Troops................... 3d Brigade, 1st Division, Twentieth Corps..... 8th Indiana and 2d Kentucky, of the 1st Brigade, 3d Division, Cavalry, Major General Kilpatrick. Cavalry and Artillery, commanded by Colonel E. D. Osbu'nd, 3d II. S. Colored Cavalry. 3d Cavalry Division, Army of the Military Division of the .Mississippi, Major General Kilpatrick. Fourth Corps, MajorGeneral Stanley, and Cavalry. 1st and 3d Colorado Cavalry.......................... Fourth Corps, Major General Stanley, of the Army of the Cumberland; Twenty-third Corps, Major Gen. Cox, of the Army of the Ohio, coniinanded by Maj. General Schofield. 25th Ohio. 56th and 155th New A'ork Volunteers, and 26th, 3.'d, 35th, and lOJd II. S. Colored Troops, and 51th and 5">th M iss ichuseits Colored Troops, of the Army ofthe South, commanded by Brig. Gen. Hatch. UNION LOSS. CONFED. LOSS. 18 3 189 21 1,033 100 1,104 3,800 100 REMARKS AND REFERENCES. Casualty List, S. G. O. Official Report of Major General Thomas. Official. Official Report, of Major General Thomas. Official Report of Major General Thomas. Official Report of Major General O. O. Howard. Official. Official. Official Report of Major General Sherman. Also designated Buffalo Creek. Official Report of Colonel E. II. Murray, command- ing brigade Official Report of Major General Sherman. Also designated Reynold s Plantation, Jones' Planta- tion, and Browne's Cross Roads. Official Report of Lieutenant General R. E. Lee, { C. S. A. Official Report of Major General Thomas. Also designated Mount Carmcl. Oflicial. Casualty List, S. G. O. Appendix to Part I, Medi- cal mid Surgical History ofthe AA'ar, page 323. Official Reports of Major General G. H. '1 homas, U. S. A., and Lieutenant General Hood, C. S. A. Among the casualties were Major Generals Stanley and Bradley, U. S. A., wounded, and Major General Cleburne, Brigadier Generals Adams, John Williams, Strahl, Geist, and Gr.ui- i berrj', killed, and MajorGeneral J. Brown, Brig. . Generals S. Carter, Manigault, Quarles, Cockcr- elle, and Scott, C. S. A., wounded. Casualty Return, S.G.O. Also designated Gra- hauisville. w Pi O YA O f O Q M Q > f1 Hi o Nov. 30th to Deo. 4th. Dec. 1st to 31st. Deo. Is to 14th. Dec. 1st... Dec. 2d... Dec. 2d... Dec. 2d and 3d. Dec. 3d... Dec. 4th... Dec. 4th... Dec. 4th... Dec. 5th to 8th. Dec. 6th to 9th. Bermuda Hundred, Virginia. Stoney Creek Station and Duvall's Mills, AA'eldon Railroad, A'irginia. Twelve miles from Yazoo City, Miss... Trenches before Petersburg, Virginia.. Skirmishing in front of Nashville, Tenn Milieu Grove, Georgia........ Rocky Creek Church, Georgia. Mississippi. Block House, No. 2, Mill Creek, Chatta- nooga, Tennessee. Thomas' Station, Georgia...... Coosaw River, South Carolina. Block House, No. 7, Overall's Creek, Tennessee. Waynesboro' and Brier Creek, Georgia. Statesboro', Georgia...... Murfreesboro', Tennessee. Deveaux's Neck, South Carolina. Dec. (ith... | AA'hitc Post, Virginia................. Dee. 7th... Ebenezer Creek, Cypress Swamp, Ga. Dec. 7th j Ogeechee River, Georgia. to 9th. Weldon Railroad expedition. Dec. 7th to llth. Dec. 8th : Reconnoissance to Hatcher's Run, A'a. and 9th. I Deo. 8th | Raid to Gordonsville. Virginia. to 28th. I Pickets of the 20th Colored Troops.................... 2d Division, Gregg's, Cavalry, of the Army of the Potomac. Detachment, of the 2d AVisconsin Cavalry............. Army of the Potomac................................ Fourth Corps, Major General AA'ood, of tho Army of the Cumberland; Twentj'-third Cores, Major Gen. Schofield, Armj' of the Ohio; and 1st and 3d Divi- sions, ofthe Sixteenth Corps, Major Geu. A. J. Smith, Armj' of the Tennessee, and Cavalrj-, commanded by Major General AA'ilson. 5th Kentucky and 8th Indiana Cavalrj-, of Sherman's army. 3d Kentucky and 5th Ohio Cavalrj', advance of Sher- man's army. 2d New A'ork Cavalry................................ Detachment of the 115th Ohio Volunteers, 44th and two companies 14th U. S. Colored Troops. 92d Illinois Mounted Infantry......................... 25th Ohio Volunteers................................. Troops commanded by General Milroj'................ 3d Division, Cavalrj' ofthe Army ofthe Militarj- Divi- sion of the Mississippi, Brigadier General Kilpatrick. Foragers of the 15th Corps........................... Troops commanded by General Rosseau............... 26th, 33d, 31th, and 102d U. S. Colored Troops, 54th and 55th Massachusetts Colored Troops, 56th and 155th New A'ork, and 25th and 10?th Ohio A'olunteers, and 3d Rhode Island Artillery, commanded by Gen. Hatch. Naval Brigade commanded by Commander Preble. Fifty men of the 21st New York Cavalry.............. Uth Michigan and 9th Ohio Cavalry, rear guard of the left wing of Sherman's army. Fifteenth and Seventeeth Corps, of the right wing, Major Genera] O. O. Howard, of the Army of the Military Division of the Mississippi, Major General AA'. T. Sherman. 2d Division, Cavalry Corps, Fifth Corps, and 3d Divi- sion of the Second Corps,.Army of the Potomac. 3d and 13th Pennsj-lvania and 6th Ohio Cavalrj', and the 1st Division, Second Corps. 1st Division, Merritt's, and 3d Division, Custer's, Cav., Army of the I'otomac, commanded by Gen. Torbett. * Killed, wounded 175 j Casualty List, S. G. O. Official dispatches. Report of Adjutant General of AVisconsin, 1865, page 618. Casualty List, S. G. O. Official Report of Maior General Thomas. Appen- dix to Part I, Medical and Surgical History of the AA'ar, page 323. Casualty List, S. G. O. Official Report of Brigadier General Kiljatrick. Official Report of Brigadier General Kilpatrick. Official Report of Colonel L. Johnson, 44th U. S. Colored Troops. Official Report of Brigadier General Kilpatrick. Ohio in the War, Vol. 2, page 180. "100* Official Report of Major General Thomas. 200 Official Report of Brigadier General Kilpatrick. 2 Official Report of Major General Hazen. 197 Official Report of Major General Thomas. Also called the Cedars. 400* Casualty Return. S. G. O. Also designated Tilla- finney River, Mason's Bridge, aial Gregory's Farm. The Confederate General L. H. Gartrell , was wounded. 17 ' Official Report of Brigadier General Kilpatrick. Oflicial Report of Afajor General W. T. Sherman. Also designated Jenks' llridge, Eden Station, and Poole's Station. Casualty Lists, S. G. O. Casualty Lirt, S.G.O. Casualty List, S. G. O. LOCALITY. Expedition into Western North Carolina Fort Lyons, Indian Territory.......... Cuvhr's Plantation, Montcith Swamp, Georgia. Expedition to Hamilton, North Carolina Bellefield and Hicksford, A'irginia. Siege of Savannah, Georgia...... Elkton, Kentucky. Stoneman's raid from Bean's Station, Tennessee, to Saltville, A'irginia. Kingsport, Tennessee.... Fort McAllister, Georgia. Bristol, Tennessee Memphis, Tennessee. Abingdon, A'irginia .. Murfreesboro', Tennessee. Glade Springs........... Nashville, Tennessee..... UNION TROOPS ENGAGED. Hopkinsville, Kentucky. 3d North Carolina Volunteers, commanded bj' Colonel Kirk. 1st Colorado Cavalrj-, commanded by Colonel J. M. Chivington. Fourteenth Corps of the left wing of the Army of the Military Division of the Mississippi. 27th Massachusetts and 9th New Jersey A'olunteers, North Carolina Cavalry, and 3d New York Artillery. 2d Division, Cavalry Corps, Army of the Potomac____ Fourteenth Corps. MajorGeneral Davis, and Twentieth Corps, Major General AA'illiams,—left wing, Major General Slocum; Fifteenth Corps, Major General J. A. Logan, and Seventeenth Corps, MajorGeneral F. P. Blair.—right wing, Major Gen. O. O. Howard ;— Army of the Military Division of the Mississippi, Major General AV. T. Sherman. 1st Cavalrj'Division, commanded by Brigadier General McCook. Cavalrj- of the Army of the Ohio, commanded by Gens. Burbridge and Gillem. 8th, 9th, and 13th Tennessee Cavalry, commanded by Brigadier General Gillem. 2d Division, Major General Hazen's, Fifteenth Corps, of the Armj- of the Military Division of the Missis- sippi, Major General W. T. Sherman. Cavalry commanded bj' General Burbridge............ 4th Iowa Cavalry.................................... Cavalry commanded by General Burbridge............ Troops commanded bj' General Rosseau............... 12th Kentucky Cavalry..........................-___ Fourth Corps, Major General AA'ood, Army of the Cum- berland ; Twentj'-third Corps, Major General J. M. Schofield, Army of the Ohio; 1st and 3d Divisions, Sixteenth Corps, Major General A. J. Smith, Army of the Tennessee; detachments of colored troops, convalescents. rei.ruits, &c. Major General Steadman, and Cava'ry Corps, Major Gen. AVilson,—commanded by Major General G. H. Thomas. 2d and 3d Brigades, 1st Division, of Cavalry, McCook.. UNION LOSS. 400 7 110 1,740 15 CONFED. LO-S. 800 86 250 4,462 REMARKS AND REFERENCES Casualty List, S. G. O. Massacre of 500 Indians. Also known as Sand Creek. Official Report of Major General J. C. Davi Skirmishes at Foster's Bridge, 10th, and Butler's Bridge, 12th. Skirmish during the Weldon Railroad expedition. Official Report of MajorGeneral Sherman. Appen- dix to Part I, Medical and Surgical Historj' of the War, page 3v.T. Casualty List, S. G. O. Engagements at Kingsport, 13th; Bristol, 14th; Abingdon and Glade Springs, 15th; Marion. Kith andl8th; and Saltville, 20th. Casualty List,S.G.O, Official dispatches. Engagement during Stone- man's raid to Saltville. Official Report of Major General W. T. Sherman. Official dispatches. Engagement during Stone- man's raid to Saltville. Official. Engagement during Stoneman's raid to Saltville. Official Report of Major General Thomas. Engagement during Stoneman's raid to Saltville. Official Reports of Major General Thomas. Appen- dix to l'art I, Medical and Surgical Historj- of the AVar, page 323. Casualty List, S. G. O. Also designated Brentwood and Overton's Hills. Lieutenant General S. D. Lee and Brig. General Rulker, C. S. A., were wounded. Report of Adjutant General of AA'isconsin, 1865, page 592. O W Pi O o t-1 o Q i—i Q !> d ► Pi O Marion and AVytheville, Virginia. Millwood, Virginia........... Hollow Tree Gap, Tennessee. Franklin, Tennessee. Mitchell's Creek, Florida..... Pine Barren Creek, Alabama. Marion, A': Franklin Creek, Mississippi... Rutherford Creek, Tennessee. Saltville, A'irginia........... Lacey's Springs, A'irginia.............. Madison Court House......... ...... Lynnville, Tennessee.................. Jack's Shop, near Gordonsville, A'a..... Buford's Station, Tennessee............ Elizabethtown, Kentucky.............. Mocassin Gap, Virginia..... Murfreesboro', Tennessee___ Fort Fisher, North Garolina. Pulaski, Lamb's Ferry, Anthony's Hill, and Sugar Creek, Tennessee. Verona, Mississippi................... 8th, 9th, and 13th Tennessee Cavalry, commanded by General Gillem. A scouting party of the 14th Pennsylvania Cavalry___ 5th Division, Hatch's, and 7th Division, Knipe's, of Wilson's Cavalry, of General Thomas's army. 6th Division, Johnson's, of Wilson's Cavalry, of Gen. Thomas's army. 82d U. S. Colored Troops, of Col. Robinson's command. 82d and 97th U. S. Colored Troops, commanded by Colonel Robinson, 97th U. S. Colored Troops. Cavalrj' of the Army of the Ohio,commanded by Gen. Burbridge. Troops of the Third Corps, Major General Granger Cavalry of General Thomas's army Gillem's and Burbridge's Cavalrj', commanded by Gen. Stoneman. 3d Division of Cavalry, Custer's, of the Army of the Potomac. Michigan Cavalrj- Brigade ofthe 1st Division, Cavalry, Armj' of the Potomac. Cavalry of General Thomas's armj-, commanded by General AA'ilson. 1st Cavalrj- Division. Merritt's. Armj- of the Potomac, and M Division. Cavalry, Powell's, Army of West A'irginia. Cavalrj' of General Thomas' armj', commanded by Gen. AA'ilson. 1st Wisconsin Cavalry, of the 1st Cavalry Division, McCook's, Army of the Cumberland, 8th Tennessee Cavalry 12th U. S. Colored Troops............................ North Atlantic Squadron, commanded bj-Rear-Admiral Porter, and troops of the Tenth Corps, Army of the James, Major General B. F. Butler. Cavalry of General Thomas's army ' 7th Indiana Cavalry, of Grierson's command Decatur, Alabama.....................j Major General Steadman's Provisional Division Egypt Station, Mississippi. Pond Spring, Alabama. 7th Indiana, 4th and llth Illinois, 4th and 10th Missouri, 2d Wisconsin, 2d New Jersey, 1st Mississippi, and 3d U. S. Colored Cavalry. 15th Pennsylvania and detachments of the 2d Tennes- see and 10th, 12th, and 13th Indiana Cavalry, com- manded by Colonel Palmer. * Killed, Casualty Return, S. G. O. Official reports. En- gagement during Stoneman's raid to Saltville. Casualty List, S. G. O. Official Report of Major General Thomas. The prisoners captured were Confederates wounded in the engagement November 30th. 200 Official dispatches. Engagement during Stone- man's raid to Saltville. Casualty Return, S. G. O. Official Report of Major General Thomas. Official Report of Major General Thomas. Casualty List, S. G. O. Skirmish during the Gordonsville raid. Official Report of Major General Thomas. Casualty List, S. G. O. Official Report of Major General Thomas. 11 Report of Adjutant General of Wisconsin, 1865, page 592. Stoneman's raid. All the casualties were in the navj-. and were caused by the bursting of six one-hundred-pound Parrott guns. Official report. Casualty List, S. G. O. Official Report of Major General Thomas. Official Report of Major General B. H. Grierson. Official Report of Major General Thomas. Official Report of Brigadier General B. H. Grier- son, commanding. Brigadier General Gholson, C. S. A., was killed. 45 Official Report of Major General Steadman. DATE. 1865. Jan. 2d... Jan. 2d... Jan. 3d... Jan. 5th... Jan. 7th... Jan. 8th... Jan. 8th... Jan. llth.. Jan. 13th to 15th. Jan 14th.. Jan. 14th.. Jan to 14th Kith. Jan. lfilh.. Jan. 18th.. Jan. 19th.. Jan. 24th.. Jan. 25th.. Jan. 25th.. Jan. 25th.. Jan. to Fc 29th b llth. LOCALITY Franklin, Mississippi....... Nauvoo, Alabama.......... Thorn Hill, Alabama...... Smithfield, Kentucky---.'. Julesburg, Indian Territory Scottsboro', Alabama...... Ivy Ford, Arkansas........ Beverly, West A'irginia--- Fort Fisher, North Carolina Red Hill, Alabama ... Dardanclle, Arkansas . Pocataligo, South Carolina............. Explosion of the magazine of Fort Fisher. Ten miles from Columbus, Kentucky__ Half-moon Battery, Sugar Loaf Hill, North Carolina. Fort Brady, A'irginia.................. Coinbahee River, South Carolina........ Powhatan, A'irginia..... Simpsonville, Kentucky. Expedition into AA'esteni North Caro- lina. UNION TROOPS ENGAGED. 4th and llth Illinois and 3d U. S. Colored Cavalry, commanded by Colonel Osband, 3d U. S. Colored Cavalrj'. 15th Pennsylvania and detachments of the 2d Tennes- see and 10th, 12th, and 13th Indiana Cavalry. 15th Pennsj-lvania and detachments of the 10th, 12th, and 13th Indiana and 2d Tennessee Cavalrj'. 6th U. S. Colored Cavalry............................ One company of the 7th Iowa Cavalry................ Fifty-four men of the 101st U. S. Colored Troops...... 79th U. S. Colored Troops............................ 34th Ohio Volunteers and 8th Ohio Cavalry............ 2d Division and 2d Brigade 1st Division, Twenty- fourth Corps, and 3d Division, Twenty-fifth Corps, of the Army of the James, commanded bj- Major General A. H. Terry, and sailors and marines of the Atlantic blockading squadron, commanded bj- Rear- Admiral Porter. 15th Pennsylvania Cavalry, coniinanded bj- Colonel W. J. Palmer. 2d Kansas Cavalry and Iowa Cavalry................. Seventeenth Corps, Major General Blair, Army of the Tennessee. Troops of General Terry's detachment of the Army of the James. Tennessee Cavalry................................. Portion of the Twenty-fourth and Twenty-fifth Corps, Armj' of the James. U. S. Colored Troops and Heavy Artillery of the Army of the James. Fifteenth Corps, Major Gen. Logan, and Seventeenth Corps, Major General Blair,—Army of the Tennes- see, Major General O. O. Howard, ofthe Army of the Military Division of the Mississippi. 1st U. S. Colored Cavalry..................:........ 5th U. S. Colored Cavalry.......................... 3d North Carolina, Colonel Kirk..................... UNION LOSS. 5 184 25 CONFED. LOSS. 20 583 22 12 10 501 20 4001 REMARKS AND REFERENCES Casualty List, File A, No. 372, S. G. O. Official Report of Brigadier General B. II. Grierson. Official Report of Colonel Palmer, 15th Pennsyl- vania Cavalry. Capture and -destruction of Hood's supply and pontoon train. Official Report of Colonel Palmer. 15th Pennsyl- vania Cavaby. Official. Report of Adjutant General of Iowa, 1865, p. 147. Engagement with Indians. Official Report of Brigadier General C. Cruft. Official. Casualty Return, S. G. O. Ohio in the AVar, Vol. 2, pages 227, 807. Official reports. Casualty List, S. G. O. Major Geueral AV'. II. C. AA'l'iiting, commanding the Confederates, and Brig. Generals Bell, Curtis, and Ponybacker, U. S. V., were wounded. 100 I Official Report of Miijor General Thomas. ......! Casualty Return, File F, No. 233, S.G.O. Official Report of Major General Sherman. Casu- alty List, S. (1. O. ' Official. Casualty List, 3. G. (). Report of Adjutant General of Connecticut, 1865, page 169. Casualty List, S. G. O. Also designated Fort Burnham or Boggs' Mills. List of casualties, S.G.O. Appendix to Part I, Medical and Surgical History of the AA'ar, p. 321. Official Report of Major General Sherman. Official. Official. Casualty Return, 8. G.O. Q W W o o t-< o Q o r/3 ► to o River's llridgo, Salkahatchie, South Carolina. Dabney's Mills, Hatcher's Run, Va. Dunn's Lake, A'olusia Countj', Florida. Bind Springs, Indian Territory......... AA'iliston, South Carolina.............. Binnaker's Bridge, South Edisto River, South Carolina. Rush Creek, Indian Territory... James Island, South Carolina... Blackville, South Carolina Smar Loaf Batterj', Federal Point. North Carolina. Aiken, South Carolina Orangeburg, North Edisto River, South Carolina. Gunter's Bridge, South Carolina. Congaree Creek, South Carolina. Cedar Keys, Florida..... Columbia, South Carolina Fort Jones, Kentucky...... Ashby Gap, Virginia....... Charlsston, South Carolina. Fort Anderson, North Carolina.......... Fort Myers, Florida......... Town Creek, North Carolina Seventeenth Corps, MajorGeneral Blair, and Fifteenth Corps, Major Gon. Logan, —Army of the Tennessee. 2d Division Cavalry, Gregg's ; Second Corps, Major General Humphrey ; Fifth Corps, Major General G. K. Warren; and 1st Division, Sixth Corps,—Army of the Potomac, Major General Mcado. Detachment of the 17th Connecticut A'olunteers..... 11 th Ohio and 7th Iowa Cavalry.................... Cavalrj' commanded by Brigadier General Kilpatrick 1, 062 Seventeenth Corps, MajorGeneral Blair, Army of the Tennessee. llth Ohio and 7th Iowa Cavalry..................... Schimmelfemiig's Division ofthe troops of the Depart- ment of the South, MajorGeneral Gillmore. 3d Division Cavalry, Kilpatrick's, Army of the Mili- tary Division of the Mississippi. 2d Division and 1st Brigade of the 1st Division, Twentj'-fourth Corps, anil 3d Division ofthe Twenty- fifth Corps, Armj' of the James, Major Gen. Terry. 3d Division Cavalry, commanded by Gen. Kilpatrick .. Seventeenth Corps, Army of the Tennessee, Major General Blair. 3d Division Cavalry, Major General Kilpatrick, Army of the Militarj- Division of the Mississippi. Fifteenth Corps, Major General Logan, Army of the Tennessee. 2d U. S. Colored Troops.............................. Fifteenth Corps, Major General J. A. Logan, Army of the Tennessee. 12th U. S. Colored Heavy Artillery................... Detachment of the 14th Pennsylvania Cavalry........ Troops of the Department of the South, Major Gen. Q. A. Gillmore. Navy, commanded by Rear-Admiral Porter; troops of the Twentj'-fourth Corps, Army ofthe James, Major General 'terry, and Twenty-third Corps, Army of the Ohio, Major General Cox. 3d Division, Twenty-third Corps, Army of the Ohio, Major General J. D. Cox. 201 501 1,200* 160 Includes skirmishes at Hickory Hill, Owen Cross Roads, Lowtonville, Duck Creek, and AA'hiphy Swamp. Official Report of Major General Sher- man. List of casualties, S. G. O. Official Report of Major General Grant. Casu- alty List. S. G. O. Appendix to Part I, Medi- cal and Surgical History of the War. Also des- ignated Rowantj' Creek and A'aughn Road. Among the casualties in the Union army were Brigadier Generals Morrow, Smythe, rtavis, Gregg, Aj-res, Sickel, and Gwyn, wounded; in tlie Confederate army, General Pegram, killed, and Brigadier General Sorrell, wounded. Engagement with Indians. Official Report of Mtjor General Sherman, com- manding Military Division of the Mississippi. Casualtj- List, S. G. O. Official Report of Major General Sherman, commanding Militarj- Divis- ion of the Mississippi. Engagement with Indians. Casualtj- List, File F, No. 208, S. G. O. Official Report of Major General Sherman. Official Report of Major General Schofield. Official Report of Major General Sherman. Official Report of Major General Sherman. Casu- alty Lists, S. G. O.' Official report. Official Report of Major General Sherman, com- manding Military Division of the Mississippi. Official Report of Major General Sherman, com- manding Military Division of the Misissippi. Official. Official Confederate reports. Official Reports of Rear-Admiral Porter and Major General Schofield, commanding. Official Report of Major General Schofield. Casu- alty List, S. G. O. * Killed, wounded, and missing. t Killed and wounded. DATE. 1865. LOCALITY Feb. 22d. Feb. 26th. Feb. 26th.. Feb. --- Feb. 27th to Mar. 25th Feb. 29th.. Mar. 2d... Mar. --- Mar. 2d... Mar. 2d- aud 3d. Mar. 3d... Mar. (ith... Mar. 6th... Mar. 6th.. Mar. 7th.. Mar. 8th to 10th. Mar. 10th.. Mar. llth.. Mar. 13th.. Mar. 14th.. Mar. 15th.. AA'ilmington, North Carolina............ Douglas Landing, Pine Bluff,-Arkansas. Mount Clio, South Carolina........... Lynch Creek, South Carolina. Chattanooga, Tennessee...... Sheridan's raid in A'irginia ... Blount Craw ford, A'irginia___ AA'aynesboro' A'irginia........ Clinton, Louisiana.......... Chesterfield, South Carolina Cheraw, South Carolina............... Florence, South Carolina.............. Olive Branch, Louisiana............... Natural Bridge, Florida............... North Fork, Shenandoah, A'irginia..... Rockingham, North Carolina.......... Wilcox's Bridge, AA'isc's Fork, North Carolina. Monroe's Cross Roads, North Carolina.. Clear Lake, Arkansas................. Silver Run, Fayotteville, North Carolina Kingston, North Carolina.............. South Anna River, A'irginia........... UNION TROOPS ENGAGED, 2d and 3d Divisions of the Twenty-third Corps, Army of the Ohio, Major General J. D. Cox, and a portion of the Twenty-fourth Corps, Army of the James, Major General Terry. 13th Illinois Cavalry................................ Detachment of mounted men, commanded by Capta Duncan. Advance of the Fifteenth Corps, Major General Logan 16th U. S. Colored Troops......................... 1st Division, Major General Devin, and 3d Division, Major General Custer, Cavalry Corps,—Army of the Potomac, Major General Sheridan. 3d Brigade, 3d Division, Cavalry Corps, Army of the I'otomac. 3d Division, Brigadier General Custer, Cavalry Corps, Major Gen. Sheridan, Armj- of the I'otomac. 4th AVisconsin Cavalry............................... Advance of the Twentieth Corps, Major General A. S. Williams. Advance of the Seventeenth Corps, Major General I P. Blair. Detachment of mounted infantrj' from General Sher- man's Armj-. 4th AA'isconsin Cavalrj'............................... 2d and 99th U. S. Colored Troops, and other troops, commanded bj' General Newtown. Portion of Sheridan's Cavalry, commanded by Colonel Thompson, 1st New Hampshire Cavalry, guarding prisoners. Cavalry Division, Kilpatrick's, of Sherman's Army 1st Division, Palmer's, and 2d Division, Carter's, ofthe District of Beaufort, and 1st Division, Ruger's, Twenty-third Corps, Army of the Ohio. Cavalry Division, Brigadier General Kilpatrick........ 3d AA'isconsin Cavalry........................1....... Advance of the Fourteenth and Seventeenth Corps Major General Sehofield's command 5th II. S. Cavalry, 1st Division Cavalry, Major General Sheridan. UNION LOSS. 13 600 103 11 CONFED. LOSS. 26 30 1,600 1,500" REMARKS AND REFERENCES. Official Report of Afajor General Schofield. Casu- alty List, S. G. ().' Official. Official Report of Major General Sherman.' Official Report of Major General Sheridan. In- cludes skirmishes at Mount Crawford, Feb. 29th, Wajrnesboro', March 2d, and Ashland, .Alar. 15th. Skirmish daring Sheridan's raid, February 27th to March 25th. Official Report of Major General Sheridan. Casu- alty List, S. G. O. Official Report of MajorGeneral Sherman. Casu- alty List, S. G. O. Official Report of Major General Sherman. Casu- alty List, S. G. O.' Official Report of Major General Sherman. Report of Adjutant General of AVisconsin, 1865, page 637. Official. Official report. Official Report of Major General Schofleld> Official Report of Major General Sherman. Official. Official Report of Major General Sherman. Occupied by nationals. Offioial Report of Major General Sheridan. o Mar. 15th.. Mar. 15th.. Mar. 16th.. Mar. 18th.. Mar. 19th to 21st. Mar. 20th to Apr. 6th. Mar. 21st.. Mar. 21st.. Mar. 23d.. Mar. 24th.. Mar. 24th.. Mar. 25th.. Mar. 26th to Apr. 9th. Mar. 26th to Apr. 8th. Mar. 22d to Apr. 24th. Taylor's Hole Creek........ Ashland, Virginia........... Averysboro', North Carolina. Boyd's Station, Alabama___ Bentonville, North Carolina Stoneman's raid, Southwestern A'irginia and North Carolina. Goldsboro', North Carolina___ Hamilton, Virginia............ Sumpterville, South Carolina.. Rerock, Arizona Territory..... Coxe's Bridge, North Carolina. Fort Steadmau, in front of Petersburg, Virginia. Petersburg, A'irginia . Pine Barren Creek, Alabama . Siege of Mobile, Alabama___ Spanish Fort, Alabama....... Quaker Road, Gravelly Run, Virginia. Wilson's raid, Chickasaw, Alabama, to Macon, Georgia. Kilpatrick's Cavalrj', advanoe of General Sherman's forces. 2d Brigade, 3d Division, Cavalrj- Corps, Army of the Potomac. Twentieth Corps, MajorGeneral AA'illiams, and Cavalry Division, Brigadier Gen. Kilpatrick,—Armj' of the Military Division of the Mississippi, Gen. Sherman. 101st U. S. Colored Troops.........................., Fourteenth Corps, Major General J. C. Davis, and Twentieth Corps, Major General A. S. Williams,— left wing, MajorGeneral Slocum; Fifteenth Corps, MajorGeneral J. A. Logan, and Seventeenth Corps, Major General F. P. Blair,—right wing, Major Gen. O. O. Howard; and Cavalry Division, llrig. General Kilpatrick ;—Armj' of the Military Division ofthe Mississippi, Major General AV. T. Sherman. Palmer's, Brown's, and Miller's Brigades of Ca commanded by Major General Giliem. Major General Schofield's command. 12th Pennsj-lvania Cavalrj-......... 1st New Mexico Cavalrj-............................ Provisional Corps, commanded by Major Gen. Terry... 1st and 3d Divisions, Ninth Corps, Major General Parke, Armj- of the Potomac. Second Corps, Major General A. A. Humphrej-s, and Sixth Corps, Major General II. G. Wright,—Army of the Potomac. Cavalry advance of General Steele's column.......... Army ofthe Militarj- Division ofthe West Mississippi commanded by Major General E. R. S. Canbj-. Thirteenth Corps, Major General F. Steele, and Six teenth Corps, Major Gen. A. J. Smith,—Army ofthe Military Division of the West Mississippi, com manded by Major Gen. E. R. S. Canby, and Navy, commanded by Commodore Thatcher. 1st Division, Major General Griffin, and Fiflh Corps Major General G. K. Warren,—Army of the Potomac 1st Brigade, Brigadier Gen. Croxton, and 2d Brigade Colonel O. H. Lagrange,—1st Division, Maj. General E. M. McCook; 1st Brigade, Col. O. A. Miller, and 2d Brigade, Colonel R. G. Minty,—2d Division, Brig- General Eli Long; 1st Brigade, Brigadier General E. F. Winslow, and 2d Brigade, Brigadier Gen. Alex ander,—4th Division Cavalrj', Maj. Gen. E. Upton ;— Cavalry Corps of the Military Division of the Missis sippi, Major General Jos. H. AVilson. 100 25 306 1 287 540 1,200 8001 1,200 f 1, 025 6,820 Official Report of Major General Sherman. Casualty List, S. G. O. General Sheridan. Official Report of Major Offioial report. Also designated Smith's Farm. Casualty List, S. G. O. Appendix to Part I, Medical and Surgical History of the War, p. 323. Official. Appendix to Part I, Medical and Surgical History of the War, page 321. Casualty List, S. G. O. Official report. Occupied by the nationals. Casualty List, S. G. O. Ohio in the War, Vol. 2, page 578. Official. Casualty List, S. G. O. Appendix to Part I, Medical and Surgical History of the War, page 203. Casualty List, S. G. O. Official reports. The Confederate Generals Terry and Cooke were wounded. Appendix to Part I, Medical and Surgical History of the AVar, p. 203. List of casualties, S. G. O. Official reports. Also known as Bluff Spring. Gen. Clanton, C. S. A., killed. See engagement at Spanish Fort, March 26th to April 9th, and Fort Blakely, April 9th. Appendix to Part I, Medical and Surgical History ofthe War, page 337. List of casualties, S.G.O. Appendix to Part I, Medical and Surgical History of the War, page 204. List of casualties, S. G. O. Official reports. Official Report of Major General J. H. AA'ilson, commanding. Appendix to Part I, Medical and Surgical Historj- of the War, page 327. List of casualties, S. G. O. General Eli Long, wounded. Includes engagements at Montavallo, Mar. 31st; Plantersville, 'Prion, April 1st; Scottsville, Selma, April 2d; Northrop, April 3d; Tuscaloosa. Apr. 4th ; Pleasant Ridge, April 6th ; Lowndesboro', April 10th ; Montgomery. Apr. 12th ; Fort Tyler, AA'est Point, and Columbus, April lbth ;" and Tobosofkee and Macon, April 20th. ' Killed, wounde1, end missing, t Killed and wounded. DATE. 1865. Mar. 31st.. Mar. 31st.. Mar. 31st.. Apri 1st.. Apri 1st.. Apri 1st.. April ist.. Apri 1st.. Apri! 1st.. April 2d.. . A mil 2d... April 2d... April 3d.. April 3d.. April 3d... April 3d.. LOCALITY Boydton and White Oak Roads, Va. Dinwiddic Court House, A'irginia... Montavallo and Six Mile Creek, Ala. Five Forks, A'irginia,.............. Boone, North Carolina. Trion, Alabama. Mount Pleasant, Alabama.............. Centreville, Alabama................;. Bogler's Creek and Plantersvillc, Ala... Selma, Alabama....................... UNION TROOPS ENGAGED. Fifth Corps, Major General G. K. AA'arren, and Second Corps, Major General A. A. Ilumphrej's,—Army of the Potomac. Ist Division, Devins; 2d Division, Crook ; 3d Division, Custer,—Cavalry Corps, Major General Merritt;— Armj' ofthe Potomac, MajorGeneral P. H. Sheridan. 4th Division, Cavaliy Corps, Major General Upton..... Division of Cavalrj' of the Armj- of the James, Me- Kenzie; 1st Division, Devins, 2d Division, Crook, and 3d Division, (Ulster,—Cavalrj' Corps, Major General Merritt, and Fifth Corps, Maj. General G. K. Warren, of the Army of the I'otomac, commanded by Major General P. IL Sheridan. Scottsville, Alabama........ Fall of Petersburg, A'irginia. Namoziu Church and AA'illieomack, A'a. Richmond, Virginia................... Salem, North Carolina , AA'ytheville, A'irginia... 1st Brigade, Croxton, 1st Division, McCook, Cavalry Corps, of the Armj' of the Militarj' Division of the Mississippi. Cavalry of General Canby s forces, commanded by General Lucas. 2d Brigade, La Grange, 1st Division, McCook, Cavalry Corps, of the Military Division of the Mississippi. 2d Division, Brigadier General Eli Long, and 4th Divi- sion, Major General Upton, Cavalrj' Corps, of the Militarj' Division of the Mississippi. 2d Division, Brigadier Gen. Eli Long-, Cavalry Corps, of the Militarj- Division of the Mississippi, Major General J. H. AA'ilson. 2d Brigade, La Grange, 1st Division, McCook, Cavalry Corps, of the Military Division of the Mississippi. Second Corps, Major General A. A. Humphrej'; Sixth Corps, Major Gen. II. G. Wright ; and Ninth Corps, Major General J. G. Parke,—of the Army of the Potomac, Major Gen. G. G. Meade: Twenty-fourth Corps, Major General Gibbons,—Armj' of the James, Major General E. O. C. Ord. 3d Division, Custer, Cavalry Corps, Major Gen. P. II. Sheridan, Armj' of the I'otomac. Cavalrj-, commanded by Colonel Palmer.............. 15th Pennsylvania Cavalry, commanded by Colonel Miller. UNION LOSS. CONFED. LOSS. Pi k| O Northport, Alabama. Deep River Bridge, North Carolina. Tuscaloosa, Alabama.............. Amelia Springs, Virginia. Sailor's Creek, Virginia... Sipsey Swamp, Alabama............ High Bridge, Appomattox River, Va. FarmviUe, Virginia................. Appomattox Court-House, Virginia . Fort Blakelj-, Alabama............ Lee surrendered . Sumterville, South Carolina . Neuses River, North Carolina. Lowndesboro', Alabama...... Montgomery, Alabama. Grant's Creek, Salisbury, North Caro- lina. Whistler's Station, Alabama.......... South Fork, John Day's River, Oregon. Fort Taylor, West Point, Georgia..... Columbus, Georgia Berryville, Virginia............ Boykin's Mills, South Carolina 1st Brigade, Croxton, 1st Di Corps, of the Militarj' Divh ision, McCook, Cavalrj- in of the Mississippi. 1st Brigade, Croxton, 1st Division, McCook, Cavalry Corps, of the Militarj' Division of the Mississippi. 2d Division, Crook, Cavalry Corps, Sheridan, of the Armj' of the Potomac. Cavalry Corps, Major General P. H. Sheridan ; Second Corps, MajorGeneral A. A. Humphreys ; and Sixth Corps, Major General II. G. AV'riglit,—Armj' of the Potomac. 1st Brigade, Croxton, 1st Division, McCook, Cavalry Corps, of the Military Division of the Mississippi. Portion of the Twentj--fourth Corps................... Second Corps, Major General A. A. Humphrey, Army of the Potomac, Major General G. G. Meade. Cavalry of the Army of the Potomac, Major General Sheridan, and Twenty-fourth Corps and one division of the Twenty-fifth Corps, Major General Ord. Thirteenth Corps. Major General F. Steele, and Six- teenth Corps, Major General Smith,—Army of the Military Division of the West Mississippi, Major General E. R. S. Canby. Armies of the Potomac and James, Major General U. S. Grant. Troops of the Department of the South.............. Advance of Major General Sherman's Army........... 2d Brigade, La Grange's, 1st Division, McCook's, of the Cavalry Corps of the Military Division of the Mississippi. 2d Brigade, La Grange's, 1st Division, MeCook's, Cav- alry Corps of the Military Division of the Missis- sippi. 3d Division of the Thirteenth Corps, Army of the West Mississippi. One company of the 1st Oregon Cavalry............. 2d Brigade, La Grange's 1st Division, McCook's, Cav- alry Corps, of the Military Division of the Missis- sippi. 4th Division, Upton's, Cavalry Corps of the Military Division of the Mississippi. Major General Hancock's command---- Troops of the Department of the South 20 166 96 1,014 1,000 200" l,000t 60 AA'ilson's raid, March 22d to April 20th. 00 150 6,000 5001 29 20 26,000 218 1,200 700 Stoneman's raid. Wilson's raid, March 2.'d to April 20th. Official Report of Major General P. H. Sheridan. Also designated Jettersville. Appendix to Part I, Medical and Surgical History of the AVar, page 203. Casualty List, S. G. O. Official Report of Major General P. H. Sheridan, commanding. Also designated Harper's Farm and Deatonsville. Wilson's raid, March 22d to April 20th. General Theodore Read, commanding, was killed. Casualty List, S. G. O. Appendix to Part I, Medical and Surgical History of the War, page 203. List of casualties, S. G. O. Generals Smyth and Mott were wounded. Appendix to Part I, Medical and Surgical History of the War, page 203. Casualty List, S. G. O. Also designated Clover Hill. Appendix to Part I, Medical and Surgical History of the War, page 337. Casualty List, S. G. O. Siege of Mobile. Casualty List, File F, No. 209, S. G. O. Official Report of Major General Sherman. Engagement during Wilson's raid, March 22d to April 20th. Official report. Engagement during Wilson's raid, March 22d to April 20th. Stoneman's raid. Official. Wilson's raid, March 22d to April 20th. The Con- federate commander, General Tyler, was killed. Wilson's raid, March 22d to April 20th. Surrender of Mosby's command. Also called Bradford Springs. * Killed, wounded, and missing, t Killed and wounded. X DATE. 1 S(i5. LOCALITY. UNION TROOPS ENGAGED. UNION LOSS. CONFED. LOSS. •a « a 3 o i 13 u -a a s o bo a i REAIARKS AND REFERENCES. | April 19th. April 19th. April 19th. April 20th. April 20th. April 22d.. April 23d.. April 23d.. April 26th. May 4th... May 10th.. May 10th.. May llth.. May 13th.. May 26th.. 10 Stoneman's raid. Stoneman's raid. Wilson's raid, March 22d to April 20th. Wilson's raid, March 22d to April 20th. Wilson's raid in Alabama, March 22d to April 20th. Wilson's raid, March 22d to April 20th. Jefferson Davis captured. Official Report of Major General Wilson. The casualties were caused bj' the pursuing parties firing into each other. Official reports. Report of Adjutant General of Indiana, Vol. II, page 343. 325 30 2,193 17th Indiana Mounted Infantrj-, advance of Wilson's Cavalry. Talladega, Alabama................... Mumford's Station, Blue Mount, Ala___ 1st Brigade, Croxton's, 1st Division, McCook's, Cav-alry Corps of the Militarj' Division of the Missis-sippi. 150 alrj- Corps of the Military Division of the Missis-sippi. Armies of the Tennessee, Georgia, and Ohio, Major General Sherman. 29, 924 10, 000 21 8,000 7,454 o 4 Sam Jones surrendered at Tallahassee, Florida. Jeff Thompson surrenders at Chalk Bluff, Arkansas. Detachment from AA'ilson's Cavalrj' Corps, commanded by Major General McCook. 62d IT. S. Colored Troops, 34th Indiana Volunteers, and 2d Texas Cavalry. 118* ... 20,000 1 Killed, wounded, and missing. O O fej O d CO M o o W a W to o « o t-l o Q M a t> t-i d INDEX CHRONOLOGICAL SUMMARY OF ENGAGEMENTS AND BATTLES. Page. Aberdeen, Ark............................................ LI Aberdeen. Ala........................................... CXXIX Abbeville, Miss........................................CXX, CX XI Abbs A'alley, Va.......................................... CVII Abingdon, Va............................................ CXXXII Acton, Minn............ ................................. LATI Ackworth, Ga............................................ CXI Adamsville, Tenn...................................... XLA'I Adair County, Mo........................................ LIII Adairsville, Ga........................................... (TX iEtna, Mo................................................ XXXV Aiken.S.C............................................. CXXXV Alimosa, N. Mex.......................................... XXXATI Alpine Station, A'a........................................ XI. Alpine Gap, Ga........................................... LXXXVI Algiers, La.............................................. XLIX Allen's Farm, ATa......................................... L Aldie, A'a.............."...........................LX, LXI, LXXVIII Alexandria, La.......................................... CIV Alexandria, near, La...................................... CV Alabama, Rebel Steamer................................LXVI, CXIII Alabama, raid in......................................... CXVI Albemarle, Ram, N. C.................................... CV Albemarle, Ram, destruction of........................... CXXVIII Allatoona Hills, Ga........................................ CX ALLATOONA, GA......................................... CXXAT Amelia Springs, A'a....................................... CXXXIX Amite River, La.......................................XLIX, LXX Ammunition, explosion of, at City Point, Va................ CXIX Anandale, A'a............................................. XXXIX Antietam, Md........................................... LVIII Anxvois River, Mo...................................... LX Antioch Station, Tenn................................... LXXI Anderson's Gap, Tenn....................................LXXXATII Anderson's Cross Roads, Trim.................. .........LXXXAIII Antoine, Ark............................................. . (TI Anthony's Hill, Tenn..................................... CXXXIII Apache Canon, N. Mex.................................... XLIII Apache Pass, Ariz....................................... LII Apalachicola River, Fla.................................. LX Appomattox River, A'a.................................... CXXXIX Arro&iATTOX Court-house, A'a........................ CXXXIX Aquia Creek Batteries, Va................................ XLIII Aranzas Pass, Tex........................................ XCIII Armstrong Ferry, Tenn................................... XCVI Arrow Rock, Mo.......................................... LXXXIX Arrowfield Church, Va................................... CVU Arkansas Post, Ark....................................... LXAT Arkansas River, Ark.......................,.............. CXVI Arkansas, Rebel Ram, attempt to destroy................... LI Arkadelphia, Ark.........................................LXVHI, CI Arthur's Swamp, Va...................................CXXII, CXXA' Assault on Fort Wagner.................................. LXX XII Ashland, La............................................. LXX ATI Ashland, A'a...................................C All. CX, (XXXATI Ash Bayou, La.......................................... CXXIX Ashwood Landing, La.................................... CV Ashepoo River, S. C................... ................. C\ 111 10* Page. Ashley's Mills, Ark....................................... LXXXVI Ashley Station, Ark...................................... CXXI Ashby's Gap, A'a.....................LIX, LXX XII, CX ATI, CXXXV Attack by guerrillas on transport Crescent City............. LXXVI Atehafalaj-a River, La.................................. LXXXVI Atlee's, Va.............................................. C Athens, Mo.............................................. XXXVI Athens, Ala............................XLVI, XCVI, CXXIV, CXXV Athens, Ky.............................................. LXATII Atlanta, capture ofthe...... ............................. LXX IX Atlanta Railroad, raid on.................................. CXXI Atlanta, Ga.............................................. CXXIX Atlanta, Ga., Hood's first sortie............................ CXATI Atlanta, Ga., Hood's second sortie....................... CXATII Atlanta, Ga., campaign to, from Chattanooga............... C X XII Atlanta, Ga., siege of...................................... CXVIII Atlanta, Ga., occupation of................................ CXXII Austin, Miss............................................LIII, LXXVI Austin, Ark............................................... LXXXV Auburn, A'a.............................................. XC Auburn, Ga.............................................. CXVII Augusta, Ky.............................................. LIX Augusta, Ark............................................ CI Averill's Raid, AV. \Ta..................................... LXXXV Averill's Raid, Southwestern Va.......................... XCIV Avoyelle's Prairie, La.................................... CATII AVEitYSUOnO', N. C...................................... CXXXATI Baltimore, streets of...................................... XXXIV Baltimore Cross Roads, Va............................LXXX, LXXXI Baj-ou Cache, Ark........................................ LI Bayou De View, Ark..................................... LI Baj-ou Barnard, C. N...................................... LII Bayou Teche, La........................................LXII, LXVI Baj-ou Bontecou, La...................................... LXI1I Baj'ou Vermilion,.La..................................... LXXI Bayou Pierre, Miss.................-...................... LXX IV Baj-ou Tensas, La ....................................... LXXX Bayou Metoe, Ark........................................ LXXXV Baj'ou Borbeaux, La...................................... XCI Baj-ou Sara, Miss......................................... XCII Bayou Rapides, La....................................... CI Bayou La Mourie, La.......... .................. ....... CAT Bayou De Glaize, La.................................. CIX Bayou Biddell, La....................................... CXXATI Bayou La Fouche, La.................................... CXXIX Ball's Cross Roads, A'a.................................... XXXVI Ball's Bluff, Va......................... ............. XXXVIII Ball s Ferry, Ga.......................................... CXXX Barboursville, AV. A'a................................XXXV, XXXVII Bayles' Cross Roads, La.................................. XXXVIII Bagdad, Ky.............................................. XL Bath, Va ............................................XL, LXXXVI Barry Countj', Mo......................................... XLII Bates County, Mo...............-.......................* XLVI Banks's Retrkat, A'a ................................. XLA'II Battle Creek, Tenn.................---................. XLIX Batcsville, Ark......................................IT, LXA II, XCI X Baton Rouge, La.......................LIII, LXXI, LXXXVI, CV TXLTI INDEX. Page Bardstown, Ky............................................ L1X Bnrliee's Cross Roads. Ara.............................LX1I, LXXXAT Bachelor's Civ. k, N. C.....................LXII, LXXVI, XC ATI, CX Bacon Creek. Ky.......................................... LX V Baxter Springs, Ark......................................LXXXATII Baker Springs, Ark....................................... Baker's Creek, Miss....................................LXXA' XCVI XCA'II Barton Station. Miss. Bay Springs, Miss.. Barnwell's Island, S. Barren Fork, I. T ... Barnett's Ford, A'a.. Barber's Place, Fla.. Bajlor's Farm, A'a.. Baldwin, Miss...... Baldwin, Fla........ Batterj- Huger, Va. XC XCI XC11I XCV XCAT11 XCATH CX1II XLATll.LlX LXX LXXII Battery Gregg, S. C...................................... LXXXAT Bealington, AV. Va.................-...................... XXXA' Bealton, A'a......................................-.......XCI, XCVI Bean's Station, Tenn.............................XC1V, XCV, CXXXII Beaver Creek, AIo........................................ LXIII Beaver Creek, Ky........................................ LXXX Beaver Dam Lake, Miss.................................. LXXAT Beaver Dam Station, A'a.................................. CATI Bear AV allow, Ky........................................ LXV Bear River, AV. T....................................... LXATI Bear Creek, Mo........................................... LXATI Bear Creek, Ala........................-................LXXI, XCI Bear Creek Station, Ga................................... CXXIX Bear Skin Lake, Mo..................................... LXXXAT Beverly, AV. Va..........XXXV, LXXII, LXXXI, CXXVIII, CXXXIV Bevkuly Fihid, A'a....................................LXXVH1, XC Benuct's Mills, A'a....................................... XXXAT Beher's Mills, A'a......................................... XXXATI Beckwill Farm, Mo....................................... XXXATII Belmont, Mo............................................ XXXIX Bertrand, Mo............................................. XL Beech Creek, AV. A7a...................................... LIII Beech Grove, Ky......................................... XLI Beech Grove, Tenn.................................... LXXIX Bentonville, Ark.......................................... XLII Bentonville, N. C...................................... CXXXAll Berryville, Va......LXIII, LXXVII, LXXATII, XC, CXXIII, CXXXIX Benyville Pike, A'a....................................... CXIX Berry's Farm, A'a................. ....................... LXXV Berwick City, La......................................... LXIX Beersheba Springs, Tenn.................................. XCII1, CI Benton, Miss............................................. CAT Bent's Old Fork, Tex..................................... CXXX Belcher's Mills, A'a......................................CIX, CXXIII Bermuda Hi-nuked, A'a........CATII, CXI, CXXI, CXXIX, CXXXI Bellefield, A'a............................................ CXXXII Big Hurricane Creek, Mo................................. XXXATII Big Creek Gap, Tenn.....................................XLII, LVH Big Creek, Ark......................................LXXXII, CX ATI Big Indian Creek, Ark.................................... XLVII Itiir Beaver Creek, Mo..................................... LXII Big River Bridge, Mo..................................... XXXVHI Big Black River, Miss...........LXXV, LXXXI, LXXXIX, XCA'II liir Black River Bridge, Miss ............................ CXXX Big Hatchie River, Miss.................................. LIX Big Sandj- River, Ky..................................... t_ XIII Big Sandy, C. T.......................................... CXXX Big Pigeon River, Tenn................................... CXXIX Big Piney, Mo............................................ LII Big Hill, Ky.............................................. LV Big Hill Road, Ky........................................ LXI Big Mound, D. T......................................... LXXXIV Big Sewell, W. A'a........................................ XCV Big Shanty. Ga.........................................CXI, CXXIII Big Blue. Mo............................................. CXXVIII Birds Point, Mo...............'...................XXXVI, XXXVIII Birch Coolie, Minn........................................ LVH Bisland, La.............................................. LXXI Bidnella's Cross Roads. A'a................................ C Page. Binnaker's Bridge. S. 0................................... CXXXV Blue Springs, Mo.......................................... LXIX Blue Springs, Tenn.............................LXXXVIII, LX X X1X Blue Mount, Ala......................................... (XL, Blue Mills, Mo......................................XXXV, XXXATI Blue Gap, A'a............................................ XL Blue Island, Ind.......................................... LXXIX Black River, Mo................................XXXATI, LI, CXXIII Black River, Miss..................................LXXXI, LXXXII Black River, La........................................ CXXIX Blackwater, Mo................................XL, LXXXIX, CXXIV Blackwater, Ya...............................LIX, LXI, LXIV, LXIX Blackwater. Fla...................................CXXVII, CXXVIII Black Creek, Fla.......................................... CXVIII Black Warrior Creek, Ala..................... ........... LXX1II Black Walnut Creek, Mo................................... XXXIX Blackford's Ford, A'a.......*............................... LATH Black Bayou Expedition, Miss............................. LXXI Blackburn's Ford, A'a.....................................XXXV, XC Black Jack Forest, Tenn.................................. XLIII Blackland, Miss.......................................... XLVIII Blackville, S. C.......................................... CXXXV Blooming Gap. Va........................................ XLI Bloomfield, A'a........................................... LXI Bloomfield, Mo..............................XLVI, LA', LVH, LXXI1I Blount's Mills, N. C...............................'....... LXXI Blount's Farm, Ala....................................... LXXIV Blountsville, Tenn..............................LXXXVII, LXXXIX Blain's Cross Roads, Tenn................................. XCV Block-House No. 2, Tenn................................. CXXXI Block House No. 4, Tenn.................................. CXX Block-House No. 5, Tenn.................................. CXXII Block-House No. 7, Tenn.................................. CXXXI Blockade Runners in Tampa Bay, Florida, destruction of... XC Bluffton, S. C............................................. LXXVII Booneviile, Mo..............................XXXIV, XXXATI, CXXVI Boonville, Miss........................................... XLVII, LI Boone Court-house, W. Va................................ XXXAT Bolivar Heights, A'a.........................XXXVHI, LXXXIII, CXV Bolivar, Tenn...............LAT, LXVIII, LXIX, XCV, XCVI1I, CI, CV Bolivar, Miss........................................... LIX Bowling Green, Ky...................................... XLI, XLII Boles Farm, Miss........................................ LII Botts' Farm, Mo.......................................... LII Bollinger's Mills, Mo................................ .... LIII Boonsboro', Md.......................................LVI1I, LXXXII Boonsboro', Ark.......................................... LXIII Boston Mountain, Ark.................................... LXIII Bone Yard, Tenn......................................... LX ATI Bombardment of Fort Sumter, S. C........................ LXXI Boston, Ky............................................... LXX VIII Boone, N. C.............................................. CXXXATII Boy d's S tat ion, A la..................,.................... C X X X A 11 Pogler's (reek, Ala....................................... CXXXVIII Boykin's Mills, S. C....................................CI A', CXXXIX Bottom's Bridge, Va.................................LXXXI, LXXXV Bolton Depot, Miss....................................... XCA'II Bolton and Birdsong Ferry, Miss.......................... LXXXI Bonfouca, La............................................. XCIII Boydtown Plank Road, Va...........CXXVI, CXXATII, CXXXV III Bogg'sMill, N. C........................................ CXXXIV Brunswick, Mo........................................... XX X AT Briar, Mo................................................ XLIII Bridgeport, Ala.......................................... XLV Brownsville, Tenn........................................ LII, LIII Brownsville, Ark........................LXXXV, LXXX ATI, CXXVIII Brownsville, Miss......................................... XC Brown Springs, Mo........................................ LII Brown's Ferry, Tenn..................................... XCI Brown's Gap, Ara......................................... CXXIV Browne's Cross Roads..................................... CXXX Brandy Station, Va.................LV, LXXV1II, LXXX1A', LXXXAT Bristoe Station, A'a................................... XC, CHI Britton's Lane, Tenn..................................... LVI Bristol, Tenn....................................LXXXATI, CXXXII Brasbear City, La................................LXII, LXIX, LXXIX [NDEX, CXLIII Cage. Brentsville Tenn.......................................... LX IV Brentsville, A'a.........................................LXVHI, XCIX Bradyville, Tenn......................................LXVHI, LXXV Branchville, Ark......................................... XCA'I Brentwood, Tenn......................................LXX, CXXXII Broad Run, A'a........................................... LXX Broad River. S. C.-....................................LXXI, CXXX Bradenburg, Ky ........................................ LXXXII Brandon. Miss............................................ LXXXlll Brimstone Creek, Tenn................................... LXXXAT Brazios Santiago, Tex .................................. XCI Brook Turnpike, A'a...................................... C Briee's Cross Roads, Miss................................. CXII Brier Creek, Ga..... ................................... CXXXI Bradford Springs, S. C.................................... CXXXIX Buchanan, Arn............................................ LII, CXI 1 Buckhannon, AA'. A'a....................... .............. XXXV Bunker Hill, AV. A'a ..................................... XXXV BULL RUN, Va...........................................XX X A, LAT Bushy Creek, Ark....................................... XL Bushy Creek, Mo........................................ LXXVII Burke s Station, A'a....................................... XLII Butler, Mo............................................... XLVI, LXI Butler Creek, Ala........................................ CXXIX Burnt Ordinary, A'a....................................... LXATI Bute La Rose, La........................................ LXXII Burkesville, Ky.......................................... LXXXI Buffington Island, Ohio................................... LXXXIII BufordsGap, A'a......................................... CX1II Buford's Station, Tenn.................................... CXXXIII Bull Pasture Mountain, A'a........................... XLAT Bull Run Bridge, Va.................................. LV Bulltown, Braxton County, A'a............................ LXXXIX Bull Baj-ou, Ark......................................... CXXI Bull's Gap, Tenn....................................CXXIV, CXXIX Buffalo Hill, Ky.......................................... XXXATI Buffalo Mills, Mo......................................... XXXVHI Buffalo, W. A7a........................................... LIX Buffalo Creek, I. T.................................:--- LXXXATI Buffalo Creek, Ga......................................... CXXX Buffalo Gap, AV. Va...................................... CXI Burning of Royal Yacht, Galveston Harbor, Tex........... XXXIX Buckton Station, A'a...................................... XLVII Buckland's Mills, Va.................................... XC BuckHead Creek........................................ CXXX Buzzard Roost, Ga...........................-......... C Buzzard Roost Gap, Ga................................... CATI Buzzard Roost Block-House, Ga........................... CXXA'II Burton's Ford, Va........................................ C Burned Hickory, Ga...................................... CX Burned Church, Ga....................................... CX Burger's Farm, Va........................................ CXXATII Butler's Bridge, N. C..................................... CXXXII Byhalia, Miss............................................. LXXXIX Camp Jackson, Mo........................................ XXX1A- CampCole, Mo......................................----- XXXIV Camp Cullenden, Mo...................................... XXXVII Camp Advance, Va....................................... XXXATI Camp Alleghany, W. A'a.................................. NL Camp Babcock, Ark...................................... LXIII Camp Moore, La.......................................... LXXV Cape Hatteras Inlet, N. C................................. XXXVI Cape Fear River, N. C................................... LX Cape Girardeau, Mo.................................LXXIII, XCATII Carthage, Mo..................................XXXIV, XLIII, LXXV Carthage, Ark............................................ LXIII Cameron, Mo............................................. XXXVIII Cameron, A'a...........................-................. XCVI Calhoun, Mo............................................. XL 1 Calhoun, Tenn........................................... LXXXVI1I Calhoun Station, La...................................... CIX Canton, N. C............................................. XLVI Canton, Miss.........................................LXXXIII, XC, C Canton, Ky............................................... CXXI Cache River, Ark........................................ CIV ache River Bridge, Ark. assvillc, Mo............. assville, Ga............. CassviUe Station, (la..... ass Countj-, Mo......... une River, La...... --- Cane Hill, Ark........... e Creek, Ala......... Page. ................ XLVII ................ LIX ................ CIX .............. CX ................ LXII ............... CIV ............... LXIII ................ XCI, CXII lie, Va..............................LX, LX VII, LXX A', LXX AT Cainsville, Tenn................................... ..... LX VIII 'aricr's Station, Tenn.................................LXV, LXXXVII barter's Station, Ark..................................... CXXV Carter's Raid in East Tennessee........................... LXV Carter's Farm, Va........................................ CXV1I Carroll County, Ark.................'..................... LXX, CHI ................ CI ................ CXATI ................ CXVII ................ LV ............... CIX ................ CXXIII ................ LXV ............... XCIII Carrolton Store, A'a.................................... Carrolton Landing, Miss................................. Caroline Bend, Miss.................................... Capture of Rebel Steamer Fair Play..................... Capture of Steamtug Columbine, Fla.................... Capture of Fort Hell, Va................................ Campbell County, Tenn................................ Campbell Station, Tenn.:........................... Campbellville, Tenn..................................CXXIII, CXXX Campbelltown, Ga........................................ CXVIII Cabin Creek, I. T....................................LXXXI, CXXIII CXIX LIX CII CHI XXXV Cabin Point, Va........................................ Cambridge, Mo......................................... Campti, La......................-....................... Camden, Ark.......................................... Carrick's Ford, W. Va..................................■ Carnifex Ferry, AAr. Va................................- - - - XXXATI Catlett's Station, Va...................................LV, LXI, LXVI Cacapon Bridge, Va...................................... LATI Castor River, Mo.......................................... LXXHI Carrion Crow Bayou, La..................................XCI, XCIII Caddo Gap, Ark.......................................XCVI, XCATII Canon de Chelley......................................... XC ATI Calf Killer Creek, Tenn................................... C, CI Cabletown, Va............................................ C Cavalry Raid (Kautz's), Va............................... CV, CVII California, Mo............................................ CXXVI Catawba River, N.C...................................... CXL Cedar Mountain, V.v................................... LIV Cedar Run, Ara............................................ LIV Cedar Run Church, Va.................................... CXXVII Cedar Creek, Va....................................... CXXA'II CXXIX CV CXXXV LXXII XCIV LXXI Cedar Springs, A'a...................................... Cedar Bluffs, C. T..................................... Cedar Keys, Fla........................................ Celina, Ky...........................................- ■ Celina, Tenn.......................................... Centreville, La......................................... Centreville, Tenn.........................................XCI, CXXV Centreville, Ala.......................................... CXXXATII Central Railroad, Va..................................... CXII Centralia, Mo., Massacre at..-.............................. CXXV Charlestown, Mo.........................................XXXAT, XLI Charlestown, AV. Va......XLVII, LVII, LX, LXIII, LXXXIX, XC, CXIV Charleston, Tenn......................................... xcv Charleston, Ills........................................... CI Charleston, S. C.......................................... CXXXV Charleston Bar, S. C...................................... LXVII Charleston Harbor, S. C..................................LXXI, XC1X Chariton Bridge, Mo. LIH Cheat Mountain, W. Va................................. XXXATI Cheat River, W. A'a...................................... XLI Chalk Bluffs, Mo................................. .....XLVI, LXXIII Chalk Bluffs, Ark..........................................LXX, CXL Chester Gap, Va.......................................LXILLXXXIV Chester Station, Va.....................................CVI> CXXIX Chesterfield, S. C......................................... CXXXVI Chapmansville, W. Va.................................... XXXATI Chapel Hill, Tenn........................................ LXVHI CXLIY INDEX, Page. Champion Hills. Miss.................................LXXV, XCVII Chapin's Farm, Va........................................ CXXV ("hainbersburg, A'a........................................ CXATII Charles City Cross Roads, A'a...................L, XCIII, CXII, CXXV Chantilly, A'a............................................ LAT Ciiantkllorsville, A'a................................. LXXIV Chackahoola Station, La.................................. LXXIX Chattanooga, Tenn...............LXXXV, XCIII, CXXXI, CXXXVI Chattahoochie River, Ga.................................. CXAT Cheese Cake Church, Va.................................. XL Cherokee Station, Ala.................................... XC, XCI Cheek's Cross Roads, Tenn................................ CI Cherry Grove, Va........................................ CIII Chewa Station, Ga....................................... CXATI Cheraw, S. C............................................ CXXXVI Chickamicomico, N. C.................................... XXXVIII Chiekahominy, Va....................................XLVII, L, CATII Chickasaw Bayou, Miss........................... ....... LXV c hickamauga, Ga....................................... LXXX ATI Childsburg, A'a............................................ CVII Chickasaw, Ala., to Macon, Ga., AA'ilson's Raid............ CXXXATI Church in the Woods, Mo................................. LIII Chuckatuck, Va.......................................... LXXII Chunky Station, Miss..................................... XCVIII City Belle Transport, La.................................. C\' City Point, Va............................................ CVI, CXIX Civiques Ferrj', La........................................ LXXI A' Clark's Hollow, W. Va.................................... XLVI Clarendon, Ark.........................................LIV, CI, CXIV Clarendon Road, Ark..................................... LXAT Clarksville, Tenn......................................... LA', LVII Clarksville, Ark....................................XCI, XCH, CXXV Clarkson, Mo............................................. LXI Clark's Neck, Ky......................................... LXXXV Clara Bell transport, Miss................................. CXV1I Clay County, Mo........................................ LX XVI, CXV Clear Creek, Mo..........................................LIII, CV1II Clear Springs, Mo........................................ CXATII Clear Lake, Ark.......................................... CXXXVI Clendenin's Raid below Fredericksburg, Va................ LXXAT Cleveland, Tenn...........................XCIV, XCV, CII, CIII, CXX Clinton, Miss..................................XC, XCVII, CXV, CXVI Clinton, La........................LXA', LXXVII, CV, CXXI, CXXXVI Clinton, N. C............................................ XLVI Clinton, Ga............................................... CXXIX Clinton, Mo.............................................. LI Clinton County, Mo....................................... XXXIX Clinton Creek, La........................................ CXXIX Clinch River, AV. Va ..................................... XCIV Clinch Mountain, Tenn................................... XCJV Cloutersville, La......................................... CIV Cloyd's Mountain, A'a..................................... CVII Columbus, Mo............................................ XLI, LII Columbus, Ky............................................ CXXXIV Columbus, Ga............................................ CXXXIX Columbia, S. C........................................... CXXXV Columbia, Tenn..........................................LVII, CXXX Columbia, Ky............................................ LXXXI Columbia Baj-ou, La...................................... CXI Cobb's Point, N. C........................................ XLI Cochran's Cross Roads, Miss.............................. LVII CoffeevUle, Miss.......................................... LXVHI Coggin's Point, \ra........................................ LIII Cold Harbor, Va....................................... L, CXI Cold water, Miss........................................... LII, LVII, LXII, LXIII, LXVIII, LXXH, LXXXIV, LXXXV Coldwater Grove, Mo..................................... CXXVIII Cold Knob Mountain, A'a.................................. LX1H College Hill, Miss........................................ CXXI Colman's, Miss............................................ C, CXV Colliersville, Tenn................................LXXXIX, XCI, XCV Colliersville, Miss......................................... CXIV Comfort, N. C............................................ LXXXI Como, Miss............................................... LA'XXIX Page. Combahee River, S. C.................................... CXXXIV Construction train near Murfreesboro', Tenn................ LX ATI 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 Coobomo County, Miss.................................. LIII Coon Creek, Mo.......................................... LV Coosa River, Ala.......................................... CXVI Corinth Road, reconnoisance on, Miss...................... XLV Corinth, Miss...............................XLVI, LIX, LXXXII, CXII Corinth, Miss., evacuation of.............................. XLVII Corydon, La............................................. LXXXII Courtland, Tenn.......................................... LV Courtland, Ala........................................... CXV1I Courtland Bridge, Ala.................................... LII Courtland Road, Ala...................................... CX CosbyCreek, Tenn....................................... XCVI Cotton Plantation, Ark.................................... LI, CIV Cotton Hill, W. A'a....................................... LVII Cotton Gap, Ark.......................................... LXXXAT Cottage Groove, Tenn.................................... LXIX Cove Creek, N. C......................................... LXHI Cove Mountain, Va...................................... CVII 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...................................... XXXAT Cross Keys, Va......................................... XLVIII Cross Hollows, Ark....................................... LXI Cross Timbers, Mo........................................ XC Crump's Landing, Tenn................................... XLIII 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........*............................. LXXV Culpeper, Va...........................LI, LXXXVII, LXXXIX, XCII Culp's House, Ga......................................... CXPV Cumberland, Md....................................... CXIX Cumberland River, Ky.................................... xLI Cumberland Mountains, Tenn...........................XLIII XLVI Cumberland Mountain, W. Va............................. XLAT 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.............................4............. LII, CXII Dabney's Mills, Va...................................... CXXXV Dallas, Mo...............................................XXXVI, LV Dallas, Ga........................................ cx Dallas, N.C.............................................. CXXXIX Dalton, Ga................................XCVI, CVII, CXX, CXXVII Dam No. 4, Potomac, Va................................ xl Dandridge, Tenn.................................... XCVI Danville, Ky........... ................................. LXIX Danville, Ark................................... qj Darbytown Roads, A'a................................CXXAT CXXVII Dardanelle, Ark.............................LXXXAT, CVII, CXXXIV Darkesville, Va.......................................CXATI, CXXIII Darnestown, Md.................................. ...... XXXATI Davis's Farm, Va......................................... CXIV INDEX. CXLV Page. Davis s Mill's, Miss....................................... LX V Davis's Cross Roads, Ga.................................. LXXXVI Daj-'sGap, Ala.......................................... LXXIII Decatur, Ga.............................................CXATI, CXIX Decatur, Tenn., near..................................... LII Decatur, Miss..................................... ...... XCATII Decatur, Fla....................C, ( IV, CX, CXX, CXXVIII, CXX X III Deer Creek, Miss......................................LXATII, LXIX Denmark, Tenn............................. ............ LA'I Dent County, Mo............................. ........... XXXIX Dos Allemands, La....................................... LATI Des Arcs, Ark..........................................LXVI, CXVII Dead Buffalo Lake, D. T................................. LXXXIV Deatonsvilie, A'a.......................................... CXXXIX Denver, C. T............................................. CIII DEEr Bottom, A'a...................................CXATI, CXATII Deep Bottom Run, A'a.................................... CXX Deep River Bridge, N. C.................................. CXXXIX Deserted House, A'a...................................... LXA'II Devil's Backbone, Ark.................................... LXXXAT Devaux's Neck, S. C.................................... CXXXI Diamond Grove, Mo...................................... XLV Dinwiddie Court-house, A'a................................ CXXXVIII Ditch B-ij-ou, Ark........................................ CXI Dobbin's Ferry, Tenn.................................... LXIV Dodge County, Mo...................................... LIII DogAValk, Ky.......................................... LX Donaldsonville, La....................LXXX, LXXXIII, XCVIII, CXIX Donaphan, Mo......................... ...............XLIII, CXXIII Doubtful Canon, A. T.................................... CV Douglas Landing, Ark........................ .......... CXXXVI Dover, Tenn.............................................. XLI Dover Road, N.C........................................ LXXIII Downer's Bridge, Va..................................... CIX Draft Riot, New York City................................ LXXXIII Drainesville, A'a....................................XXXIX, XL, XCIX Dresden, Ky............................................. XLVI Dripping Springs, Ark.................................... LXV Driver's Gap, Ala........................................ LXXIII Droop Mountain, A'a..................................... XCII Drury's Bluff, Va.....................................___ CVII Dry Forks, Mo............................................ XXXIV Dry Forks, W. Va........................................ XLI Dry AVood, Mo........................................... XXXVII Dry Creek, Ala.......................................... LXXXV Dutch Gap, A'a..............................LXXXIV, CXIII, CXXIII DutchMilU, Ark......................................... C1H Dug Springs, Mo.......................................... XXXVI Dug Gap, Ga.........................,..................LXXXVI, CVI Duck River Shoals, Tenn.................................. LXXII DuckRun, Tenn.......................................... CXXX Dukedom, Ky............................................ C Dunbar's Plantation, La.................................. LXXI Dumfries, Va............................................. LXV Dunksburg, Mo........................................... XL Dunn's Baj-ou, La........................................ CV Dunn's Lake, Fla____............................ ....... CXXXV Durhamville, Tenn..........'............................. LVIII Dutton's Hill, Ky......................................... LXX Duval's Bluff, Ark................................LXVI, XCIV, CX XI Duvall's Mills, Va........................................ CXXXI Dyersburg, Tenn......................................... LXVII Eagleville, Tenn........................................ LXVIII East Pascagoula, Miss.................................... LXXI East Point, Miss.......................................... CXXVI Ebenezer Church, Ala.................................... CXXXVIII Ebenezer Creek, Ga...................................... CXXXI Eden Station, Ga......................................... CXXXI Edgefield Junction, Tenn.................................. LV Edisto Island, S. C................... .................... XLVI Edwards's Ferry, A'a................................XXXIV, XXXVIII Edwards's Station, Miss................................... LXXV Egypt Station, Miss..........................;............ CXXXIH Elkwater, AV. Va........................................ XXXVII Page. Klk River, AV. Va...... ................................ LVH Elk River, Tenn....................................LXXXI, LXXXIII Elk Fork, Tenn................................ ......... LXV Elk Shute, Mo........................................... CXIX Fllrton.Ky............................................... CXXXII Elkton Station, Ala....................................... XLVI III k horn Tavern, Ark..................................... XLII Flkin's Ford, Ark........................................ CII Flizabethtown, Ky.".....................................LXV, CXXXIH Elliott Mills, Mo.......................................... XXXVII Ellison's Mills, Va........................................ XLIX Eltham's Landing, Va.................................... XLVI Estill County, Ky........................................ LXXXIV Evlington Heights, Va............:....................... LI Ezra Chapel, Ga.......................................... CXVIII Fairfax Court-House, A'a.....................XXXIV, LI, LXIX, LXXX Fairfax Station, Va...................................... CXX III Fairfield, Penn........................................... LXXXI Fairbur.-i, Ga............................................. CXX Fair Gardens, Tenn....................................... XC ATI Fairmount, AV. Va........................................ LXXIII Fair Oaks, Va....................................XLVIII, CXXVIII Falling Waters, Va........ ........................XXXIA', LXXXIII Falmouth, Va............................................. XLVI Farmington, Miss......................................... XLVI Farming-ton, Tenn...................................... LXXXIX Farmville, Va............................................ CXXXIX Farr's Mills, Ark......................................... CXVI Faj'ette, Mo.............................................. CXXIV Fayetteville, Ark..............LH, LXI, LXIV, LXXII, CIX, CXXVIII Fayetteville, W. Va...............................LVII, LXIII, LXXV Faj-etteville, Tenn........................................ XCI Fayetteville, N. C........................................ CXXXVI Federal Point, N. C....................................... CXXXV Fishing Creek, Ky.......................................XLI LXXVI Fish Springs, Tenn........................................ LXVII Fish Bay, Ark........................................... CXI Fisher's Hill. Va................................CXX, CXXIV, CXXVI Fitzhugh's Crossing, A'a.................................. LXXIII Fitzhugh's AVoods, Ark.................. ................ CI Five Points, Va......................................... XCV Five forks, Va......................................... CXXXVIII Flat Lick Ford, Ky...................................... XLI Flat Shoals, Ga.......................................... CXVIII Flint Creek, Ark......................................... C Flock's Mills, Md......................................... CXIX Florida, Monroe County, Mo.............................. XLATI, LII Florence, S. C............................................ CXXXAT Florence, Kj-............................................ LVIII Florence, Ala............................LXXVII, XCVI, CHI, CXXVI Floj-d's Fork, Ky......................................... LIX Floyd County, Ky........................................ LXXX Fort Abercrombie, D. T................................... LATI Fort Adams, La.......................................... CXXAT Fort Anderson, Ky........................................ CI Fort Anderson, N. C..................................... CXXXV Fort Blair, Ark........................................... LXXXIX Fort Blakelj', Ala........................................ CXXXIX Fort Blunt, I. T.......................................... LXXVI Fort Brady, Va.......................................... CXXXIV Fort Burnham, Va........................................ CXXXIV Fort Cobb, I. T.......................................... LXI Fort Craig, N. Mex.............................XXXVII, XLII, XLVII Fort Cottonwood, Nev.................................CXXII, CXXIII Fort Darbng, Va..........................................XLVI, CVII Port Davidson, Mo........................................ CXXIV Fort De Russy, La....................................... CI Fout Donelson, Tenn..................: - -. XLI, LV, LXVII, CXXAT Fort Esperanza, Tex...................................... XCIV Fort Fillmore, N. Mex....................................XXXV, LIV Fort Fisher, N. C.................................CXXXHI, CXXXIV Fort Gaines, Mobile Harbor, Ala.......................... CXIX Fort Gibson, I. T.....................................LXXVI, CXXIII Fort Gilmore, Ara......................................... CXXV cxLvr INDEX. Page. Fort Halleck, I. T........................................ LXXXII Fort Harrison, A'n........................................ CXXA7 Fort Hatteras, N. C...................................... XXXVI Fort Ileiman, Tenn....................................... CXXVIII Fout Henry, Tenn..................................... XLI Fort Hill, A'icksburg, Jliss..............................LXXIX, LXXX Fort Hindman, Ark....................................... LXAT Fort Jackson and St. Philip, La........................... XLAT Fort Johnson, S. C.......................................XLIX, CXV Fort Jones, N. C.......................................... CXXXA' Fort Kelly, AV. A'a....................................... CXXX Fort Leavenworth, Kans.................................. CXXVII Fort Lj'on, I. T.......................................... CXXXII Fort Lyons, A'a........................................... LXX ATI Fort McAllister, Ga..........................LXATI, LXVIII, CXXXII Fort McCook, Ala........................................ LV Fort McRae, N. Mex..................................... LXXIX Fort Macon, N. C......................................... XLAT Fort Morgan, Ala........................................CXIX, CXXI Fort Myers, Fla.......................................... CXXXV Fort Pemberton, Miss.................................... LXIX Fort Pickens, Fla......................................... XXXIX Fort Pike, La............................................ LXIII Fort Pillow, Tenn........................XLA', XLVI, XLVHI, CI, CIII Fort Pulaski, Ga......................................... XLV Fort Rice, D. T.......................................... CXXV Fort Ridglej', Minn....................................... LV Fort Sanders, Tenn....................................... XCIV Fort Scott, Mo........................................... XXXATI Fort Scott, Ark........................................... LXXXATII Fort Sedgwick, A'a.....................................CXXV, CXXIX Fort Smith, Ark..............................LXXXAT, CXATII, CXXI Fort Steadman, A'a...................................... CXXXA'II Fort Stevens, D. C........................................ CXVI Fort Sumner, N. Mex..................................... XCV Fort Sumter. S. C............................XXXTV, LXXI, LXXXVI Fort Taylor, Ga.......................................... CXXXIX Fort Wagner, S. C.......................LXXXII, LXXXIII, LXXXVI Fort Wright, Tenn........................................ XLVIII Fort Brown Road, Tex................................... LXIV Forsyth, Mo.............................................XXXV, LHI Forty Hills, Miss......................................... LXXIV Foster's Bridge, N. C..................................... CXXXII Foster's Expedition, N. C................................ LXIV Fourteen Mile Creek, Miss................................ LXXV Fox Creek, Mo........................................... XLII Frankfort, A'a............................................ LXIH Frankfort, Kj'............................................ CXI Franklin, Tenn......................................... LXIAT LXATI, LXIX, LXX, LXXIII, LXXVII, CXXII, CXXX, CXXXIII Franklin, Mo............................................. CXXV Franklin, Miss............................................ CXXXIV Franklin, A'a........................................LIX, LXI, LXIII* Franklin, La....................................v......... LXX AT Franklin's Crossing, Va................................... ' LXXATI Franklin County, Ark................................... LXXXVIII Franklin Creek, Miss..................................... CXXXIII Frazier's Farm, A'a........................................ L Frederick, Md...........................................LVII CXVI Fridericksburg, Mo...................................... CXATI Fredericksburg, Va.....................XLAT, LXII, LXIV, LXXVI Fredericksburg Road, Va................................. CA'in Fredericktown, Mo.......-................................. XXXVHI Freeman's Ford, A'a....................................... Ly Fremont's Orchard, C. T.................................. qjjj French Broad, A'a....................................... XCA'II Front Royal, A'a.........................................XLATI, CXX Front Royal Pike, Va..................................... CXXIV Frying Pan, A'a.......................................... LXXVn Fulton, Mo.............................................. XXXV Fulton County, Mo........................................ LIII Funkstown, Md.......................................... LXXXH Gaines's Mills, Va..................................... L £XI Gainesville, A'a...................................... LVI Pago Gainesville, Fla..........................................XCIX, CXX Gallatin, Tenn........................................... LIA', LIX Galveston, Texas......................................... L.XA'l Garrettsburg, Ky........................ ................ LXII Gauley Bridge, AA'. Va.................................... XXXIX Geiger Lake, Kj-.................................... .... LATI Genesis Point, Ga.....................................LXA'II, LX A'III Georgia Landing, La..................................... LXI Georgia, Raid in......................................... CXA'I Germantown, Tenn...................................XLATII, XCA'III Gettysburg, Pa........................................ LXXX Ghent, Ky................................................ CX XII Glade Springs............................................ CXXXII Gladesville, Va........................................... CXXV Glasgow, Ky....................................LX, LXV, LXXX VIII Glasgow, Mo............................................. CXXVII Glendale, Miss........................................... XLVI Glendale, A'a............................................. L Glorietta, N. Mex......................................... XLIII Gloucester, Va............................................ LXIII Gloucester Point, Va...................................... LXATI Golding's Farm, A'a............................ .......... L Goldsboro', N. C.....................................LXIV, CXXXVII Golgotha, Ga............................................. CXIII Goose Creek, Va.......................................... LAID Gordon's Landing, La..................................... LXATII Gordonsville, Va....................................CXAXI, CXXXIII Gov. Moore's Plantation, La............................... CV Grafton, AV. Va........................................... XXXAT Grahamsville, S. C........................................ 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. Va........................................XLVI, CVII GravelHill, Va.......................................... CXX Gravelly Run, Va........................................ CXXXATI Graysville, Ga.......................................LXXXAT, XCIV Great Bethel, Va.......................................XXXIV, XLIII Great Falls, Va........................................... XXXV Great Cacapon Bridge, Va........................ ....... XLI Greasy Creek, Ky........................................ LXXV Greenville, Mo........................................... LII Greenville, N. C..........................................XCHI, XCV Greenville, Miss.......................................... LXATII Grennville, Tenn....................................CXXIII, CXXA'II Green Bridge, W. Va.................................... XXXATI Green's Chapel, Ky....................................... LXV Greenville Road, Ky...................................... LXII Greenville Road, N. C................................... XLATII Greenland Gap, AAT. Va................................... LXXII Greenland Gap Road, W. Va............................., CXI Green Springs Depot, Md.........................,....... CXIX Greenwich, Va............................................ LXX ATI Greencastle, Pa........................................... LXXIX Green River Bridge^ Ky.................................. LXXXI Gregory's Farm, S. C..................................... CXXXI Grenada, Miss................................... ........ LXXXV Griswoldville, Ga........................................ CXXIX Grosse Tete Baj'ou, La................................... XCIX, CI Ground Squirrel Church and Bridge, A'a.........■.......... CVII Groveton, Va............................................. LVI Guerrilla Campaign in Missouri........................... LIV Gum Swamp, N. C....................................... LXXVI Gunter's Bridge, S. C..................................... CXXXV Guyandotte, W. A'a...........................'............ XXXIX Guy'sGap, Tenn......................................... LXXX Hampton, Va............................................. XXXAT Hampton Roads, A'a...................................... XXXII INDEX. C'A'LVII Page. Harper's Ferry, A'a..................XXXIV, XLVII, LVII, LXXXATII Harpers Ferry Bridge, A'a............................... LXXXII Harper's Farm, A'a........................................ CXXIX Harpeth River, Tenn...................................LXVIII, LXXI Harrisonville, AIo........................................X X XA', LXII Harrison's Island, A'a..................................... XXXATII Harrison's Landing, A'a................................... LIII Harrisonburg, A'a......................................... XLATII Harrisonburg, La......................................... C Harrison, Mo ............................................ CXXV Harrisburg, Pa........................................... LXXX Harrodsburg, Ky........................................LX, CXXVII Hartsville, Tenn......................................... LXIV Hartville, Mo............................................. LXA'I Hartwood Church, A'a.................................LX III, LXVIII Hartford, Ky..................... ....................... LXXVI Hamilton, N. C...........................................LI, CXXXII Hamilton, A'a............................................. C X X X ATI Hanover, Pa.............................................. LXXX Hanover Court-house, A'a...........................XLATI, LXXX, CX Hanoverton, A'a........................................... CX Hancock, A'a............................................ XL Hanging Rock, AV. Va.................................... XXXATI Hankinson's Ferry, Miss.................................. LXXIV Hawks Nest, AV. A'a...................................... XXXVI Hatchie Kiver, Tenn......... .......................... LII Hatcher's Run, A'a.......................CXXATII, CXXXI, CXXXV Hall's Ferry, Miss........................................ LXXV Hallton-n, A'a................................LXXXIII, CXXI, CXXII Hager's Mountain, Md.................................... C X AT Hagerstown, Md...............................LXXXI, LXXXII, CXV Hague wood Prairie, Tenn............................... LXXXATII Half Mount, Ky.......................................... CIII Hammact's Mills, AAT. A'a................................. CXV Half Moon Battery, N. C.................................. CXXXIV Hardy County, AV. A'a.................................... LX AT Harney Lake A'alley, Oreg............................... CII Hatteras, U. S. Steamer................................... LXVI Hawe's Shop, A'a......................................... CX, CXI Haxal's, Va.......................-....................... LI Haymarket, Va............................................ LX HaynesviUe, A'a.......................................... XXXIV Hazel Bottom, Mo........................................ LX Hedgeville, A'a........................................... LXI, XC Helena, Ark............LIV, LATH, LX, LXIII, LXVI, LXXVI, LXXXI Henderson Hills, La......................... ............ CI Henderson's Mill, Tenn................................... LXXXIX Henderson, Ky........................................CXATI, CXXIV Hendricks, Miss.......................................... LXXXVII Hernando, Miss.......................................LXXII, LXXIX Henrytown, Mo.......................................... XXXATII Hicksford, A'a............................................ CXXXII Hickory Grove, Mo....................................... LVIII Hickman, Ky............................................ LV High Bridge, Va......................................... CXXXIX Hillsboro', Ky..............................'.............. XXXVIII Hillsboro', Ga............................................ CXIX Hillsborough, Ala........................................ LXXI Hill's Plantation, Ark..................................... LI Hill's Plantation, Miss.................................... LXXIX Hill's Point, A'a........................................... LXXII Hodgeville, Ky.......................................... XXXVHI Holly River, AV. Va...................................... XLVI Holly Springs, Miss..........................LXIII, LXV, CIX, CXXII Hollow Tree Gap, Tenn.................................. CXXXIII Holland House, A'a....................................... LXXV Holston River, Tenn.....................................XCIII, XCIX Honey Spring, I. T................. ..................... LXXXIII Honey Hill, S. C......................................... CXXX Hoover's Gap, Tenn...................................... LXXIX Hopkinsville, Ky......................................... CXXXII Horse-shoe Bend, Ky..................................... LXXA' Horton's Mills, N. C...................................... XLAT Hot Springs, Ark......................................... XCVII Page. Howard Countj', Mo......................................LVI, CX XII Howe's Ford, Ky......................................... LXXIII Housatonic, loss of, S. C.................................. XCIX Hudnot's Plantation, La................................... CV Hudson, Mo.............................................. XL Hudsonville, Miss........................................ LXII Huffs Ferry, Tenn....................................... X CII Hunnewell, Mo........................................... XL Humonsville, Mo......................................... XLIII, XC Huntersville, Va.......................................... XL Huntsville, Ala..........................................XLV, CXXV Huntsville, Tenn......................................... LXII Hurricane Bridge, W. A'a................................. LXX Hurricane <'reek, Miss..........................CXX, CXXI, CXXATII Hulchinson, Minn........................................ LVII Illinois Creek, Ark........................................ LXIV Independence, Mo....................................... XXXIV, XXXIX, XLII, XLIII, LIV, LXVII, CXXATII Indian Bay, Ark.......................................... CIII Indian Vi lage, La....................................... LXA'II Indian City Village, La................................... CXIX Indian Ridge, La......................................--- LXXI Indiantown, N. C......................................... XCV Ingraham's Plantation, Miss............................... XXXIX Ingham's Mills, Miss...................................... LXXXIX Ironton, Mo................................XXXVII, XXXATII, CXXIV Irish Bend, La............................................ LXXI Irwinsville, Ga........................................... CXL Irvine, Ky............................................... LXXXIV Isle of AVight Court-house, Va............................. LXV Island No. 10. Tenn......../............................... XLV Island No. 76, Jliss...................................... XCVI Island Ford, A'a........................................... CXATI Iuka, Miss.............................................LVIII, LXXXII Ivy Ford, Ark............................................ XCVI Ivy Ford, Ky............................................. CXXXIV Ivy Hills, Miss........................................... XCIX Jackson, Tenn.......................................LXIAr, LXXXIII Jackson, Miss.......................LXXA7, LXXXII, LXXXIII, CXV Jackson, La...........................................CXXAT, CXXIX Jackson Cross Roads, La.................................. LXXIX Jacksonville, Fla......................................... LXX, CAr Jacksonport, Ark......................................... XCA', CIV Jacksboro', Tenn......................................... XLII Jack's Shop, Tenn.........................................LXXXVII Jack's Shop, A'a.......................................... CXXXIII James City, Va.......................................... LXXXIX James River, A'a................XLVI, LXXXIV, CAT, CXIII, CXXATII James Island, S. C............XLVIII, XLIX, LXXXIII, CXV, CXXXV Jarrett's Station, A'a...................................... CATI Jefferson, Tenn........................................... LXV Jefferson City, Mo........................................ CXXVI Jeffersonton, A'a.......................................... LXXXIX Jeffersonville, Va........................................ CVII Jenkins's Ferry, Ark...................................... CV Jenk's Bridge, Ga........................................ CXXXI Jennie's Creek, Kj'...................................... XLI Jerusalem Plank Road, Va..............................CXIAT. CXXIII Johnstown, Mo........................................... XXXIX Johnson Depot, Tenn.-.................................... LXXXA'II Johnson's Mills, Tenn..................................... XCIX Johrrsonville, Tenn...................................CXXIA', CXXIX John's Island, S. C........................................ CXV John Day's River, Oreg.................................. CXXX IX Jonesboro', Mo.....................................XXXAT, LXXXIX Jonesboro', Ark.......................................... LIII Jonesboro', Ga...............................CXXl.cxxil, CXXIX Jones's Bridge, Va....................................... CXIV Jones's Ford, Miss........................................ LXXXII Jones's Hay Station, Ark.................................. CXXI Jonesville, Va...........-.......................--........ XCV Jornado Del Muerto, N. Mex.............................. LXXATII Judah, Rebel Privateer................................... XXXAT Julesburg, I. T.............................'.............. CXXXIV IWLYIII INDEX, Page. Kearnstown, Va......................................... XLII, CXATI Kearneysville, A'a........................................ CXXI Kearsarge and Alabama, off France....................... CXIII Kelly's Island, A'a........................................ XXXIV Kelly's Ford, A'a....................LAr, LXIX, LXXXIV, XCII, XCA'II Kelly's Store, A'a......................................... LXATI Kcllar's Bridge, Ky....................................... CXII Kenhsaw Mountain, Ga................................ CXI, CXIV Kentucky River, Ky...................................... LXII Kettle Run, A'a........................................... LV Kej-ettsville, Mo......................................... XLII Kincaels, Tenn.......................................... XCII Kilpatrick's raid in Virginia............................... C Kilpatrick's raid in Georgia............................... CXXI Kinderhook, Tenn....................................... LIV Kingstou, N. C.......................................LXIV, CX.XXAT Kingston, Tenn.......................................... XCIII Kingston, Ga..............................:.............. CIX King George County, A'a.................................. LXXX A' Xing George Court-House, Va............................. LXIII King's Cchool House, Va................................. XLIX King's River, Ark........................................ CIII Kingsport, Tenn........................................ CXXXII Kingsville, Mo............................................ CXII Kirksville, Mo........................................... LIII Knob Noster, Mo.......................................... XLI Knoxville, Tenn......................LXXXAT, XCIII, XCIV, XCA'II Kock's Plantation, La..................................... LXXXIII Lavergne, Tenn.......................LX, LXIII, LXIV, LXVI, CXXII Labadiesville, Ld......................................... LXI Lacey's Springs, A'a...................................... CXXXIII Ladija, Ala.............................................. CXXATII Lafayette County, Mo.....................................XLIII, CXII Lafayette, Tenn................................XCV, CXI, CXIV, CXV La Fourehe Crossing, La.................................. LXXIX La Grange, Ark........................LATI, LX, LXII, LXAT, LXXIV La Grange, Tenn...................................LXII, LXXI, CXV Lake Providence, La................LXATI, LXXVII, LXXATII, LXXX Lake City, Fla........................................... XCVIII Lake Chicot, Ark......................................... CXI Lamar. Mo............................................... LXn Lamar, Miss............................................ LXIH Lamb's Ferry. Tenn...................................... CXXXIII Lamine Crossing, Mo..................................... LXXXIX Lancaster, Mo........................................... XX.XIX Lancaster, Kj-............................................ LX Lane's Prairie, Mo....................................... XXX A', CX LanqueUe Ferrj-, Ark..................................... LIII Lauderdale Springs, Miss................................. XCIX Laurel Hill, AV. A'a.....................................XXXA', CXXV Lattemore's Mills, Ga.................................... CXIII Lawrence, Kans.......................................... LXXXV Lawrence County, Ky.................................... LXXXV Lawrenceburg, Ky....................................... LX Lawrenceburg, Ohio..................................... LXXXHI Lawrenceburg, Tenn.....................................XCI, CXXX Leather wood, Kj-......................................... LXII Leavenworth, Ind........................................ LXXIX Lebanon, Mo............................................. XLIII Lebanon, Tenn............................XLAT, LXII, LXIII, LXATI Lebanon, Ky.............,........................LI, LXXXL_CXATII Lebanon, Ala............................................ XCA'II Leesburg, A'a............................................. X X X ATH Leesburg, Mo............................................. CXXAT Leesburg Road, A'a....................................... LATH Leetown, Ark............................................ XLII Leetown, A'a.............................................. CXV Lee's Mills, A'a.................................XLA', CXVI, CXATII Lee. Surrender of......................................... CXXXIX Legare's Point, S. C...................................... XLVIII Legaresville, S. C........................................ X(V Leiper's Ferrj-, Tenn..................................... XCI Lewisburg, A'a............................................ XLATI Lewisburgh, Ark......................................... XC\T Page. Lewinsville, \Ta.......................................... XXXATI Lett's Tan Yard, Ga...................................... LXXXVII Lexington, Mo................XXXAT, XXXATI, XLIII, CXII, CXXVII Lexington, Ky.....................................LX, LX XXIA', CXII Lexington, Tenn......................................... LX IV Lexington, AA'. A'a........................................ CXI, CXII Ley's Ferry, Ga.......................................... CVHI Liberty, Mo.............................................. lx Liberty, Va............................................... C XIII Liberty, La............................................. CXXIX Liberty Gap, Tenn....................................... LXXIX Liberty Mills, A'a......................................... XC Liberty Post Office, Ark.................................. cm Liberty Creek, La........................................ CXXIX Licking, Mo.............................................. XLVI Licking River, Ky........................................ CXII Lick Creek, Ark.......................................... LXAT Limestone Station Tenn.................................. LXXXVI Linden, Va............................................... XLAT Linden, Tenn............................................. LXX A' Linn Creek, A'a........................................... XLI Linn Creek, Mo.......................................... XXXATII Little Bear Creek, Ala...................................LXIII, LXIV Little Black River, Mo................................... LXXATI Little Blue, Mo...........................XXXIX, XLA', CXA', CXXVII Little Blue, D. T......................................... CXX Little Cacapon, Va....................................... cm Little Creek, N. C........................................ LXII Little Harpeth, Tenn...................................... LXX Little Missouri River, Ark................................. CII Little Missouri River, D. T............................... CXIX Little Osage River, Kans................................ CXXATII Little Pond, Tenn......................................... LAT Little Red River, Ark.................................... XLIX Little River, Tenn........................................ CXXA'II Little Rock, Ark........................................LXXXAT, CX Little Rock Road, Ark.................................... LXX Little Rock Landing, Tenn................................ LXXII Little Santa Fe, Mo....................................XXXIX, XLIII Little Tennessee River.................................... XCI Little AA'ashington, Va.........„......................... LXHI Liverpool Heights, Miss.................................. XCATI Lock's Ford, A'a.......................................... CXXHI Lockridge Mills, Ky...................................... XLAT Lohpeach Farm, Mo.............'......................... LI Logan Countj', A'a........................................ XLI Logan Cross Roads, Ky................................... XLI Lone Jack, Mo............................................ LA' Long Prairie, Ark........................................ CXXI Lorigview, Ark............... ........................... CI Lookout Station, Mo...................................... XXXAT Lookout Mountain, tenn.............................. XCIII Lost Mountain, Ga........................................ CXI Loudoun County, A'a..................................... LXI Loundon Heights, Va..................................... XCAT Louisa Court-House, Va.................................. LXXIV Louisville, Tenn......................................... XCIV Lovejoy Station, Ga....................CXVIII, CXXI, CXXn, CXXIX Lovettsville, A'a........................................XXXAT, LXI Low Creek, AV. A'a....................................... LXXIX Lowndesboro', Ala....................................... CXXXIX Lucas Bend, Ky......................................... XXVII Lumkin's Mills, Miss .................................... LXHI Luna Landing, Ark...................................... XCIX Lundj-'s Lane, Ala....................................... LXXI Luray, A'a................................................ L, CXXIV Lynchburg, A'a........................................... CXIII Lynch Creek, S. C........................................ CXXXVI Lynnville, Tenn.....................................CXXX, CXXXIII McAfee's Cross Roads, Ga................................ CXII McConnellsburg, Tenn ................................LXXIX, LXXX McCook's Raid in Georgia................................ CXATI McDowell, Va............................................ XLAT McLean's Ford, A'a....................................... XC INDEX. OXLIX Page. MeMinnville, Tenn..........................LAT, LXXII, LXXXV11I Macon, Ga.............................CXVII, CXVIII, CXXIX, CXL Macon County, Tenn...................................... CXIV Madison, Ark............................................ LXX Madison Court-house, Tenn............................... LXXXVII Madison Court-house, A'a.................................. CXXXIII Mad ison Station, Ala.....................................CIX, CXXX Madison County, Kj-...................................... LV Madisonville, Ky......................................... LAr, L X Madisonville, La.......................................... XCVI Magoffin County, Ky...................................... CIII Magnolia Hills, Miss...................................... LXXIV Malvern Hill, Va...........................LI, LIII, CXIII, CXVIII Manassas. Va.............................................XXXV, LVI Manassas Junction, Va.................................... LXI Manassas Gap, Va....................................LXII, LXXXIV Manchester, Tenn......................................... LVI, CI Mansfield, La............................................. CII Mansura, La.............................................. CV1II Markham, Va............................................. LXII Marksvilie, La............................................ CVHI Mark'sMills, Ark........................................ CIV Maria Des Cj'gnes, Kan................................... CXXVIII Maryland Heights, Va.................................... CXV Marietta, Ga.............................................. CXI Marianna, Ark............................................ LXII Marianna, Fla............................................ CXXV Marrowbone, Ky.......................................... LXXXI Marshall, Mo....................................LXXXIV, LXXXIX Marj-sville, Tenn......................................... XCII Marion County, W. Va.................................... XXXVI Marion, Miss................:............................ XCIX Marion; A'a............................................... CXXXIH Marshfield, Mo........................................... XLI, LXI Mason's Neck, Va........................................ XLII Mason's Bridge, S. C..................................... CXXXI Matapony, Va............................................ LIH Majsville, Ark........................................... LXI Maysville, Ala...................................LXXXV, LXXXIX Mayfield, Ky............................................. XCVI Maplesville, Ala..........................................CXXXVIII Matagorda Bay, Tex...................................... XCV Mazzard Prairie, Ark..................................... CXVIH Martinsburg, Va..............XXXTV, LVH, LXXVHI, CXX, CXXHI Martinsburg, Mo.......................................... XXXV Martin's Creek, Ark....................................... XCV Mathew's Point, Va....................................... XXXIV Memphis, Tenn....................XLVIH, LIX, CV, CXXI, CXXXH Memphis, Mo............................................. LII Merriweather's Ferry, Tenn............................... LIV Mesila, N. Mex........................................... XXXVI Mechamcsville, Va..................................... XLIX Mechanicsville, Miss...................................... LXXVH Medon Station, Tenn...................................... LXVni Meadow Bridge, Va....................................... CVHI Meadow Bluff, W. Va..................................:.. XCV Medalia, Miss............................................. LXXI Mechanicsburg, Miss...................................... LXXVII Medley, W. Va........................................... XCVII Meridian, Miss, Expedition to............................. XCVII Meridian, Miss............................................ XCIX MerriU's Crossing, Mo..................................... LXXXIX Messenger's Ferry, Miss.................................. LXXXI Metley's Ford, Tenn...................................... XCI Metamora, Miss........................................... LIX Middle Creek Ford, W. Va................................ XXXV Middle Creek, Ky........................................ XLI Middleburg, Va.............:..........................XLIH, LXXIX Middleburg, Miss........................................ LXV Middletown, Va...........................XLVH, LXXVIIL CXXVII Middletown, Tenn.............LXVI, LXVII, LXXVI, LXXIX, XCVI Middleton, Md............................................ CXVI Millsville, Mo............................................ XXXV Mill Creek Mills, W.Va............'...................... XXXVIII Mill Creek Valley, W. Va................................. XCII Mill Springs, Ky......................................... XLI 20* Mill Point, W. Va. Mill Creek, Ga.... Mill Creek, Tenn.. Millen Grovo, Ga.. Page. ................................. XCII ................................. CVI ................................. CXXXI ................................. CXXXI Millwood, Va............................................. CXXXIII Milton, Tenn...........................................LXVIII, LXIX Milton, Fla............................................... CXXVIII Milliken'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, Kas......................................... CXXVIII Mississippi River, Miss.................................... LXVIII Mississippi City, Miss..................................... XLII Mississippi Central Railroad..........................LVI, LXV, CXXX Missouri River, D. T...................................... LXXXIV Missionary Ridge, Tenn................................... XCHI Mitchell's Station, Va..................................... LIV Mitchell's Creek, Fla...................................... CXXXm Moorefield, Va............................................ LXII, LXVI, LXXXVI, LXXXVII, XCVII, CXI, CXIX Moore's Mills, Mo......................................... Lni Moresburg, Tenn......................................... XCIV Monroe Station, Mo....................................... XXXV Monroe County, Mo....................................... XLVII Monroe's Cross Roads, N. C............................... CXXXVI Morristown, Mo............................................ XXXVH Morristown, Tenn..................XXXIX, XCIV, CXXVIII, CXXIX Morris Island, S. C........................LXXXII, LXXXV, LXXXVI Morris Connty, 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..................................... XXXVHI Monocacy, Md........t................................... CXVI Monocacy River, Md...................................... LX Moffat's Station, Ark...................................... CHI Mosby's Raid in Virginia.................................. LXIX Moscow, Tenn............................................ XCI, CXHI Moscow, Ark............................................. CIH Moscow Station, Miss..................:.................. XCIV Mosquito Inlet, Fla....................................... XLIII Mount Zion, Mo.......................................... XL Mount Zion Church, Va.................................... CXV Mount Sterling, Ky...................................LIU, LXIX, CXI Mount AVashington, Ky................................... LIX Mount Vernon, Ark....................................... LXXV Mount Tabor Church, N. C................................ LXXXIV Mount Jackson, Va....................................... XCIII Mountlvy, Miss.......................................... XCIX Mount Elba, Ark......................................... CI Mount Pleasant Landing, La.............................. CVHI Mount Clio, S. C......................................... CXXXVI Mount Pleasant, Miss..................................... CIX Mount Pleasant, Ala...................................... CXXXVIII 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........................................ XCVIII Morton, Miss.............................................. XCVIII Monetir's Bluff, La....................................... CIV Morrow Creek, Ark....................................... CIV Morreausville, La..................-.................---- CVHI Moulton, Ala............................................. CX Montgomery County, Ark................................. CXVI Montgomery and West Point Railroad, Ga................. CXVII Montgomery, Ala......................................... CXXXIX Moreau Bottom, Mo...................................... CXXVI Monteith Swamp, Ga..................................... CXXXH CT, INDEX. Page. Mocassin Gap, A'a........................................ CXXXIII Mountain Grove, Mo.......................'............... XLH Mountain Store, Mo....................................... LII Monterey, Ky............................................ XLIX Monterey, A'a............................................. XLV Monterey, Tenn.......................................... XLVI MontereyGap, Md........................................ LXXXI Montavallo, Mo...............'............................ XLV, LIII Montavallo, Ala.......................................... CXXXVIII Morning Sun, Tenn....................................... LI Mobile, Ala.............................................. CXXXVII Monticello, Ky.............,.........................LXXIV,LXXVII Monticello, Ark..........................,................ CI Munson's Hill, Va....................................XXXAT, XXXVII Mumford's Station, Ala.................................... CXL Mumfordsville, Ky.....................................XL, LVII, LIX Murfreesboro', Tenn...................................... LI, LXV, LXIX, LXXVII, LXXIX, CXXIII, cxxxi, cxxxn, CXXXIII Murfreesboro' Road, Tenn................................. LXXXVIII Muldraugh's Hill, Ky..................................... LXV Muddy Run, Va.......................................... XCU Mud Springs, I. T.........................,.............. CXXXV Mussel Shoals, Ala....................................... CXXVHI Mulberry Gap, Tenn...................................... XCIX Mustang Island, Tex..................................... XCIH M yerstown, Va............................................ CXXIX Nansemond, Va........................................... LXXI Nansemond River, Va..................................... LXXIV Namozin Church, Va...................................... CXXXATII Narrows, Ga___:......................................... CXXAT Nashville, Tenn......-......XLII, LII, LX, LXII, CIX, CXXXI, CXXXII Nashville and Chattanooga Railroad, Tenn................CXX, CXXII Natches, Miss...................................LXXXIV, XCII, XCIV Natchitoches, La.......................................... CI, CIV Natural Bridge, Fla...................................... CXXXVI, Nauvoo, Ala.............................................. CXXXIV Nelson's Farm, Va........................................ L Neosho. Mo................................XLVI, XLATH, LXXXATII Neuses River, N. C.............................:......... CXXXIX Ne\vark, Mo.............................................. Lin Newnau, Ga.............................................. CXVHI New Berne, N.C......................................... XLHI, XLAT, XLVII, LXII, LXVIII, LXIX, XCVII, C New Market, Va...............................CVIH, CXVIII, CXXAT New Market Bridge, Va................................... XL New Market Cross Roads, Va.............................. L New Market Heights, Va...............................CXXV, CXXVI Newport News, A'a .................................XXXIV, XL, XLII Newport Barracks, N. C................................... XCATI Newtonia, Mo........................................LVn, CXXVIII Newton, La...............................................LXX XATII Newtown, Va..........................................XLVH. CXXIX New Creek, AA'. A'a..............................XXXFV, CXIX, CXXX New Creek Valley, W. Va................................ XCVII New Albany, Miss.................................LXXH, LXXXVIH New Baltimore, Va....................................... LXH New Bridge, Va.......................................... XLVII New Hope, Kj-........................................... LI New Hope Church, Ga.................................... CX New Lisbon, Ohio........................................ LXXXIV New Madrid, Mo................................XLII, XLHI, LXXXV New Madrid Bend, Tenn.................................. XCI New Orleans, La......................................... XLVI New River Bridge, Va.................................... CVII New Ulm, Minn........................................... LV Nickajack Trace, Ga...................................... CIV Nickajaci Creek, Ga...................................... CXV Ninevah, Va.............................................. CXXIX Niobrara, Neb............................................ XCIV Nolansville, Md........................................... LATI Nolansville, Tenn.......................................LXV LXVIII Noonday Creek, Ga...................................... CXHI Norfolk, Va '............................................. XLVI Northeast River, N. C.................................... LXVI Page. Northport, Ala....................................;...... CXXXVIII North Anna River, Va.................................LII, CVII CIX North Edisto River, S. C.................................. CXXXV North Fork, A'a........................................... CXXXVI North Mountain, A'a....................................... CXV North Missouri Railroad................................... CXXV North River, AV. Va...................................... CXV North Shenandoah, A'a.................................... CXXAT Nose's Creek, Ga..................................CXI, CXni, CXXV Nottaway Creek, Va...................................... CVII Nottaway Court-house, Va................................. CXIV Nuece's River, Tex....................................... LIV Oak Grove, Va........................................... XLIX Oakland, Miss............................................ LXIII Obion River, Tenn........................................ LIV Occoquan, Va............................................ XLII, LXV Occoquan Creek, A'a...................................... XXXIX Occoquan Bridge, Va..................................... XL 1 Ocean Pond, Fla.......................................... XCIX Oconee River, Ga......................................... CXXX Offett's Knob, Mo......................................... CIV Ogeechee River, Ga...................................... CXXXI Okalona, Miss............................................ XCIX Okalona, Ark............................................. CII Oldtown, Md............................................. CXIX Old Church, A'a........................................... CX, CXII Old Fort Wayne, Ark..................................... LXI Old Oaks, La............................................. CIX Old River, La............................................LXVII, CIX Old River Lake, Ark...................................... CXI Olive Branch, La......................................... CXXXAT Olive Hill, Ky............................................ LIX Olustee, Fla.............................................. XCIX Oostenaula, Ga........................................... CA'l II Opelousas, La............................................ XC Opequan, A'a............................................ CXXIII Orangeburg, S. C......................................... CXXXV Orange Court-house, Va................................... LH, LIII Orchards, Va............................................. XLIX Orchard Knob, Tenn...................................... XCIII Oregon Mountains......................................... XCATI Orleans, Ind.............................................. LXXATH Osage, Mo................................................ LXI Osceola, Mo..........................................XXXVn, XLATI Osceola, Ark............................................. CH, CXIX Otter Creek, Va........................................... CXHI Overall's Creek, Tenn..................................... CXXXI Overton's Hill, Tenn...................................... CXXXII Owens Valley, Tenn...................................... LXVIII Owens River, Cal......................................... XLV OAvens County, Ky....................................... XLIX Owensburg, Ky.......................................... LA'HI Owensboro' Ky........................................... CXXII Oxford Hill, Miss.......................................... CXXI Oxford Bend, Ark........................................ LXI Ox Hill, Va.............................................. LVI Ozark, Mo..........................................LHXLXIH, CXVI Paint Rock Railroad Bridge............................... XLAT Paintsville, Ky........................................... XLI, XCHI Palo Alto, Miss........................................... LXXII Palmyra, Mo............................................. XXXIX Palmyra, Tenn........................................... XCII Palmetto Ranch, Tex..................................... CXL Paducah, Ky............................................. ci Pamunkey River, Va...................................... CX Panther Creek, Mo........................................ LIV Panther Springs, Tenn.................................... C Panther Gap, W. Va...................................... CXI Papinsville, Mo........................................... XXXVII Paris, Ky.......................................LIII, LXIX, LXXXIV Paris, Tenn...........................................XLII, LXXXVII Parkersville, Mo.......................................... XXXV Parker's Cross Roads, Tenn............................... LXV Pasquotank, Mo........................................... LXXXV INDEX. CLI Pago. Pass Christian, Miss...................................... XLIII Pattacassey Creek, N. C................................... LXXXIV Patten, Mo............................................... LII Patterson, Mo............................................. LXXII Pattersonville, La..............,........................... LXX Patterson Creek, Va...................................XXXIV, XCATI Pavrneo Reservation...................................... LXXIX Pawnee Forks, Kas....................................... CXXX Peach Orchard, A'a........................................ L Peach Tree Creek, Ga.................................... CXVII Pea Ridge, Ark........................................... XLII Pea A'ino Creek, Ga....................................... XCIV Pechacho Pass, D. T...................................... X LV Pembiseott Baj-ou, Ark................................... CII Pensacola, Fla............................................XXXIX, CII Peralto, N. Mex........................................... XLV Perry Countj-, Ky........................................ LXII Pgkryville, Ky........................................ LX Perryville, Ark........................................... LXXXV Petersburgh, AV. Va...................................XXXATI, XCVI Pkteksburg, A'a......................................... LIII, CXII CXIII, CXA', CXATII, CXIX, CXXII, CXXXI, CXXXVII, CXXXVIII Petersburg, Tenn......................................... LXVI 11 Petit Jean, Ark........................................... CXVI Philadelphia, Tenn....................................... XC, XCI Philip's Creek, Miss...................................... XLATI Phillippi, AV.A^a.......................................... XXXIV Philomout, A'a............................................ LXI Piedmont, A'a............................................. CXI Piedmont Station, A'a..................................... LXXV Pierce's Point, Fla........................................ CXXVII Pierson's Farm, Va....................................... CXIII Pike Countj-, Ky........................................ XXXIX Piketown, Ky............................................ XXXIX Pike Creek, Ky........................................... CVHI Pikeville, Ky............................................ LXXI Pikesville, Ark........................................... CXIV Pilot Knob, Mo............................................ CXXATII Pinckney Island, S. C........-............................. LV Pine Bluff, Ark..............XCI, XCAT, CXIII, CXA', CXXIII, CXXVI PineBluff, Tenn.......................................... CXXI Pine Barren Creek, Ala...........................CXXXIII, CXXXATI Pine Knob, Ga............................................ CXIII Pine Mountain, Ga........................................ CXII Pineville, Mo............................................. LXXXV Piney Factory, Tenn...................................... XCI Pi ney Woods, La......................................... CII Pinos Altos, Ariz......................................... LXVII Pittman's Ferry, Ark...................................... LH Pittman's Ferrj-, Mo..................................... LXI Pittsburg Landing, Tenn.................................. XLII, XLV Plaquemine Bayou, La.................................... LXVII Plaquemine, La........................................LXXIX, CXIX Plain Stores, La.......................................... LXXVI, CII Plattsburg, Mo........................................... XXXIX Platte City, Mo........................................... CXV Pleasant Hill, Mo......................................... LI, C X Pleasant Hill, La......................................... CIII Pleasant Hill Landing, La................................. CIII Pleasant Grove, La....................................... CII Pleasant Valley, Md...................................... CXV Plj'mouth, N.C....................................LVII, CIII, CXXIX Plantersville.............................................. CXXXVIII Pocataligo, S. C.................................XLVII, LXI, CXXXIV Pocahontas County, W. Va................................ XCII Point Lookout, Va....................................... CVHI Point of Rocks, Md.................................XXXVI, CXI, CXV Point Lick, Ky........................................... LXI Point Pleasant, W. Va.................................... LXX Point Pleasant, La............:........................... CXIV Point AA'ashington, Fla.................................... XCVIII Poison Springs, Ark...................................... CIII Polk's Plantation, Ark.................................... LXX AT Poplar Eprings Church, Va................................. CXXV Page. Pollocksvillo, N. 0........................................XLV, LXVI Polk County, Mo......................................... XLIII l'ond County, Ky......................................... CVHI Pond Spring, Ala......................................... CXXXIII Pontotoo, Miss............................................ CXAT Ponchatoula, La...................................LVIII, LXX, LXXV Pooltsville, Md........................................... LVH Pope's Campaign in Virginia............................... LAT Port Royal, S. C..........................................XXXIX, XL Port Republic, Va........................................ XLVI1I Port Gibson, Miss............................LXXIV, XCV, CXV, CXVI Port Hudson, La.......................................... LXIX Port Hudson, La.....................LXXVH, LXX VIII, LXXX If, CII Port Hudson Plains, La................................... LXXA'I Port AA'althal, Va......................................... CVI Poole's Station, Ga........................................ CXXXI Potosi, Mo..........................................XXXVI, XXXATII Pound Gap, Va........................................... CXXV Pound Gap, Tenn......................................XLIII, LXXXI Pound (Jaii, Ky........................................... CIII Powel's River Bridge, Tenn............................... XCIX Powder Springs, Ga.....................................CXHI, CXXV Powhattan, Va............................................ CXXXIV Prairie D'Ann, Ark....................................... CIII Prairie Station, Mo....................................... LXVIII Prairie Station, Miss...................................... XCIX Prairie Grove, Ark....................................... LXIV Preble's Farm, Va........................................ CX XV Prentis, Miss............................................. LIX Price's Invasion of Missouri............................... CXXIV Princeton, AA'. Va......................................... XLVII, CVI Princeton, Ky............................................ CXII Princeton, Ark..................................XCIV, CIH, CXXVIII Prince's Place, Mo........................................ CXXVI .Pritchard's Mill, Md...................................... XXXVII Pueblo Colorado, Mo...................................... LXXXV Pulaski, Ala.............................................. LXXXIII Pulaski, Tenn.............................LXXXIX, CXXV, CXXXIII Pulaski, Ga............................................... CVHI Pumpkin Vine Creek, Ga.................................. CX Putnam's Ferry, Mo....................................... XLHI Quaker Bridge, N. C.....'................................ LXXXI Quaker Road, Va......................................... CVII Qualltown, N. C......................................___ XCVIH Quicksand Creek, Ky.................................... CII Raccoon Ford, A'a........................................ LXXX ATI Raccoon Ford, Ala........................................ CXXVHI Raceland, La............................................. XLIX Randolph County, Mo..................................... XXXIX Rapidan, Va..........................................LXXXIX, XC, C Rapidan Station, Va................ ..........____LXXIV, LXXXVII Rapidan Railroad Bridge, Va.............................. LI Rappahannock, Va.......................................LXXXIX, CI Rappahannock River, Va..................................LV, LXXIII Rappahannock Bridge, Va................................. LXII, XCI Rappahannock Crossing, Va............................... XC Rappahannock Station, Va..............................LXXXIV, XCII Rawle's Mills, N.C....................................... LXII Ray County, Mo.......................................... XXXVIII Raymond, Miss.........................................LXXV, XCVII Raytown, Mo............................................. XLIX Readyvillc, Tenn......................................... LVI Ream's Station, Va................................CXIV, CXVI, CXXI Rectortown, Va........................................... XCV Red Bone, Miss........................................... CIV Red Bone Church, Mo..................................... LXXXVII! Red Clay, Ga............................................. • CV Rod Hill, Ala............................................ CXXXIV Red House, AA'. Va........................................ XXXV Red Mound, Tenn........................................ LXV Red Oak, Ga............................................. CXXI Red River, La........................................LXATII, CIV, CV Redwood Creek, Cal...................................... LXXXII Redwood, Miss............................................ LV CLII INDEX, Page. Reed's Mountains, Ark.................................... LXIII Reedy Creek, W. A'a...................................... XLVI Renick, Mo............................................... XXXIX Rerock, Ariz............................................ CXXXVII Resaca, Ga............................................CVHI, CXXVII Reynold's Plantation...................................... CXXX Rhea's Mills, Ark......................................... LXn Rheatown, Tenn.......................................... LXXXIX Richfield, Mo............................................. LXXVI Richland, Ark.........................t.................. CV Richland, Tenn........................................... CXXIV Rich Mountain, W. Va.....................-".............. XXXV Richmond, Ky..........................................LVI, LXXXIV Richmond, La.........................................LXX.LXXVIII Richmond, Va...........................C, CVII, CXXVIII, CXXXVIII Ri chmond & Petersburg Railroad, Va...................... CVII Rickett's Hill, Tenn....................................... LVII Riddle's Shop, Va........................................ CXH Rienzi, Miss.............................................. LV Ringgold, Ga.........................................LXXXVI, XCIV • Ripley, Tenn............................................. LXVI Ripley, Miss..................................XCIA', CXI, CXn, CXVI River's Bridge, S. C....................................... CXXXV Robertson's Run, Va...................................... LXXXIX Roan's Tan Yard.......'.................................. .XLI Roanoke Island, N. C..................................... XLI Roanoke River, N. C...................................... CV Roach's Plantation, Miss.....................^............ CI Rocheport, Mo............................................ LXXATI Rockford, Tenn........................................... XCII Rockingham, N.C........................................ CXXXVI Rockport,-Mo............................................. CXXIV Rockvillc, Md............................................ LXXXVII Rocky Creek Church, Ga................................. CXXXI Rock j' Crossing, Miss..................................... LXXIX Rocky Face Ridge, Ga.................................. C, CVI Rocky Gap, Ky........................................... LXXATI Rocky Gap, A'a........................................... LXXXV Rocky House, AV.Va..................................... XCVIII Rocky Mount Raid, N.C.................................. LXXXIII Rodgersville, Ala......................................... XLVI Rodgersville, Tenn....................................... CXXI Rodney, Miss............................................. XCV, C Rogersville, Tenn........................................ XCII Rolla, Mo...............................................XXXV, CXIX Rolling Fork, Miss........................................ CXXIX Rolling Prairie, Ark....................................... XCVI Rolling Prairie, Mo....................................... XCVII Rome, Ga..'.......................................LXXIII, CVHI, CIX Romney, W. Va............................XXXIV, XXXVIH, LXVHI Rood's HiU, A'a..........................................C A'HI, CXXX Rosecrans' Campaign in Tennessee.......................j. LXXIX Roseville, Ark............................................ XCH, CII .Rousseau's Raid in Alabama and Georgia.................. CXVI Rousseau's Pursuit of \Arheeler, Tenn.. .*................... CXXH Round Away Bayou, La.................................. LXX RoundHiU, Ark.......................................... LI Round Hill, Tenn......................................... LVI Rover, Tenn..........................................."... LXVII Rowanty Creek, Va....................................... CXXXV Rowlett's Station, Ky..................................... XL Running Vicksburg Batteries.............................. LXXI Rural Hills, Tenn......................................... LXIII Rush Creek, I. T.......................................... CXXXV Bussel's House, Miss...................................... XLAT Rutselvilie, Tenn......................................... LI RnsselviUe, Ky........................................... LIII, LIX Rutherford's Creek, Tenn.................»...........LXIX, CXXXHI Sabine Pass. Tex___..................................... LXXII Sabine Pass, La ......................................... LXXXVI Sabine Cross Roads, La................................... CII Sacramento, Ky.......................................... XL Sacramento Mountain, Va................................. CXXI Salem, N.C.............................................. CXXXVIII Page. Salem, Miss.............................................. LXXXIX Salem, Va.............-..................................LXII, CXIII Salem, Mo................................................ XXXIX Salem, Ark............................................... XLIII Salem Cemetery, Tenn.................................... LXIV Salem Pike, Tenn......................................... LXIX Salem Church, A'a........................................ CXI Salkahatchie, S. C........................................ CXXXV Salisbury, Tenn.......................................... LIV, XCIV Salisbury, N.C........................................... CXXXIX Saline County, Mo........................................ LXXXIV Saline River, Ark......................................... CV Salt Lick, Va............................................. XC Saltville, Va................................CXXA', CXXXII, CXXXIII Salyersville, Ky.......................................... XCIV Sailor's Creek............................................ CXXXIX Saint Charles River, Ark.................................. CXIV Samaria Church, Va......................................CXIII, CXIV Sam Gaty, Massacre on Steamer........................... LXX San Carlos River, Cal..................................... CX Sand Creek, I. T.......................................... CXXXII Sand Mountain, Ala....................................... LXXIII Sandersville, Ga.......................................... CXXX Sangster's Station, Tenn.................................. XCV SantaFe, N. M........................................... XLIII SantaFe, Mo............................................. LII Santa Rosa, Fla.......................................... XXXVHI Saratoga, Ky............................................. XXXATII Sartoria, Miss............................................. LXXVII Saunder3, Fla............................................ CIX Saulsbury, Miss.......................................... CXV Savage Station, Va..........._.......................... L Savannah, Tenn.......................................... XLV Savannah, Ga., Siege of................................... CXXXII Scatterville, Ark.......................................... LI Scott's Mills Road, Tenn.................................. XCATI Scott'sFarm, Ark......................................... XCVIII Scottsboro', Ala........................................... CXXXIV Scottsville, Ala...........................'................ CXXXVHI ScrougesviUe, Tenn....................................... LXIII Scullyville, I. T........................................... Cm Seabfook's Point, 8. C..................................... XLVIII Searcy, Ark.........................................CXI, CXV, CXXIII Searcy Landing, Ark..................................... XLVI Scarytown, W.Va........................................ • XXXIV Secessionville, S. C......................'............XLIX, LXXXIII Sedalia,Mo................................'..........XXXIX, CXXVII Selnia, Ala............................................... CXXXVIII Senatobia, Miss........................................... LX XA'I Seneca, Md............................................... LXXATII Seneca Station, I. T....................................... LXXXVn Seven Days' Retreat, A'a.................................. L Seven Pines, Va......................................... XLVIII Seviersville, Tenn........................................ XCVII Shady Springs, Va......................................LVI, LXXXIII Shanghai, Mo......................................XXXVII, XXXVHI ShannonHill, Va......................................... LXXIV Sharpsburg, Md.......................................... LVIII Shawnee Mound, Mo...................................... XL Shawnee Town, Kas...................................... LXXVH Shelby Depot, Tenn...................................... LXI Shelby County, Ky....................................... XL Shelbyville, Tenn......................................... LXXX Shelbyville Pike, Tenn.....................LXXVII, LXXIX, LXXXIX Shelbina, Mo............................................. XXXVII Shelburne, Mo............................................ LATH Shenandoah, Va.......................................... CXXXAT Shenandoah River, Va.................................... CXVII Shepherdstown, Va....................................... LIX, CXXI Sheppardstown, Va...................................LVIII, LXXXIII Shcpherdsville, Ky....................................... LIX Sheridan's Cavalry Raid, Va...........................CVII, CXXXVI Sherwood, Mo............................................ LXXV Suiloh, Tenn............................................ XLV [NDEX. CLITI Page. Ship's Gap, Ga........................................... CXXVII Shirley's Ford, Mo........................................ LVIII Shoal Creek, Ala.................... .................... CXXIX Sibley's Landing, Mo..................................... 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, A'a....................................... CXX Six Mile Creek, Ala...................................... CXXXVIII Skeet, N.C............................................... LXATII Slatersville, Va........................................... XLVI Slaughter Mountain, Va................................... LIV Slaughterville, Ky........................................ LVH Smithfield, A'a...........LXVII, LXXXA'H, XCATI, CIII, CXXI, CXXII Smithfield, Ky............................................ CXXXIV Smithsburg, 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......................................... CATII Smoky Hill Crossing, Kas................................. CXX Smyrna, Ga.............................................. CXA7 Snaggy Point, La......................................... CV Snake Creek Gap, Ga.....................-.............CVII, CXXVII SniaHills, Mo............................................ CIV, CIX Snicker's Gap, A'a......................................... LXI, CXVI Snicker's Gap Pike, A'a................................... CXXI Snicker's Ferry, Va..................-'..................LXIH, CXVH Snow Hill, Tenn.......................................... LXX Snyder's Bluff, Miss....................................... LXXIII Snj-dersville, Miss........................................ CI Solomon's Gap, Md....................................... CXVI Somerset, Ky.........-.................................. XLI, LXX SomerviUe 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 Ferk, Potomac, Va...............'.................. LXH SouthFork, Oreg......................................... CXXXIX South Mills, N.C..........'............................... XLVI South Mountain, Md.................................... LVHI South Quay, Va.......................................... LXXI South Quay Bridge, Va................................... LXXIV Southside Railroad, Va.................................... CXXVIII South Tunnel, Tenn...................................... CXXVI South Union, Ky......................................... * LXXV Southwest Mountain, A'a.................................. LIV Southwest Creek, N.C.................................... LXIV SpanishFort, Ala......................................... CXXXVH Spanish Fort Canon, U. T................................. LXXI Sparta, Tenn.....................................LIII, LXXXV, XCIII Sperryville, Va........................................... LI Spoonville, Ark........................................... CII Sporting Hill, Pa......................................... LXXX Spottsylvanta Court House, Va...................... LXXIII, CVI Springfield, Mo..............................XXXVHI, XXXIX, LXVI Springfield, W. Va........................................ XCVII Springfield Landing, La................................... LXXXI Spring Hill, Tenn.......................................LXIX, CXXX Spring River, Ark......................................XLIII, XCVIII Spring River, Mo.......................................LVIII, LXVIII Stanardsville, Va......................................... 0 State Creek, Kas.......................................... LXXVIII Statesboro', Ga........................................... CXXXI Stamford, Ky............................................. LX Stahel's Reconnoissance, Va............................... LXIII Staunton Bridge, Va...................................... CXIV Stanton Road, Va.......... St. Augustine, Fla......... St. Catharine's Creek, Miss . St. Francois River, Mo..... Page. ......................... XLVIII ......................... XCV ......................... LXXXIV ......................... 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....................................... LXXXVIII Sterling's Plantation, La.................................. LXXXVII Steamer Empress, Miss.................................... CXIX Stevensburg, Va.......................................... XCH, C Stevens' Gap, Ga......................................... LXXXVI Stevenson, Ala........................................... LAT Stevenson's Depot, Va.................................... CXVH Stewart s Plantation, Ark.................................. L Stewart's Creek, Tenn....................................LXV, LXVI Stone's Farm, Ark........................................ CII Stone's Ferry, Ala........................................ CXVI Stone River, Tknn...................................... 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 River, Tenn............................ LXXXVIII 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..................XLIII, XLVIH, CXX, CXXVI, CXXVH Strasburg Road, Va....................................LXVIILLXXH 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......................................... CVHI Sulphur Branch Trestle, Ala.............................. CXXIV Sulphur Springs, Va...................................... LV Sulphur Springs Bridge, Va............................... CXIX Suffolk, Va......................................LXV, LXXI, LXXV, C Summerville, AV.Va...................................XXXVI, LXVII Summerville, Miss........................................ LXIII Summerville, Tenn....................................... XCV Summit Point, Va.............'........................... CXXI SumpterviUe, S. C................................CXXXVII, CXXXIX Sunshine Church, Ga..................................... CXIX Surrender of Lee......................................... CXXXIX Surrender of Johnson..................................... CXL Surrender of Taylor...................................... CXL Surrender of Sam. Jones.................................. CXL Surrender of Jeff. Thompson.............................. CXL Surrender of Kirby Smith................................. CXL Supply Train, Tenn...................................... XCI Sutton, Va............................................... LIX Suwano Gap, N.C........................................ CXL Swallow's Bluff, Tenn..................................... LXXXATII Swan Lake, Ark.......................................... CIV Sweden's Cove, Tenn............................:........ XLVIII Sweetwater, Tenn........................................ XCI Sweetwater Creek, Ga.................................... CXXV SwiftCreek, Va.......................................... CVII Swift Creek, S. C.......:................................ CXXXIX SwiftCreek Bridge, N.C.................................. L CLIV INDEX. Page- Sycamore Church, Va....................................LIII, CXXIII Sykestown, Mo........................................... XLII Sj-lnmore, Ark........................................... XLII Sylvan Grove, Ga........................................ CXXX Taberville, Mo........................................... LIII Tnberville, Ark.......................................... LIV Tah-Kah-o-Kuty, D. T.................................... CXVIII Tahliquah, I. T........................................... LXX Talladega, Ala........................................... CXL Talbott's Ferry, Ark...................................... XLVI Talbot's Station, Tenn.................................... XCV Tallahatchie, Fla......................................... XLIX Tallahatchie, Miss............................LXXIX, LXXXIX, CXIX Tallahassee, Fla.......................................... CXL Tallapoosa River, Ala.................................... CXAT Tanner's Bridge, Ga...................................... CVHI Tar River, N.C........................................... LXX III Taylor's Ford, Ky........................................ XXXIX Taylor's Ridge, Ga....................................XCIV, CXXVII Taylor's Hole Creek...................................... CXXXVn Taj'lorsville, Va.......................................... C Tazewell, Tenn.....................-...................... LIV, XCVI Tebb'sBend, Ky......................................... LXXXI Telford, Tenn............................................ LXXXVI Ten Islands, Ala.......................................... C XVI Ten Miles from Columbus, Ky................ ............ CXXXIV Tennessee River, Tenn.................................... CXXI Terrapin Creek, Ala...................................... CXXVIII Terre Noire Creek, Ark................................... CII Terrisville, Tenn......................................... XCVI Texas County, Mo....................................LXIII, LXXXVI The Island, Mo........................................... LXX Thibodeaux, La......................................... LXXIX Thibodeauxville, La...................................... LXI Thomas Station, Ga....................................CXXX, CXXXI Thompson Cove, Tenn.................................... LXXXVIII Thompson's Hill, Miss.................................... LXXIV Thompson's Station, Tenn................................. LXIX Thornburg, Va........................................... LIII Thornhill, Ala............................................ CXXXIV Thoroughfare Gap, A'a ................................... LX, LXII Tickfaw River, Miss...................................... LXXIV Tillafiuney River, 8. C.................................... CXXXI Tilton, Tenn.............................................. CVHI Tilton, Ga................................................ CXXA'II Tishamingo County, Miss................................. XCI Tobosofkee, Ga.......................................... CIV Todd's Tavern, Va....................................... CVI Tompkinsville, Ky....................................... LI, LXXII Tom's Brook, A'a.......................................... CXXVI Toon's Station, Tenn...................................... LVI Totopotomj', Va.......................................... CX T^otopotomy Creek, Va.................................... CX Town Creek, Ala......................................... LXXIII Town Creek, N. C........................................ CXXXV Township, Fla............................................ LXVII Tracy City, Tenn......................................... XCVI Trantner's Creek, N. C...........................;........ XLVIII Trenton, Tenn............................................-LIV, LXV Trenton, N. C............................................. LXIV Trenton Bridge, N. C..................................... XLVI Trevillian Station, A'a..................................... CXII Trinity, Ala.............................................. LII Trinity River, Cal........................................ XCII Trion, Ala................................................ CXXXVIII Triplett's Bridge, Ky..................................... LXXVIII Truine, Tenn............................................. LXXVIII Try Mountain, Ky........................................ XXXIX Tullahoma, Tenn.................................LXXIX, LXXX, XCI Tunica County, Miss...................................... LIII Tunnel Hill, Ga........................................XCVII, C, CAT Tunnel Hill, Miss......................................... XCIX Tuustall Station, A'a.................................XLIX, LXXIV, C Tupelo, Miss..........................;..........LXXIV, CXA', CXVI Page. Turkey Bend, Va......................................... l Turkey Island Bridge, Va............................ ___ \j \ i Turman's Ferry, Ky...................................... XCAT 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........................................... ci Union Church, Va........................................ XLATII 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........................................... XXXVHI Utoy Creek, Ga........................................... XLIX Vache Grasse, Ark....................................... CXXIV Valverde, N. Mex...............................■.......... XLII A'an Buren, Ark..........................................LXAr, CXIX Varnell's Station, Ga...................................... CVII Vaughn, Miss............................................. CVII Vaughn Road, Va..................................CXXVIII, OXXXV Vaught's Hill, Tenn...................................... LXIX Vera Cruz, Ark.....................................„..... CXXIX Vermillion Baj-ou, La........................_............ LXXXIX Vernon, Ind............................... .............. LXXXII A'erona, Miss............................................. CXXXIII Vicksburg, Miss..........................................XLIX, LXV LXVHI, LXXXVI, LXXIX, LXXX, LXXXV, XCVII, XCVIII, CXV Vidalia, La.................................LXXXVII, XCVIII, CXVII Vienna, Va.....................................XXXIV, XXXIX, LVII Village Creek, Ark...................................... XLIX, L Vincent's Cross Roads, Miss................................ XCI Vinegar Hill, S. C........................................ LXXXV Vining Station, Ga........................................ CXV A'olusia County, Fla...................................... CXXXV Wachita, Indian Agency, Tex............................ LXVII AVadesburg, Mo.......................................... XL Waddel's Farm, Ark...................................... XLIX L Waldron, Ark.......................L XXXVII, LXXXIX, XCV, XCVII AVallace's Ferry, Ark......................:.............. CXVII Wall Bridge, Va.......................................... CV AA'alkersviUe, Mo......................................... XLV AValkers Ford, W. Va..................................... XCIV AValkertown, Va.......................................... c Walthal, Va.............................................. CXIII Wapping4Ieights, Va.................................... LXXXIV Wardensville, A'a......................................... XLVII Warm Springs, N. Mex................................... LXXIX Warm Springs, N.C...................................... XCIII Warrenburg, Mo.........................................XLIII, XLIX Warrenton Junction, Va...........................LIX, LXXIV, LXXV Warrenton Springs, Va................................... LXXXIX Warsaw, Mo......................................XXXVIII, LXXXIX Wartrace, Tenn.......................................... LXXXVIII Washington, N. C............................XLVIII, LVII, LXX, XCI AVashington, D. C........................................ CXVI Watauga River, Ark...................................... CXXV AVaterford, Miss.......................................... LXIII AVaterford, Va.........................'................... LXXXIV AVaterloo Bridge, Va...................................... LV Waterproof, La.....................................XCIII, XCIX, CIV Water Valley, Miss....................................... LXIII Waugh's Farm, Ark...................................... XCIX AVauhatchie, Tenn........................................ XCI AA'autauga River, Tenn................................... XXXIX Wautauga Bridge, Tenn.................................. LXA7, CIV Waverly, Tenn........................................... LXLLXXI INDEX, CLV Page. AVayno County, AA'. A'a................................... XCVIII AA'ayne Court IIouso, W. A'a............................... XXXA'l AVaynesville, Mo......................................... LXXXV AVajnesboro'.A'a.....................................CXXV, CXXXVI AA'nyuesboro', Ga......................................CXXX, CXXXI AA'eaver's Store, Ky....................................... LXXIII AVeber's Falls, I. T....................................... LXXXVI AVelaka, I la.............................................. CIX AVeldon Railroad, A'a...........CVI, CVII, CXFV, CXX, CXXV, CXXXI Wentzville, Mo......,.................................... XXXV AVestern North Carolina, Expedition into................... CXXXII Westminster, Md......................................... LXXX Westport, Mo.....................................LXXVIII, CXXVIII AA'cston, AA'. A'a........................................... LVI AA'est Branch, A'a......................................... LXXI AA'et Glaze, Mo........................................... XXXATII AA'est Liberty, Ky........................................ XXXVHI AVest Point, Va........................................... XLVI AVest Point, Ark..............................LXXXV, CXIII, CXATII AVest Point, Miss......................................... XCIX AA'est Point, Ga........................................... CXXXIX West Virginia, Averill's Raid............................. LXXXV Weyer's Cave, A'a....................................... CXXIV AVhistler's Station, Ala.................................... CXXXIX Whitemarsh, Ga.......................................... XLV AA'hite's Bridge, A'a....................................... CVII AVhite's Ford, A'a......................................... LXXXVII Whiteside, Fla........................................... CXVIII AA'hittaker's Mills, A'a..................................... LXXI White County, Ark....................................... XCVIII AVhite County, Tenn...................................... XCIX AVhitehall, N. C.......................................... LXIV AVhite House, A'a.......................................... CXIII White Oak Swamp, A'a................................... L White Oak Swamp Bridge, Va............................ LIII, CXII White Oak Bridge, Kj'.................................... LV AVhite Oak Road, Va..................................... CXXXVIII AA'hite Post, AA'.Va...............................CXII, CXIX, CXXXI White River, Ark.....................XLIX, LXXXV, CXIV, CXXVIII White Stone Hill, D. T................................... LXXXVI White Sulphur Springs, A'a..................LXHI, LXXXV, LXXXIX White AVater, Mo..... ................................... LXXH Wier Bottom Church, Va.................................. CXIII Wilcox's Bridge, N. C..................................... CXXXVI WildCat, Ky............................................ XXXVIII AVlLDERNESS, A'A........................................ CVI Wiliston, S. C............................................ CXXXV Willis'Church, A'a........................................ L Williamsburg, Va.................XLVI, LI, LVII, LXVII, LXX, LXXI AVilliamsburg, Ky........................................ LXI AVilliamsburg Road, Va.................................. XLIX Williams' Bridge, La..................................... XLIX Page. Williams' Farm, Va...................................... CXIV Williumsport, Tenn....................................... LIV AVilliamsport, Md........................................LIX, LXXXI AVilliamsport, W. A'a...................................... XCVII AVilliamston, N. C......................................... LXII AA'illicomack, Va.......................................... CXXXVIII Willmarsh Island, S. C.................................... XCIX AVillow Creek, Cal........................................ XCIII AVilmington Island, Ga.................................... XLV Wilmington, N. C.............'............................ CX X X VI AA'ilson's Creek, Mo....................................... XXXVI Wilson's Creek, Ky....................................... LXXVIII AA'ilson's Farm, La........................................ CII AA'ilson's Landing, Va..................................... CXII AVilson's AVharf Landing, Va.............................. CIX Wilson's Raid on AVeldon R. R., Va........................ CXIV AVilson's Raid in Alabama and Georgia.................... CXXXVII AVinchester.Va. XLIII, XLVII, LXXVI, LXXVIII, CXVII, CXX, CXXIII AViroman's Shoals, Ky................................... LXIII Wirt Court House, W. Va................................. XXXIX Wise's Fork, N.C......................................... CXXXVI Wolf Creek Bridge, Miss................................. LIX AVolf River, Tenn........................................ CII Wolf River, Miss......................................... LXV AVolf River Bridge, Miss.................................. XCIV Woodbury, Ky........................................... XXXIX Woodbury, Tenn........................................LXVII, LXX Wood Lake, Minn........................................ LIX Wood's Fork, Mo......................................... LXVI Woodsonville, Ky........................................ XL Woodstock, Va.......................................CXXIV, CXXVI Woodville, Tenn......................................... LXI Woodville, Miss..................'........................ CXXVI Wormley's Gap, Va....................................... CXXII Worthington, W. Va...................................... XXXVI AVyatts, Miss.......................................LXXXIX, XCVIII AVyerman's Mills, Tenn................................... XCIX AVyoming Court House, W.Va............................ LIV Wytheville, Va..................LXXXIII, CVII, CXXXIII, CXXXVIII Yates'Ford, Ky.......................................... LVI Yazoo Pass, Miss......................................... LXA'III YazcoCity, Miss..............................LXXXII, C, CV, CXXXI Yazoo River, Expedition up, Miss.......................... XCVII Yellow Bayou, La........................................ CIX Yellow Medicine, Minn................................... LIX Yellow Tavern, Va.......................................CVH, CXXV Yemassee, S. C........................................... LXI Yorktown, Va......................................XLIII, XLV, XLVI Young's Cross Roads, N. C................................ LII Zagonyis Charge......................................... XXXVHI Zollicoffer, Tenn.......................................... LXXXVIII Zuni, Va................................................. LXIV ON SPECIAL WOUNDS AND INJURIES, CHAPTER 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 PUNCTURED WOUNDS. The 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 are 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, A hams, Oscar H., Assistant Surgeon 8th Ncav York Cavalry, aged 32 years. AVounded at Lacey's Springs, Virginia, December 21st, 1864, by a sabre-cut five inches in length over the right parietal and temporal regions. 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. Akixs, Charles, Sergeant, Co. A, 3d Nejv 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 ofthe right foot were amputated. Admitted to Jarvis Hospital, Baltimore, Maryland, on April 22d, and transferred, July 24th, to Hicks Hospital, from Avhence he was transferred, well, September 6th, 1865, to NeAV 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, April 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 38th Congress.) Austin, George W., Private, Co. B, 1st Vermont Cavalry, aged 23 years. Incised Avound of scalp over left parietal region. Wilderness, May 5th, 1864. Admitted to Douglas Hospital, Washington, D. C, May llth. 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 ofthe scalp at Han- over, Pennsylvania, June 30th, 1863. Admitted to Cuyler Hospital, Germantown, Pennsylvania, October 2d, 1863. Transferred 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, Washington, 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., Private, 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 ofthe head. Admitted to hospital, Petersburg, Virginia, November 18th, 1862. Returned to duty December 2d, 1862. Bechner, Abner, Private, Co. G, 21st Virginia 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. Transferred 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 ofthe left clavicle by a fall from his horse. High Bridge, Virginia, 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 6th, 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. Bennett, 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 paroled 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. Bertram, 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 7th, 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 PUNCTURED WOUNDS. 3 Blivins, John, Private, Co. K, 1st Alabama Cavalry, received a slight sabre-cut of the scalp at Moore's Cross Roads, North Carolina, March 10th, 1865. Mustered out of service July 19th, 1865. Bohne, Charles, Bugler, Co. I, 18th Pennsyh-ania 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, James P., Private, Co. A, 1st Delaware Volunteers, aged 21 years. Sabre-cut of the scalp. Weldon Rail- road, Virginia, August 25th, 1864. Admitted to Tilton Hospital, Wilmington, DelaAvare, November 1st, from Harewood Hos- pital, Washington. Returned to duty November 14th, 1864. Bolton, Mauaix, Corporal, Co. G, 1st Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1863. Admitted to JarA-is Hospital, Baltimore, July 20th. Transferred to Carver Hospital, Washington, July 23d. Returned to duty November 17th, 1863. Boulson, Edaa'ard F., Sergeant, Co. B, 5th Michigan Cavalry. Sabre-cut ofthe 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, AA'inchester, Virginia, on the same day. Recovered and transferred for exchange December 20th, 1864. Boyer, Joseph C, Captain, Co. L, 12th Tennessee Cavalry, aged 23 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, James, Private, Co. 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. Returned 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. Culpepper, A'irginia, August 1st, 1863. Admitted to Douglas Hospital, Washington, August 3d. Transferred to Carlisle Barracks September llth, 1863, and returned to duty. Brenage, Lafayette, Sergeant, Co. D, 21st Pennsylvania Cavalry. Sabre-cuts of the scalp and face. Jettersville, Virginia, April 5th, 1865. Admitted to Cavalry Corps Hospital April 12th. Returned to duty April 18th, 1865. Briggs, AA'illiam H., Private, Co. M, 5th Michigan Cavalry, aged 17 years. Sabre-cuts of the scalp and right ear. Lynchburg, ATirginia, June llth, 1854. Admitted to Mount Pleasant Hospital, AVashington, June 20th. Returned to duty July 26th, 1864. Brill, Willlim, 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. Returned to duty March 25th, 1865. Brooks, J. K., Sergeant, Co. C, 1st Maine Cavalry. Sabre-cut of right side of scalp. Middleburg, Virginia, June 19th, 1863. Admitted to Emory Hospital, AVashington, June 21st. Returned to duty July 3d, 1863. Brown, James, Private, Co. H, 1st Maryland Volunteers, aged 34 years. Sabre-cut of the scalp, while on picket at Hatcher's Run, A'irginia, 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, 1853. Admitted to hospital at Gettysburg July 3d. Transferred to Patterson Park Hospital, Baltimore, November llth. Returned to duty February 24th, 1864. Brown, R. H., Private, Co. K, 1st Arkansas Cavalry, aged 18 years. Sabre-cut ofthe scalp. Osage, Missouri, October 25th, 1864. Admitted to hospital at Fort Scott, Kansas, October 23th. Returned to confinement November 30th, 1864, and subsequently exchanged. Bryan, George P., 1st Lieutenant, Co. G, 2d North Carolina Regiment. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 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. Sabre-cut of the scalp. Trevillian Station, Virginia, June llth, 1864. Admitted to Finley Hospital, Washington, June 21st. Returned to duty, well, August 22d, 1864. Burroughs, Harmon, Commissary Sergeant, 8th New York Cavalry, aged 17 year3. Sabre-cut, four inches in length, over the left parietal region. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, Washington, June 10th. Returned to duty July 4th, 1863. Butcher, Robert A., Private, Co. H, 82d Pennsylvania Volunteers, of the 3d Brigade, 1st Division, 6th Corps, aged 21 years, received, in an encounter with the enemy's cavalry near Burke's Station, Virginia, on April 6th, 1355, two sabre-cuts over the vertex, parallel to each other, and at right angles to the sagittal suture. The wounds appeared to implicate .the scalp only, and were approximated by adhesive plaster, after the hair had been shaven away. The patient was conveyed to 4 WOUNDS AND INJURIES OF THE HEAD, Washington, and entered Harewood Hospital on April 16th. The Avounds 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 Avound 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, 1865, it had almost entirely healed, and, at his own request, the patient was discharged from the hospital and from the service of the United States. Soon after his admission to HareAvood, a photograph of his wounds had been taken, by direction of the surgeon in charge, Brevet Lieut. Col. R. B. Bontecou, U. S. A'ols. 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 group of heads in the accompanying plate. Cain, Patrick, Private, Co. G, 62d New York Volunteers, aged 38 years. Sabre-cut of the scalp. Cold Harbor, A'irginia, June 3d, 1864. Admitted to McKim's Mansion Hospital, Baltimore, June llth. Returned to duty August 3d, 1864. Campbell, Harrison G., Private of Co. F, 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 sabre wounds of the scalp, one over the right parietal eminence, the other behind the left ear. He had head- ache, with frequent pulse, constipated boAvels, and appeared to be very feeble. He Avas purged, and then ordered good diet, and " whiskey and quinine freely." On May 20th erysipelas attacked the left leg, Avhich had received no injury. Tincture of iodine locally and tincture of the sesquichloride of iron internally were employed to combat this complication. On May 21st there Avas epistaxis; the pulse was small, at 110; the tongue heavily coated. On the 23d there Avas diarrhoea, which was controlled by pills of opium and camphor. The next day the pulse had risen to 120, and was soft. The abdomen Avas 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 ordered. 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 an unconscious state until June 14th, 1863, when he died. Acting Assistant Surgeon J. M. Matlock, Avho 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. C'apron, James P., Sergeant, Co. F, 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. Carboigh, Daniel, Private, Co. E, 18th Pennsylvania Cavalry, aged 46 years. Sabre-cut of the right parietal region, in a skirmish on the Rapidan, A7irginia, November 17th, 1863. Admitted- to Douglas Hospital, Washington, November 23d. Transferred to Satterlee Hospital, Philadelphia, November 23th. Returned to duty March 24th, 1864. Carey, William H., Private, Co. G, 15th NeAV York Cavalry, aged 18 years. Sabre-cut of the scalp. NeAvmarket, Arirginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Discharged from service May 20th, 1865. Carney, AA'illiam, Private, Co. L, 2d NeAV York Cavalry. Sabre-cut of the scalp, and a shell and gunshot Avound of the upper third of the right thigh. Aldie, Virginia, June 17th, 1863. Admitted to Hospital No. 1, Annapolis, Maryland, June 22d. Died June 22d, 1863, from the effects of the gunshot injury. Carper, Fhilip 77"., 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, ATirginia, June 9th, 1863. Admitted to Second Division Hospital, Alexandria, A'irginia, June 10th. Transferred to Old Capitol Prison June 17th, 1863, for exchange. Carson, AV. L., Private, Co. B, 10th New York Cavalry, aged 21 years. Sabre-cut of the scalp.. Admitted to Second Division Hospital, Annapolis, Maryland, June 22d, 1863. Discharged from service September 17th, 1864. Cebutt, George, PriA-ate, Co. F, llth United States Infantry, aged 19 years. Sabre-cut.of the right parietal region. Petersburg, A'irginia, 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. Discharged from service May 30th, 1865. Chambers, John, PriA-ate, Co. I, 1st Michigan Cavalry. Sabre-cut of the left side of the head. Gettysburg, July 1st, 1863. Admitted to Fort Schuyler Hospital, NeAV York Harbor, July 15. Returned to duty August 28,1863. Chan, H., Private, Co. F, 2d Georgia Cavalry. Sabre-cut of the head. Admitted to hospital, Petersburg, Virginia, December 10th, 1862. Furloughed December 19th, 1862. Chantrell, Octave, Private, Co. M, 4th New York Cavalry. Sabre-cut of the scalp and of the right arm. Upper- ' ville, 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. Draiusville. A'irginia, April 1st, 1863. Clemens, A., Private, Co. C, 51st Virginia Infantry. Sabre-cut of the scalp. Opequan Creek, Virginia, September 19th 1864. Admitted to Field Hospital, AVinchester, Virginia, September 20th. Transferred for exchange, well, November, 1864. Boll Ward & French. phot Private R A.Buti-Vr 8* *P win* Auk. J. Bien.lith. Private .1 A Howard 2] « Penaa Ca>- Plivale T K Ro-i< a^Al'iRebelllul SABRE WOUNDS OF THE HEAD. INCISED AND PUNCTURED WOUNDS. 5 Clemmens, Lawrence, Bugler, Co. I, 1st Massachusetts Cavalry, aged 27 years. Sabre-cut of the scalp. Admitted to Judiciary Square Hospital, AVashington, February 20th, 1864. Deserted March 24th, 1864. Coclrill, y. J., Private. Co. (!. 5th Alabama. Sabre-cut of the head. Petersburg, Virginia, April 2d, 1865. Admitted to Lincoln Hospital, Washington, April 10th. Sent to Old Capitol Prison, April 25th, 1865, for exchange. Colley, John, Private, Co. E, 2d West ATirginia Cavalry, aged 20 years. Sabre-cut of the left parietal region. Five Forks, A'irginia, April 2d, 18G5. Admitted to Slough Hospital, Alexandria, Virginia, June 7th. Discharged from service June 20th, 1865. Collykr, Edavard A., Private, Co. B, 2d NeAV York Cavalry. Sabre-cut of the left occipital region, tAVO and a half inches in length. Brandy Station, A'irginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June llth. 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 loAver third of the left arm. AA'aynesboro', North Carolina, 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 Ohio Cavalry, aged 45 years. Sabrc-cut of the scalp. Fayetteville, North Carolina, March 10th, 1865. Admitted to Dennison Hospital, Cincinnati, Ohio, April 15th. Discharged from service July 19th, 1865. Conoa'er, 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., Musician, Co. K. 2d New A'ork Cavalry, aged 21 years. Sabre-cut of the scalp. Admitted to Judiciary Square Hospital, AA'ashington, 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 parietal region. Smithfield, A'irginia, August 29th, 1864. Admitted to Jarvis Hospital, Baltimore, Maryland, September 4th. Returned to duty October 1st, 1864. Couch, Daniel, Private, Co. F, 1st Massachusetts Cavalry. Sabre-cut of the scalp, and pistol wound of the abdomen. Aldie, A'irginia, June 9th, 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. Coaa'LEA', Frank, Corporal, Co. G, 6th United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania, July 3d, 1863. 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 right 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 Winchester, Virginia, the same day. Transferred for exchange December 10th, 1864, well. Crane, James, Private, Co. A, 6th Michigan Cavalry. Sabre-cut of the scalp. . Gettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty September 23d, 1863. Crocker, Jay, Private, Co. D, 10th NeAV York 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, 1863. 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, AA'ilijam, Captain, Co. I, 96th Pennsylvania A'olunteers, aged 34 years. Sabre-cut of the forehead over the left eye. Spottsylvania, Virginia, May 8th, 1864. Admitted to Seminary Hospital, Georgetown, District of Columbia, May 12th. Discharged from service July 28th, 1864. Cutter, William, Private, Co. H, 4th Vermont Infantry, aged 38 years. Sabre-cut of the scalp. Strasburg, ATirginia, August 16th, 1864. Admitted to Field Hospital at Sandy Hook, Maryland. August 19th, and transferred to Brattleboro', Ver- mont, February 6th, 1865, for muster out of service. Dancer, George W., Private, Co. A, 6th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, Pennsylvania, July 1st, 1863. Admitted to Satterlee Hospital Philadelphia, July 10th. Returned to duty August 6th, 1863. De Graw, Isaac, Private, Co. A, 6th Michigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 1st, 1853. Admitted to Satterlee Hospital, Philadelphia, July 10th. Returned to duty September 23d, 1863. De Groot, Henry, Private, Co. A, 17th Connecticut Volunteers. Sabre-cut on the left side of the scalp. Admitted to Knight Hospital, NeAV Haven, Connecticut, January 23d, 1864. Transferred to Fort Trumbull February 27th, 1864, for duty. Delamater, H., Corporal, Co. M, 15th NeAV A'ork Cavalry, aged 24 years. Sabre-cut of the scalp. NeAvmarket, Virginia, December 21st, 1861. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 31st, 1865. 6 WOUNDS AND INJURIES OF THE HEAD, Deniiirst, H., Private, Co. D, 17th Connecticut A'olunteers. Sabre-cut of the scalp. Gettysburg, July 1st, H63. Admitted to Seminary Hospital, Gettysburg, same day. Transferred to South Street Hospital, Philadelphia; thence to Knight Hospital, NeAV Haven, Connecticut, on March 24th, 1864. Returned to duty April 21st, 1864. Dodd, Thomas, Sergeant, Co. B, 6th United States Cavalry. Sabre-cut o\Ter the anterior and posterior regions of the scalp. FunktoAvn, Maryland, July 7th, 1863. Admitted to First Divison Hospital, Annapolis, Maryland, August 3d. Returned to duty, well, October 12th, 1863. Donlin, 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, Alaryland, June 14th. Discharged from 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. Doavns, 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, recei\Ted 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 years. 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. Transferred to the A'eteran Reserve Corps, May 4th, 1865. Mustered out of service August 24th, 1865. Drew, J. H., Private, Co. F, 45th North Carolina. 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 A'irginia 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, AA'ashington, June 12th, 1863, for exchange. Ducket, J., Private, Co. E, Thomas's Legion. Sabre-cut of the scalp. Opequan Creek, Virginia, September 19th, 1864. Admitted to Field Hospital, AVinchester, A'irginia, September 20th. Transferred for exchange December 20th, 1864, entirely well. Dudley, C. 7'., 1st Lieutenant, Co. K, 15th Virginia Cavalry, aged 25 years, received several sabre-cuts ofthe scalp, and one of the right side, at Culpepper, Virginia, September 13th, 1863. Admitted to Lincoln Hospital, Washington, September 17th. Recovered, and Avas 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. NeAV- market, A'irginia, 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 years. Sabre-cut of the scalp over the occipital region. Brandy Station, A'irginia, 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. Edavards, AVilliam A., Private, Co. B, 5th United States Cavalry. Sabre-cut of the left parietal region. Chancellors- ville, A'irginia, May 4th, 1863. Admitted to Second Division Hospital, Annapolis, Maryland, May 19th. Deserted August 7th, 1863. Ells, AA'illiam S., Private, Co. K, 9th New A'ork Cavalry. Sabre-cut of the scalp and right arm. Culpepper, Virginia, August 1st, 1863. Admitted to Douglas Hospital, AA'ashington, 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 angle 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 hospital, and the wound closed with sutures. Discharged from service April 20th, 1886. Fagle, Frederick, PriA-ate, Co. C, 10th New York Cavalry. Tavo 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 First Division Hospital, Annapolis. Maryland, June 14th. Returned to duty May 2d, 1864. Filler, Joseph, Private, Co. A, 4th NeAv 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 PUNCTURED WOUNDS. 7 Fink, Anthony, Private, Co. G, 15th NeAV York Cavalry, aged 35 years. Sabre-cut ofthe scalp. NeAvmarket, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 3d, 1865. Finnigan, AA'., Private, Co. L, 4th Noav York Cavalry. Sabre-cut of the scalp. Aldie Gap, Virginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, A'irginia, June 18th. Furloughed July 22d. Returned to duty August 22d, 1863. Fisher, Charles AA'., Private, Co. C, 3d Pennsylvania Cavalry. Sabre-cut ofthe right occipital region while attempt- ing to escape from the patrol guard at Annapolis, Maryland, March 29th, 1883. Admitted to Hospital No. 1, at Annapolis, the same day. Returned 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. Returned to duty July 13th, 1863. Folsom, AAriLLiAM M., Private, Co.E, 5th AVisconsin Volunteers, aged 31 years. Sabre-cut of the scalp and hand. July 20th, 1864. Admitted to Harvey Hospital, Madison, Wisconsin, August 1st. Returned to duty August 7th, 1864. Fox, Elias, Private, Co. G, 15th New York Cavalry, aged 26 years. Sabre-cut of the scalp. NeAvmarket, 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. Returned 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. Returned 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, PriA-ate, Co. L, 14th Pennsylvania CaA'alry, aged 18 years. Sabre-cut of the scalp. Millwood, Virginia, December 17th, 1864. Admitted to Field Hospital, AVinchester, Virginia, December 20th. Returned to duty January ]7th, 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. Returned to duty January 23d, 1865. Gardner, AA'illiam, 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 from 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. Gehrett, James AV., Private, Co. D, 1st Louisiana Artillery, aged 33 years. Sabre-cut of the scalp. Cedar Creek, Virginia, October 19th, 1864. Admitted to McClellan Hospital, Philadelphia, October 24th. Returned to duty November 24th, 1864. Giddings, Benjamlx, 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, AVashington, 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. Faecal 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. N, 2d United States Cavalry, aged 22 years. Sabre-cut of the scalp. Beverly Ford, Vir- ginia, 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, AVashington, June 24th. Transferred to Lincoln Hospital June 26th, and thence to the Old Capitol Prison for exchange, October 26th, 1864. s WOUNDS AND INJURIES OF THE HEAD, Gray, Elijah G., Private, Co. F, 1st Michigan Cavalry, aged 25 years. Sabre-cut of the head, and wound of breast by pistol ball, (iettysburg, July 1st, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Returned to duty December 23d, 1863. Green, John, Sergeant, Co. D, 18th New A'ork Cavalry, aged 20 years. Sabre-cut of the scalp. Alexandria, Louisiana, April 21st. 1864. Admitted to Marine Hospital, New Orleans, Louisiana, May 23d. Furloughed June 18th, 1881. Deserted August 31st, 1865. Griffin, 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, AA'ashington, July 21st. Transferred thence to Lovell Hospital, Portsmouth Grove, Rhode Island, July 28th. Returned to duty August 23d, 1864. Griffith, G. AV., Private, Co. G, 2d United States Cavalry, aged 23 years. Sabre-cut. an inch and a half long, ofthe left frontal region. Culpepper, A'irginia, August 1st, 1863. Admitted to Douglas Hospital, AArashington, August 2d. Returned to duty August 14th, 1863. Hand, Charles F., Private, Co. F, 2d United States Cavalry. Sabre-cut, tAvo 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 31st, 1863. Harmon, Martin, Sergeant, Co. I, 9th New York Cavalry. Sabre-cut of scalp. Rapidan, Virginia, October llth, 1863. Admitted to Regimental Hospital, and returned to duty October llth, 1863. Harvey, Joshua, Sergeant, Co. I, 60th Arirginia Infantry, aged 40 years. Sabre-cut of the scalp. Winchester, Virginia, September 19th, 1864. Admitted to AA'est's Building Hospital, Baltimore, October 19th. Transferred for exchange, well, October 25th, 1864. Haskell, David E., Sergeant, Co. F, 8th New A'ork Cavalry. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, AA'ashington, June llth. Returned to duty June 17th, 1863. Hazelet, Leavis, PriA-ate, Co. L, 14th Pennsylvania Cavalry, 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 MoAver Hospital, Philadelphia, February 10th. Returned to duty February 23d, 1865. Higginson, Henry Lee, Major, 1st Massachusetts Cavalry. Sabre-cuts of the scalp and neck. Aldie Gap, Virginia, June 17th, 1863. Admitted to First Division Hospital, Alexandria, Virginia, June 24th. Discharged 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, A'irginia, March 17th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, April 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 expiration of term of service. Horsefield, James, Private, Co. K, 73d Indiana A'olunteers, aged 49 years. Sabre-cut of the scalp, May llth, 1864. Admitted to Second Division Hospital, Madison, Indiana, November 28th. Returned to duty March 17th, 1865. Horton, L. P., Private, Co. L, 10th New York Cavalry. Sabre-cut of the scalp. A'irginia, May llth, 1864. Hosey, AA'illiam, Private, Co. A, 8th NeAV Jersey Volunteers, aged 34 years. Sabre-cut ofthe scalp. Chancellorsville, A'irginia, May 3d, 1863. Admitted to Mower Hospital, Philadelphia, April 27th, 1864, from Tilton Hospital, Wilmington, Dela- Avare. Transferred to Trenton, New Jersey, for muster out, August 26th, 1864. House, AVesley L., Corporal, Co. A, 1st United States Cavalry. Sabre-cut, one inch in length, of the left occipital region. Brandy Station, A'irginia, June 9th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, June 14th. Returned to duty December 2d, 1863. Hucheby, Robert A., Private, Co. I, 53d Georgia Infantry, aged 27 years. Sabre-cut of the scalp. Cedar Creek, Virginia, October 19th, 1864. Admitted to AA'est'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, Avith 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 September 28th, 1863. Received a similar wound at Front Royal, Alrginia, August 16th, 1864. Admitted to Camp Parole Hospital. Annapolis, Maryland, October 7th. Deserted, while on furlough November lstb, 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. Transferred to Cuyler Hospital, Germantown,' Pennsyl- A-ania, October 27th. Returned to duty December 3d, 1863. INCISED AND PUNCTURED AVOUNDS. 9 Jones. AA'uxiam, Private, Co. L, 6th United States Cavalry. Sabre-cut ofthe scalp and arm. Fairfield, Pennsylvania, July 3d, 1863. Admitted to West's Building Hospital, Baltimore, July 20th. Transferred to Carver Hospital, AVashington, July 24th. Returned to duty September llth, 1863. Kelley, Jefferson, Corporal, Co. K, 6th Michigan Cavalry, aged 21 years. Sabre-cut ofthe scalp and face. Yellow Tavern, Virginia, June llth, 1864. Admitted to Alt. Pleasant Hospital, Washington, June 21st. Returned to duty September 13th, 1864. Kelly, Joseph, Sergeant, 1st NeAV 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 Avas probably trivial. Alustered out September 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. Kkni.y, AVilli.vm, Private, Co. F, 4th NeAV A'ork Cavalry. Sabre-cuts of the head and hand. Aldie Gap, Virginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, Virginia, June 20th. Discharged from service February 19th, 1864. Kkrx, Frederick, Private, Co. D, 4th NeAV A'ork Cavalry. Sabre-cut of the scalp and chest. Front Royal, Virginia, August 16th, 1864. Discharged from service June 1st, 1865. Kidavell, Philip, Private, Co. C, 3d Virginia Alounted Infantry, aged 23 years. Sabre-cut ofthe scalp. Cumberland, Maryland, July llth, 1863. Admitted to hospital at Cumberland the same day, and returned to duty November 18th, 1863. Kiernan, Michael, Private, Co. A, 6th United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, AA'ashington, 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 llth. Transferred to Harrisburg, Pennsyl- vania, September 23d, and returned to duty October 6th, 1864. Kirby, Andrew H., Private, Beckham's Battalion. Sabre-cut of the scalp. Admitted to Lincoln Hospital, Washington, September 17th, 1863. Transferred for exchange October 19th, 1863. Kirkpatrick, AVilliam, Private, Co. M, llth Pennsylvania Cavalry, aged 45 years. Sabre-cut of the scalp. Mill- wood, A'irtdnia, December 17th, 1884. Admitted to Camden Street Hospital, Baltimore, December 22d. Transferred to Phila- delphia Alarch 12th, 1865. Discharged from service May 16th, 1865, Klim, AVillla.m J., Private, Co. L, 1st Alaryland Cavalry. Sabre-cut of the left frontal region. Chambersburg, Pennsylvania, July 23th, 1864. Admitted to York Hospital, Pennsylvania, August 3d. Returned to duty September 15th, 1864. Knox, Benjamin 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, AA'illiam, Private, Co. L, 14th Pennsylvania Cavalry, aged 22 years. Sabre-cut of the right side of the scalp. Alillwood, Virginia, December 17th, 1864. Admitted to Patterson 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, Alarch 8th, 1883. Deserted April 7th, 1863. Returned from desertion April 30th, 1863, and ordered to report to Colonel AVaite, Alilitary Commander at Annapolis. Leavttt, Frank AV., Private, Co. E, 1st Maine Cavalry, aged 25 years. Three sabre-cuts on left, centre, and back of the head, aud pistol Avound through left side of upper lip. Brandy Station, Virginia, June 9th, 1863. Admitted to Hospital No. 1, Annapolis, June 15th. Returned to duty September 13th, 1863. Lee, Jeremiah, Private, Co. K, 6th Pennsylvania Cavalry. Sabre-cut of right occipital region. Culpeper, Virginia, June 9th, 18o3. Admitted to First Division Hospital, Annapolis, Alaryland, June 14th. Transferred to Philadelphia October 3d, 1863. He Avas discharged, and his application for a pension was rejected May 13th, 1864, his wound having produced no disability. Lee, Thoaias, Private, Co. C, 14th Pennsylvania Cavalry, aged 22 years. Sabre-cut ofthe left side ofthe scalp. Five Forks, Virginia, April 2d, 1835. Admitted to Slough Hospital, Alexandria, Virginia, June 6th. Discharged from service June 29th, 1865. G. 0. No. 77, A. G. O., April 28th, 1885. LrrTLE, Jesse II, Private Co. B, 18th Pennsylvania Cavalry. Sabre-cuts of the head and shoulder. Hanover, Penn- sylvania, June 30th, 1863. Admitted to Satterlee Hospital, Philadelphia, July 9th. Returned to duty January 22d, 1864. Lockavood, 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, 1883. Logan, M. M., Sergeant, Co. AI. 16th Pennsylvania Cavalry, aged 21 years. Seven sabre-cuts of the scalp, one of the right shoulder, one of the left forearm, and a pistol-shot Avound of the right hip. Aldie, Virginia, June 13th, 1863. Admitted to Lincoln Hospital, AVashington, June 21st. Returned to duty January 17th, 1864. Lotz. AVilliam L., Private, Co. L, 1st Pennsylvania Cavalry, aged 17 years. Sabre-cut of the right side of the scalp 2 10 WOUNDS AND INJURIES OF THE HEAD, Near Ivichmond. A'irginia, May 9th, 1864. Admitted to Hammond Hospital, Point Lookout, Alaryland, Alay 16th. Returned to duty July 19th, 1864. Lowry, Isaac, Private, Co. C, llth Georgia Infantry, aged 23 years. Sabre-cut of the scalp. Fisher's Hill, Virginia, October 19th, 1-64. Admitted to hospital at Point Lookout, Alaryland, January 3d, 1865. Transferred for exchange, Avell, February llth, 1865. Lucas, AA'iixard H., Private, Co. B, 1st Alaine Cavalry, aged 28 years. Sabre-cut of scalp. YelloAV 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 ofthe vertex. Drainesville, 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 A'ork Harbor, November 8th. Returned to duty November 16th, 1863. Lutes, James AV., Private, Co. F, 1st Michigan Cavalry. Sabre-cuts of forehead and vertex of scalp. Gettysburg^ July 3d, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 16th. Returned to duty August 15th, 1863. Luther, James, Private, Co. G, 8tb 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, NeAV York, while on guard. Admitted to hospital at Albany, NeAV York, August 24th. Returned to duty September 26th, 1864. Lyons, James, 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 llth, 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, Nehemiaii H., Captain, Co. M, 4th NeAV York Cavalry. Sabre-cut of the scalp, and gunshot flesh wound of chest. Upperville, A'irginia, June 21st, 1863. Admitted to Emory Hospital, AVashington, June 23d. Returned to duty Sep- tember 29th, 1863. McAlcxander, D., Private, Co. G, 21st Virginia Cavalry, aged 18 years. Sabre-cut ofthe scalp. Front Royal, A'irginia, November 9th, 1864. Admitted to AVest's Building Hospital, Baltimore, November 16th. Transferred for exchange, well, December 9th, 1864. AlcCahr, George, Private, Co. C, 2d Maryland Cavalry. Sabre-cut of the left parietal region. Monocacy, Alaryland, July 9th, 1864. Admitted to AVest's Building Hospital, Baltimore, September 3d. Transferred to Fort Ale Henry, Baltimore, for exchange, well, September 24th, 1864. McClellan, AVilliam 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. Chan- cellorsville, Virginia, Alay 3d, 1883. Admitted to Turner's Lane 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 affray. Admitted to hospital at Indianapolis, Indiana, April 13th. Returned to duty May 6th, 1864. McDowell, James, PriA-ate, 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, Jonathan, 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, Da\tenport, Private, Co. G, 14th Pennsylvania Cavalry, aged 21 years. Sabre-cut of the scalp. Mill- wood, A'irginia, December 17th, 1864. Admitted to Camden Street Hospital, Philadelphia, December 21st. Returned to duty February 23d, 1865. AIcKoaven, AVilliam, Corporal, Co. G, 1st Alaryland Cavalry. Sabre-cut of the forehead, and one on the back of the neck. Culpeper, A'irginia, September 3d, 1863. Admitted to First Division Hospital, Annapolis, Alaryland, September 24th. Returned to duty November 9th, 1863. Alt Lean, AVilliam, Captain, Co. H, 5th United States Cavalry. Two or three sabre-cuts of the posterior portion of the scalp. Hanover, A'irginia, June 13th, 1862. Taken prisoner, and confined in Libby Prison, Richmond, for a few weeks, Avhen he was released. Died of inflammation of the brain April 13th, 1863. McVeigh, T. E., Corporal, Co. F, 15th A'irginia Cavalry. Sabre-cut, three inches in length, of the superior occipital region. Brandy Station, A'irginia, June 9th, 1S63. Admitted to Prince Street Hospital, Alexandria, June 10th. Transferred to provost marshal June 12th, 1863. for exchange. INCISED AND PUNCTURED WOUNDS. 11 Meagher, Edavard, Private, Co. M, 6th United States Cavalry. Sabre-cut of the scalp. Fairfield, Pennsylvania^ July 3d, 1883. Discharged September 26th, 1864, on expiration of term of service. Meredith, D. II., Private, Co. C, 1st DelaAvare Cavalry, aged 28 years. Sabre-cut of the scalp ; also gunshot Avound of the left leg. AA'estminster, Maiyland, June 29th, 1863. Admitted to Tilton Hospital, AVilmington, Delaware, July 4th Transferred to Mower Hospital, Philadelphia, April 27th, 1884. Returned to duty July llth, 1864. Might, John, Private, Co. E, 6th United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, AVashington, June 24th. Returned to duty August 13th, 1863. Miller, Frank E., Sergeant, Co. B, 1st New York Cavalry. Sabre-cuts of the scalp and ear. Dinwiddie Court House, Virginia, Alarch 31st, 1885. Recovered, and mustered out Avith his regiment June 27th, 1865. Miller, John AA'., Private, Co. L, 14th Pennsylvania Cavalry, aged 22 years. Sabre-cut of the scalp. Asbby's Gap, A'irginia, February 9th, 1865. Admitted to hospital at Frederick, Alaryland, March 1st, 1865. Discharged from service July 10th, 1865. AIills, AA'. S., Private, Co. F, 1st Alichigan Cavalry. Sabre-cut of the scalp and shoulder. Gettysburg, July 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, Germ an town, Pennsylvania, July 5th. Returned to duty December 10th, 1803. Morris, J., Private, Co. H, 1st A'irginia Artillery, aged 20 years. Sabre wound of the scalp. Lynchburg, Virginia, June 13th, 1864. Admitted to Post Hospital, NeAV Creek, AA'est A'irginia, June 20th. Returned to duty July 6th, 1864. Mortsolf, 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, A'irginia, June 9th, 1863. Admitted to Prince Street Hospital, Alexandria, June 10th. Returned to duty July 6th, 1863. Neli.is, John, Corporal, Co. A, 6th Ohio Cavalry. Sabre-cut ofthe 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, Missouri, October 25th, 1861. As no further record can be found of this case, the injuries were probably trivial. Newkirk, James C, Private, Co. C, 1st DelaAvare Cavalry, Sabre-cut of the scalp. Westminster, Maryland, June 29th, 1863. Admitted to Tilton Hospital, AA'ilmington, DelaAvare, 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 NeAV York Volunteers. Sabre-cut of the scalp. Beverly Ford, Virginia, June 9th, 1863. Admitted to Lincoln Hospital, Washington, June llth. Returned to duty June 24th, 1863. O'Nell, Thomas, Private, Co. I, 1st Maryland Cavalry, aged 24 years. Accidental incised wound ofthe scalp. Admitted to Jarvis Hospital, Baltimore, Alarch llth, 1864. Returned to duty April 14th, 1864. Oaterton, George P., Private, Co. E, 15th NeAV York Cavalry, aged 41 years. Sabre-cut of the scalp. NeAvmarket, Virginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 21st, 1865. Palmer, Daa'id, Private, Co. K, 6th Ohio Cavalry, aged 19 years. Sabre-cut of right occipital region. Yellow Tavern, A'irginia, 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 ofthe scalp. September 13th, 1863. Admitted to Armory Square Hospital, AA'ashington, 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 Hospital, Columbus, Ohio, June 28th. Alustered out of service July 7 th, 1865. Pickett, Thomas, Private, Co. I, 2d Maine Cavalry. Sabre-cut of left side of scalp. Pine 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, Philadelphia, 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, July 3d, 1863. Admitted to Satterlee Hospital, Philadelphia, July 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 INJURIES OF THE HEAD, Putnam. Orrin J., Corporal, Co. I, 1st A'ermont Cavalry, aged 24 years. Sabre-cut of left side of the scalp. Drains- ville, Virginia, April 1st, I860. Admitted to First Division Hospital, Annapolis, Alaryland, April 8th. Transferred to Invalid Corps March 15th, 1864, and mustered out on expiration of his term of service. Pye, Oliver, Private, Co. K, 1st New Hampshire Cavalry, aged 37 years. Svvord wound of the scalp. NeAvtoAvn, 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, 1864, 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 Avound of the scalp. Acci- dental. Admitted to hospital, Indianapolis, Indiana, June 23d, from Ekin Barracks. 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, Maryfand, November 30th. Mustered out on expiration of term of service, June 5th, 1865. Rice, Horatio H., Sergeant, Co. A, 10th NeAV York Cavalry, aged 24 years. Sabre-cut of the scalp, and a gunshot flesh wound of the thigh. Trevillian Station, June llth, 1864. Admitted to Mount Pleasant Hospital, AVashington, 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, A'irginia, December 10th, 1862. Returned to duty December 23d, 1862. Richie, J. R. P., 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., Private, Co. C, 9th A'irginia Cavalry, aged 43 years. Sabre-cut of the parietal region three inches in length. Upperville, A'irginia, June 21st, 1863. Admitted to Stanton Hospital, Washington, June 23d. Transferred to Old Capitol Prison August 16th, 1863, for exchange. Robinson, AVilliam, Commissary Sergeant, 2d Ohio Cavalry. Sabre-cut of the scalp. September, 1864. Mustered out of service September llth, 1865. Rogers, George A., Private, Co. H, 1st A'ermont Cavalry. Sabre-cut ofthe scalp. Brandy Station, Virginia, October llth, 1863. Admitted to hospital at Annapolis, October 29th ; transferred to Brattleboro, Vermont, December 9th; transferred to Baxter Hospital, Burlington, December 16th. Returned to duty February 25th, 1864. Rowie, James H., 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, A'irginia, July 22d, 1863. Furloughed July 29th, 1863. Rcssell, George, Sergeant, Co. I, 1st Maine Cavalry, aged 21 years. Sabre-cut ofthe scalp. Sheridan's Raid in Vir- ginia, May, 1864. Discharged the service August 17th, 1864. Ryan, Jeremiah, Private, Co. H, 22d NeAV York Cavalry, aged 24 years. Sabre-cut of the scalp. Admitted to De Camp Hospital, David's Island, NeAV A'ork Harbor, June 3d, 1865. Discharged from service July 15th, 1865. Ryan, Sax-ey, Sergeant, Co. G, 13th Indiana Volunteers, aged 23 years. Sabre-cut of the scalp. Bermuda Hundred, A'irginia, 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 ofthe 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, Edaa'ard, Private, Co. M, 7th Michigan Cavalry, aged 18 years. Sabre-cut of the occipital region. Front Royal, A'irginia, August 16th, 1864. Admitted to Jarvis Hospital, Baltimore, Maryland, August 21st. Returned to duty Sep- tember 27th, 1864. Saxtox, Edavard 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 llth. Returned to duty June 18th, 1863. Schaefer, Gustavus, Private, 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 llth, 1863. Sciieer, AVilliam. Private, Co. M, 2d United States Cavalry. Sabre-cut of the right parietal region. Beverly Ford, A'irginia, June 9th, 1863. Admitted to Second DiA-ision 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, A'irginia, Alarch 23d, 1863. Discharged in consequence of aberation of mind, resulting from the injury, April 12th, 1>63. Secrer, James, Sergeant, Co. C, 1st United States Cavalry. Sabre-cut of the scalp. Upperville. A'irginia, June 21st, 1-68. Admitted to Tilton Hospital, AVilmington, Delaware, August 12th. Returned to duty October 2d, 1863. INCISED AND PUNCTURED WOUNDS. 13 Shaw, C. C, Private, 1st A'irginia Cavalry, aged 18 years. Sabre-cut of the left parietal region. AA'arrenton, A'irginia, Alay 3d, 1863. Admitted to Alansion House Hospital, Alexandria, A'irginia, Alay 3d, 1863. Transferred for exchange, well, June 15th. 1863. Shepherd, Herbert L., Private, Co. B, 1st Massachusetts Cavalry. Sabre-cut, two inches in length, of the right parietal region, and slight cut of the hand. Alanassas Gap, A'irginia, June 17th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 16th. Returned to duty October 5th, 1863. Shotavell, JonN, Sergeant, 5th Kentucky Cavalry. Sabre-cut ofthe scalp. Sherman's Campaign through the Caro- linas, 1885. Sheffield, John, Private, Co. D, 1st Arkansas Cavalry, aged 18 years. Sabre-cut of the forehead. Osage, Alissouri, October 25th, 1864. Admitted to hospital at Fort Scott, Kansas, October 28th. Returned to confinement November 17th, 1864. Subsequently exchanged. Singleton, AA'illiam, Private, Co. B, 16th New A'ork Cavalry. Sabre-cut of the scalp. Near Opelousas, Louisiana, October 22d, 1863. Admitted to hospital at NeAV Orleans November llth. 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 9th. Returned to duty November 27th, 1863. Saiall, 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, Alaryland, July 15th. Returned to duty September 26th, 1863. Smith, George AA'., 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. Smith, Henry M., Private, Co. C, llth Pennsylvania A'olunteers, aged 34 years. Sabre-cut ofthe scalp. AVilderness, Virginia, Alay 5th, 1864. Admitted to hospital at Pittsburg June 23d. Returned to duty March 1st, 1865. Smith, John B., Private, Co. K, 6th Pennsylvania Cavalry. Sabre-cut ofthe scalp. Beverly Ford, A'irginia, June 9th, 1863. As no further record can be found of this case, the injury was probably trivial. Smith, Patrick, PriA-ate, Co. A, 8th NeAV York Cavalry, aged 21 years. Sabre-cut of the scalp. Lacey's Springs, A'irginia, December 21st, 1864. Admitted to hospital at Frederick, Maryland, December 23d. Returned to duty January 21st, ' 1865. Southerland, 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. Alillwood, Virginia, December 17th, 1864. Stanton, C. S., Private, Co. D, 2d United States Cavalry, aged 23 years. Sabre-cut ofthe scalp. AVinchester, Virginia, September 19th, 1864. Admitted to hospital at Frederick, Maryland, October 12th. Returned to duty December 3d, 1864. Steakem, AL, Private, Co. I, 16th Massachusetts A'olunteers. Sabre-cut ofthe scalp. Gettysburg, July, 1863. Admitted to South Street Hospital, Philadelphia, July 6th. Returned to duty July 27th, 1863. Steiniiauser, J., Private, Co. C, 1st United States Cavalry, aged 22 years. Sabre-cut, tAVO 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, AA'ashington, August 2d. Returned to duty October 17th, 1863. Stellman, Charles. Private, Co. B, 6th Ohio Cavalry. Sabre-cut ofthe scalp. Beaver Dam, A'irginia, Alay, 1834. Stevens, Daniel, Private, Co. I, 36th A'irginia Infantry, aged 34 years. Sabre-cut of the scalp. AA'inchester, A'irginia, September 19th, 1864. Admitted to West's Building Hospital, Baltimore, October 13th. Transferred for exchange, October 17th, 1864. Stimpson, Robert E., Private, Co. G, let Michigan Cavalry, aged 20 years. Sabre-cut ofthe head. Gettysburg, July 2d, 1863. Admitted to Satterlie Hospital, Philadelphia, July 9th. Returned to duty September 23d, 1863. Struble, L. G., Corporal, Co. A, 5th Alichigan Cavalry. Sabre-cut ofthe scalp. Gettysburg, July 1st. 1863. Admitted to Fort Schuyler Hospital, NeAV A'ork Harbor, July 15th. Transferred to De Camp Hospital, David's Island, February 9th, 1864. Returned to duty February 20th, 1864. Sulham, Jonas G., Private, Co. I, 1st Vermont 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. Drainesville, A'irginia, April 1st 1863. Admitted to Hospital No. 1, Annapolis, April 8th. Returned to duty Alay 1st, 1863. He Avas captured June 9th, 1864, and died in a southern prison. Saa'ain, D. P., Sergeant, Co. A, 6th Alichigan 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. TarsaRI, ADOLPnus, Private, Co. B, 12th New York Cavalry, aged 19 years. Sabre-cuts of the scalp and right hand; September 29th, 1^64 ; for the latter, amputation ofthe index finger Avas performed. June 27th, 1885. Admitted to AIcDougall Hospital, NeAV A'ork 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 wound of left arm. Upperville, A'irginia, June 21st, 1863. Admitted to Stanton Hospital, AA'ashington, June 23d. Transferred for exchange August 1st. 1863. Tewksbvry, Benjamin P., Private, Co. E, 3d New A'ork Cavalry, aged 46 years. Sabre-cut of the head, and contu- sion ofthe back by a fall from his horse. Ream's Station, A'irginia, June 29th, 1864. Admitted to Balfour Hospital, Portsmouth, A'irginia, from Regimental Hospital, May 24th, 1865. Discharged July 20th, 1865. Thomas, J. W., 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, A'irginia, August 6th, 1863. Furloughed August 12th, 1863. Thompson, John, Private, Co. C, 7th Alichigan Cavalry. Sabre-cut of the scalp. Gettysburg, July 3d, 1863. Admitted to First Division Hospital, Annapolis, Alaryland, 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 Nashville December 25th, 1864. Transferred to Provost Marshal January 3d, 1865, for exchange. Tomlin, 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 llth. Furloughed April 18th. Mustered out of service August 1st, 1865. Towxe. Edward O., Corporal, Co. D, 1st Massachusetts Cavalry, aged 39 years. Sabre-cut, three inches in length, behind the right ear. Aldie, A'irginia, June 17th, 1863. Admitted to Third Division Hospital, Alexandria, Alrginia, June 18th. Furloughed July 18th, 1863. Returned to duty and mustered out with regiment October 3d, 1864. Toavnslee. Giles, Private, Co. A, 6th Alichigan Cavalry. Sabre-cuts of the scalp and left arm. HunterstOAvn, Penn- sylvania, July 2d, 1863. Admitted to Satterlee Hospital, Philadelphia, 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, NeAV Orleans, Louisiana, December 28th. Transferred to Military Prison March llth, 1865, for exchange. Tavef.dale, T., Private, Co. I, 1st United States Cavalry. Sabre-cut of the scalp. Upperville, Virginia, June 21st, 1863. Admitted to Emory Hospital, AVashington, June 23d. Returned to duty September llth, 1863. Updyke, Everett C, Private, Co. D, 10th NeAV York Cavalry. Sabre-cut of the right occipital region, three inches in length. Brandy Station, A'irginia, 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. AVinchester, Virginia, September 19th, 1864. Admitted to hospital at AVinchester the following day. Transferred to Baltimore December llth. Sent to Fort Ale Henry January 5th, 1865, for exchange. AVatson, John, Private, Co. H, 1st Alichigan Cavalry. Sabre-cut ofthe scalp. Gettysburg, Pennsylvania, July, 1863. Admitted to South Street Hospital, Philadelphia, July 8th. Returned to duty July 27th, 1863. Watts, W. C, Private. Co. D, 14th A'irginia Cavalry, aged 26 years. Sabre-cut of the scalp. Front Royal, A'irginia, November 12th, 1864. Admitted to Field Hospital, AVinchester, Virginia, November 14th. Transferred to Fort McHenry December 9th, 1864, for exchange. Weed, AVilliam H., Private, Co. C, 2d West Virginia Cavalry. Sabre-cut of the scalp. Five Forks, Virginia, April 1st, 1865. Mustered out of service June 3d, 1865. AVegman. Jacob, Private, Co. I, 16th Illinois Cavalry. Sabre-cut of the scalp. Accident. Admitted to AA'est End Hospital, Cincinnati, 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. ° AVentwoeth, George A., Private, Co! G, 2d Massachusetts Cavalry, aged 24 years. Sabre-cut of the scalp. Aldie A n-ginia, July 6th, 1864. Admitted to Third Division Hospital, Alexandria, A'irginia, 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 Roval Vir- ginia, August 16th, 1864. Admitted to Field Hospital at Sandy Hook, Alaryland, August 18th. Transferred August 20th, 1-1.4. Recovered and returned to duty. Subsequently died of chronic diarrhoea, November 13th, 1865. Wilson, M. D., Private, Co. H, llth Virginia Cavalry, aged 20 years. Sabre-cut of the scalp. Front Royal, Virginia November 12th, 1804. Admitted to Field Hospital, AVinchester, Virginia, November 14th. Transferred to Baltimore November lbth. and thence to Fort AIcHenry. December 9th, 1864, for exchange. * Wingroa e, George. Private, Co. F, 9th New York Heavy Artillery. Sabre cut ot the rhdit parietal region. Shep INCISED AND PUNCTURED WOUNDS. 15 hcrdstoAA-n, A'irginia. August 25th, 1864. Admitted to Patterson Park Hospital, Baltimore, August 27th. Transferred to Camp Parole August 29th. Returned to duty October 5th, 1864. AA'inteiis, August. Private, Co. AI, 5th Ohio Cavalry, aged 23 years. Sabre-cut of the scalp, and shell Avound of the arm. Near Fayetteville, North Carolina, Alarch 10th, 1865. Admitted to Grant Hospital, NeAV York Harbor, Alarch 30th. Transferred to Camp Dennison, Ohio, April 16th. Discharged from service June 23d, 1865. AA'ood, Samuel, Sergeant, Co. L, 2d New York Cavalry. Sabre-cuts of the occipital and parietal regions; also wound of neck. Culpepper Court House, A'irginia, September 13th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, (September 24th. Transferred to De Camp Hospital, New A'ork Harbor, October 29th. Furloughed October 31st. Returned to duty November 21st, 1863. Wbodson, W. R., Private, Co. B, 15th A'irginia Cavalry, aged 27 years. Sabre-cut of the occipital region, five inches in length. Brandy Station, A'irginia, October llth, 1863. Admitted to Hammond Hospital, Point Lookout, Maryland, November 8th, from Campbell Hospital, AA'ashington. Transferred for exchange, Avell, Alarch 3d, 1864. AA'RIGHT, John Private, Co. K, 1st Alabama Cavalry. Sabre-cut of the scalp. Sherman's Campaign through the Carolinas. 1865. AA'RIGHT, J. N., Private, Co. C, 1st A'ermont Cavalry. Sabre-cut of the scalp on median line, three inches above the forehead, and pistol-shot wound of the thorax. Drainesville, Virginia, April 1st, 1863. Admitted to Hospital No. 1, Annapolis, April 8th. Returned to duty Alay 6th, 1863.. Yeagle. JosF.ru, Private, Co. L, 5th NeAV York Cavalry, aged 32 years. Sabre-cut ofthe scalp. Middleburg, Virginia, June 21st, 1863. Admitted to Stanton Hospital, AVashington, June 25th. Returned to duty June 29th, 1863. Young, Seth, Private, Co. D, 1st Alassachusetts 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 the 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 AVounded 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 ProA'ost 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 recoA7ered 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 AVounded, 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. Of those discharged for physical disability or invalided or pensioned, tAvo 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 AVounded 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 feAV comments. Our surgeons commonly shaA'ed a sufficient space about the wound, and after suppressing haemorrhage, and, if necessary, cleansing the parts and removing foreign bodies, approximated the incised 16 WOUNDS AND INJURIES OF THE HEAD, parts by adhesive piasters.1" 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 which has not been reported in detail, in which a large semilunar flap, raised from the vertex and side of the head, presented a wound thirteen inches in length. He approximated the wound by nine points of silver suture. On the fourth day, union Avas perfect. There can be no doubt that exaggerated apprehensions haA'e been entertained Avith respect to the employment of sutures in Avounds of this class; but, as the scalp has but slight elasticity, and retracts but little after division, stitches are rarely indispensable. NeudorferJ makes the practical observation that when Avounds 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 Avas generally recognized. There was not sufficient hsemorrhage in any of the cases above enumerated to require the employment o£ 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 imperatiA'ely 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 A7irginia Cavalry, aged 34 years. Sabre fracture of the left parietal bone. Front Royal, A'irginia, November 12th, 1864. Admitted to hospital at Point Lookout, Maryland, January 31st, 1865. Transferred for exchange, well, February llth, 1865. Allen, Robert, Private, Co. I, 4th Kentucky Volunteers. Sabre fracture of the frontal bone over the external portion of the left orbital ridge. 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 Avith two kinds of '' sticking plaster;" isinglass plaster (Emplastrum Icthyocollae) and adhesive plaster (Emplastrum Resinae, U. S. P.) The first was readily detached if Avater dressings were applied over it; the second was thought by many surgeons to be tAvo irritating to be used in scalp wounds. French surgeons recommend strips of muslin spread with diachylon for the coaptation of these AAOunds. Strips of linen, secured at the ends by collodion, have also been employed. t Reriew of Works on Military Surgery, in Am. Jour, of Med. Sciences. N. S. A'ol. LA'L, p. 427, October, 1837. t NkudoRFER. Handbuch 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. ||The whimsical designations of these accidents by the older surgeons, as hedra, (superficial cut;) eccope, (perpendicular cut); diarope, (oblique section); and aposkeparnismos, (detachment of portions of bone,) have become obsolete. INCISED FRACTURES OF THE CRANIUM. 17 Fig. 1.—Interior view of a segment of the parie- tals and occipital, divided by a sabre-cut.—Spec. 1672, Sect. 1, A. M. M. Armstrong, Martin, Sergeant, Co. M, 6th United States Cavalry. Sabre fracture of the cranium. Fairfield, Penn., July 3d, 1863. Admitted to First Division Hospital, Annapolis, Alaryland, September 20th. Died October 4th, 1863, of pysemia. Basser, Adam, Private, Co. F, 6th United States Cavalry, aged 27 years, received a sabre wound ofthe scalp at Gettys- burg, July 3d, 1803. Admitted to hospital at Annapolis, Alaryland, August 4th. Transferred to Annapolis Junction, April 9th, 1864; thence to MoAver Hospital, Philadelphia, April 27th ; thence to Pittsburg, June 7th, Avhere it was found that there was a loosened exfoliation ofthe outer table of the skull. This Avas removed; the wound then healed, and the man returned to duty, cured, July 22d, 1864. B------, James F., Private, Co. F, 7th Michigan Cavalry, was captured at Gettysburg July 3d, 1863, his horse being shot under him. He was hurried to the rear 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 Avas 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 Rulison, 9th NeAV York Cavalry. He Avas in a very depressed state at this time. His pulse Avas Aveak, and beat from forty to fifty per minute. He was indisposed to mental exertion; but when aroused and interested was quite rational. He lingered until August 15th, 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 *>ase, from the left parietal, and cloven the right parietal, with great splintering ofthe vitreous plate. The sabre had pene- trated the dura mater on the left side, and on the right side the meninges Avere injured by the depressed inner table. The posterior lobes of both hemispheres of the brain were extensively disorganized. The specimen, Avith the above history, was contributed by Surgeon AA'. H. Rulison, 9th New York Cavalry, since killed in battle. An external view of the specimen is presented in Figure 55, page 40, Circular No. 6, Surgeon General's Office, AVashington, 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. NeAvtoAvn, Virginia, November 12th, 1864. Admitted to Field Hospital at Winchester, Virginia, on the same day. Inflammation ofthe brain supervened, and he died, November 30th, 1854. Bradley, Alexander, Private, Co. E, 5th NeAV York Cavalry, aged 23 years. Compound comminuted fracture ofthe occipital bone by a sabre. Hanover, Pennsylvania, June 30th, 1863. Admitted to Satterlee Hospital, Philadelphia, November 17th. Seventeen spiculae of bone were removed. Returned to duty November 2^th, 1863. Browx, James AA'., 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 Alay 18th, 1865. Brown, S. L., Private, Co. G, 8th New A'ork Cavalry. Sabre-cut of the scalp, with fracture of the left parietal bone. Gettysburg, July 1st, 1863. A segment of bone removed primarily. Insensibility lasted seven days. Admitted to hospital at York, Pennsylvania, July 19th. Returned to duty November 24th, 1863. Canfield, J. N., Corporal, Co. G, 15th New York Cavalry, aged 55 years. Fracture ofthe cranium, with depression of the inner table by a blow from a sabre. Newmarket, Virginia, December 21st, 1884. Admitted to hospital at Frederick, Mary- land, December 23d. Discharged from service Alay 20th, 1865. Clark, Richard, (colored,) officer's, servant, aged 19 years. Svrord fracture of the left side of cranium. Iceport, Mississippi, February 2d, 1865. Admitted to Strader Hospital, Louisville, Kentucky, Alarch 23d, from Field Hospital. Trans- ferred March 26th, 1865, to NeAV Albany, Indiana, Floating Hospital. Returned to duty June 27th, 1865. Colvin, John, Corporal, Co. B, 16th Pennsylvania Cavalry, being detached for service 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 spiculae, and a sharp projection was removed by Hey's saAV. The integuments Avere replaced 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 January 28th, 1864. The operation was performed by Dr. George W. Colby, surgeon in chief of the brigade, and the case Avas reported by Assistant Surgeon A. F. Herrmann. D----, Thomas, Private, Co. G, 5th Connecticut Volunteers, aged 48 years, was wounded at Chantilly, Virginia, on September 1st, 1862, by sev- eral sabre blows over the right ear. He Avas taken to Washington, and ad- mitted to Douglas Hospital on September 5th. He was then suffering from partial hemiplegia, with m#ntal hebetude. There was great tumefaction of the scalp. It was found that the right parietal was very extensively frac- tured, (Fig. 2,) one fissure running near the temporo-parietal suture, and others upAvards and backwards from the ear. Near the parietal eminence there was a marked depression. It Avas determined to raise the depressed bone, and on September 6th, Acting Assistant Surgeon J. W. Williams applied the trephine, and, after removing a button and several fragments of bone, he excised a sharp depressed angle by a Hey's saw. It was ascer- 3 Fig. 2.—A'ault of the cranium, showing several sabre-cuts of the right parietal.—Spec. 235, Sect. I, A. M. M. 1 WOUNDS AND INJURIES OF THE HEAD. tained that the dura mater had been injured by the sabre-cuts. After the elevation of the depressed fracture, the paralysis of the left Bide was relieved. The head was shaven, and cold applications were perseveringly employed. For ten days subsequently the case appeared to progress favorably; but, on September 14th, the patient began to be heaA-y and drowsy, and the folioAving day there Avei-e clonic spasms of the left side and pleurosthotonos. At night the breathing was stertorous, the pupils Avere dilated, and the general symptoms of compression of the brain were very marked. Death took place on September 16th, 1862. There Avas a large coagulum of extravasated blood under the scalp near the vertex, as though the man had fallen upon his head after being AVounded. A po t mortem examination was made on September 17th. On removing the calvaria, which Avas remarkable for its extreme thinness, it was found that the dura mater was perforated beneath the intersection of the wounds, and that, for a space of several inches, there was thickening, with other evidences of inflammatory action. The arachnoid and pia mater were disintegrated in this vicinity, and a space comprising nearly half of the right cerebral hemisphere Avas occupied by an abscess. The calvaria Avas forwarded to the Army Medical Museum by Assistant Surgeon AA'arren AVebster, U. S. Army. It is represented 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, A'irginia. on April 6th, 1865, received a sabre wound on the right side of the head. There was a cut through the scalp and pericranium three inches long, extending into the outer table of the skull and diploe, from the parietal eminence doAvinvards and backwards. The Avounded man was conveyed to the Cavalry Corps Hospital, and thence to the Base Hospital at City Point, and thence by Avater to Baltimore, where he Avas admitted to West's Building Hospital, on May llth, 1865. No report of his symptoms is given until his admission to the Baltimore hospital, when Acting Assistant Surgeon W. G. KnoAA-les records that he -suffered se- vere paroxysms of pain, re- curring frequently, and an- nounced by loud screams. In the intervals, he answered questions readily and ration- ally. In the evening of Alay llth, he became composed and slept tranquilly. He manifested signs of intelli- gence until Avithin half an hour of his death, which oc- curred on May 12th, 1865. On Alay 13th, thirty-seven days after the reception of the injury, an autopsy was made by Acting Assistant Surgeon J. H. Butler. The incised fracture ofthe outer table was two and a half inches in length. At one point it penetrated through the diploe. Its edges Avere necrosed and suppurating. On removing the vault ofthe cranium, a splinter ofthe internal table, one and three-fourths of an inch in length aud one-quarter of an inch wide, was found under the cut, depressed 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 ulceration. These communicated with an abscess of the right hemisphere, filled with offensive pus. The dura mater was thickened and softened near the fracture, and discolored on its inner surface over a space an inch in diameter. The specimen is preserved at the Army Medical Museum as a wet preparation, and is numbered 4206 of the Surgical Section. It is represented in the adjacent wood-cuts. (Fig. 3 and Fig. 4.) Dunn, George, Corporal, Co. E, 79th New York Volunteers. Fracture of the left side of the frontal bone, 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, 1862. Deserted Alarch 21st, 1863. Englekle, William, Private, Co. B, 54th Kentucky Volunteers, aged 33 years. Three sabre Avounds of the occipital region, and one of the left superciliary ridge. The latter fractured the outer plate of the frontal bone, 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' 1865. On March 4th, 1867, the examining surgeon of the Pension Office reported his disabilities as permanent. Freybeiit, Adam, Private, Co. B, 1st Maryland Cavalry, aged 34 years. Compound comminuted fracture ofthe left parietal bone by a blow from a .sabre. Brandy Station, A'irginia, June 9th, 1863. Admitted to First Division Hospital, Annap- olis. Alaryland. June 21st. Returned to duty April 21st, 1864. On the expiration of his term of service, he re-enlisted in the 1st Regiment, 1st Army Corps, (Hancock's Corps,) in the spring of 1865. On July 18th, 1865, he was treated at Stanton Hospital, AVashington, for catarrh, was furloughed, and then transferred to Douglas, and thence to Harewood Hospitals, and finally discharged on surgeon's certificate of disability, February 21st, 1866. From the hospital records it appears that he suffered little or no inconvenience from his head injury, and that he was probably an incorrigible malingerer. Godsmark, Gi:« »i:ge A., Private, Co. F, 7th Michigan Cavalry, aged 19 years. Sabre-cut of the right parietal region, four inches in length, with partial fracture of the bone. Gettysburg, July 3d, 1863. Admitted to Harewood Hospital, Washington, July Fig. 3.—Sabre-cut of the right parietal.—Spec. 4206, Sect. I, A. M. M. Fig. 4.—Interior view cf the foregoing specimen. INOISKD FRACTURES OF THE CRANIUM. 19 24th, where a spiculre of bone, one inch in length, was removed. August 18th, the patient Avas much improved, and the wound Avas nearly healed. The intellect at times Avas dull and impaired, with defective hearing. Returned to duty November llth, 1863. Haines, AA'altei: F., Corporal, Co. K, 1st Maine Cavalry, aged 30 years. Sabre-cut of the scalp, two and a half inches long, with fracture of the vertex of the cranium. Middleburg, A'irginia, June 19th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 9th. Returned to duty September 13th, 1863. Hall, Asa A., Private, Co. K, 1st NeAV Hampshire Cavalry, aged 35 years. Sabre-cut ofthe scalp, injuring the cranium. Lacey's Springs, A'irginia, December 21st, 1S64. Taken prisoner by the enemy, and admitted to hospital December 25th. Exchanged, and admitted to Patterson Park Hospital, Baltimore, February 26, 1865, from Annapolis. On May 23d fragments of the outer table Avere removed. Transferred to Hicks Hospital, Baltimore, June 14th. Discharged the service June 25th, 1865. Surgeon T. Sim. U. S. V., reports the case. H------. Kor.Ki; r. Private, Co. C, 6th United States Heavy Artillery,* (colored,) aged 18 yenrs, Avhile sick in hospital at Fort PilloAV, Tennessee, received, at the capture of that work, April 12th, 1864, three sabre-cuts over the left parietal bone, and a blow from some blunt Aveapon, which produced a depressed fracture of the right parietal. One of the sabre Avounds fissured the inner table, and drove a portion of it, an inch and a quarter in length, through the dura mater. As he raised his arm to protect his head, he received a sabre-cut on the left hand, nearly severing the index finger. The patient Avas conveyed by water to the hospital at Mound City, Illinois, and was admitted there on the 14th of April. The case book of the hospital describes him as very Ioav, and at times irrational. On the 17th, the record states that he was Aveak and very restless, disposed to sleep in the day-time, and it is added that his appetite Avas tolerably good. On the 18th, he was "very bad." On the 19th, he was at times delirious. He died at half past ten in the morning of April 21st, 1864. At one in the afternoon an autopsy Avas made by Acting Assistant Surgeon Melvin L. Rust, when a large extravasation of blood was found over the left cerebral hemisphere, and a piece of the vitreous lamina, an inch and a half long and an inch wide, detached from the left parietal by the severest of the sabre- cuts, was driAren through the dura mater, into the substance of the brain. The calvaria, which is depicted in the accompanying wood-cut, (Fig. 5,) was forwarded to the Army Medical Museum by Surgeon Horace Wardner, U. S. V. The detached fragment of bone Avas lost in transportation. The superior portions of the external table of the parietals is discolored, as if from ecchymosis. H-----. James, Private, 27th Company, 2d Battalion, Veteran Reserve Corps, aged 22 years, a patient at Ricord Hospital, Washington, in an altercation with one of the hospital guards, on the 25th of January, 1865, received a sabre Avound, tAvo and a half inches in length, on the left side of the forehead, a little within the left frontal protuberance. A cleft, an inch long, was made in the outer table of the bone. The patient Avas conveyed into the hospital, and the wound Avas closed by silver sutures, and simple dressings were applied, and he Avas restricted to Ioav diet. On the 25th, the man was feverish, and his boAvels were constipated. He had a dose of salts, which was repeated on the 27th. On the 28th, he complained of headache, and Avas ordered a mixture Avith bromide of potassium, lupulin, and hyoscyamus, and was allowed full diet. On the 31st, the report says that his appetite Avas good , but he was ordered a drachm of tincture of gentian thrice daily. On February 2d, he was reported as having passed a restless night, and was ordered eight grains of Dover's poAvder at bedtime. On February 6th, he was very comfort- able, and Avalked about the Avard. On the next day, his bowels being sluggish, he took three grains of blue pill and six of the compound extract of colocynth, and Avas placed on light diet. On the afternoon of the 8th, he complained of headache, which was aggravated at night On the next morning he was par- tially insensible. He was roused with difficulty; he answered questions slowly, but rationally. The pupils responded to light; the tongue when protruded, after great effort, did not deviate laterally. He had a dose of salts, a blister, three by five, to the nucha, and, later in the day, a terebinthinate enema. He had several involuntary dejections, and his urine dribbled away. In the evening he seemed brighter, and the control of the sphincters was re-established. On February 10th, he was perfectly rational. The urine and faeces were discharged voluntarily; the tongue when protruded deviated slightly to the right; the pulse was weak at 70; slight cephalalgia. February llth, he had passed a bad night, and he had but little appetite. From the 12th to the 15th. anorexia, weak pulse, regular bowels, no aggravation of the head symptoms. On the 16th, the patient complained of severe headache at 4 a. m., and soon after began to breathe ster- torously. At 7 o'clock he was perfectly unconscious; the pupils Avere slightly but equally contracted, and did not respond FIG. 5.—Sabre-cuts on the back of the skull.— Spec. 3307, Sect. I, A. M. I.!. Fig. 6.—Cavity of an abscess in the cerebrum, resulting from a sabre wound.—Spec. 3685, Surg. Sect. A. M. M. * In the brief abstract of this case given at page 40 of Circular No. 6,- S. G. O., 18G5, it is stated that the patient was a private of the 7th Colored Regiment, I . S. Artillery. In the report ofthe Congressional Committee on the Conduct of the War, (38th Congress, 1st session, House of Representa- tives, Report No. 65, p.'55,) Robert. Hall is named as of the 1st Alabama Artillery. The Adjutant General of the Army informs the compiler that the organization in which this man enlisted was first known as the "1st Alabama Siege Artillery." Its designation was afterwards changed to " 6th U. S. Artillery, (colored"), afterwards to "7th V. S. Heavy Artillery," and finally to "llth V. S. Colored Troops." 20 AVOUNDS AND INJURIES OF THE HEAD, to light; there was stertor, Avith foam about the lips. Coma became more and more profound, and at half past tAvelve on the folloAving day, February 17th, 1865, the patient expired. At the autopsy, an incised fracture, an inch long, involving the outer table only, was found near the left frontal protuberance. The condition of the diploe beneath it is not mentioned. The left side of the os frontis was sent to the Army Aledical Aluseum. It is numbered Specimen 3684 of the Surgical Section, and is figured by a wood-cut on page 34 of the Catalogue.* Two discolored spots on the specimen are stains from iron rust, acci- dentally made during J;he preparation ofthe specimen. An abscess was found in the left anterior lobe ofthe cerebrum, measuring two and one-half inches antero-posteriorly, and one and one-half inch laterally, the anterior and superior portions extending on the left nearly to the surface of the cerebral substance, and within six lines of the median line of the cerebrum. It contained tAvo punces of pus. Pus had also found its Avay through all the ventricles, largely distending the left lateral, and, from the fourth ventricle, had passed betAveen the substance of the medulla oblongata and its membranes as Ioav as the origin of the twelfth nerve. The boundaries of the upper and posterior portions of the abscess are indicated in Fig. 6. Specimen 3571 of the Surgical Section of the Army Medical Museum sIioavs the remaining portion of the abscess. Hinnan, Henry, Private, Co. F, 1st New York Mounted Rifles. Sabre-cut of the scalp, with fracture of the external table of the cranium. Suffolk, Virginia, May 17th, 1863. Admitted to Regimental Hospital, and returned to duty in the same month. Howard, John A., Private, Co. G, 21st Pennsylvania Cavalry, aged 24 years, was wounded in the engagement of the 2d Cavalry Division with the enemy near Jettersville, A7irginia, April 5th, 1865, by two sabre-cuts, one of the right side of the head, and the other on the back. He Avas admitted to the Field Hospital of the Cavalry Corps on the day of his injury, when it was ascertained that the Avound in the back was not serious, but that the cut on the head, six inches in length, and nearly parallel to the coronal suture, had involved the external fable of the parietal bone. The hair was shaven, the wound approxi- mated by adhesive strips, and cold Avater dressing applied. There were no grave cerebral symptoms, and on April 28th the wounded man was sent to the Base Hospital, at City Point, and thence, on April 30th, to Harewood Hospital, at AA'ashington. A day or tAvo after his admission, a photograph of his wound was made, by direction of Surgeon R. B. Bontecou, U. S. Vols., which is preserved as No. 16 of A^olume I, Photographs of Surgical Cases, A. M. M. The middle figure in the preceding litho- graph of "Sabre wounds of the head" is a faithful copy of this picture. His case progressing very favorably, HoAvard was transferred, on May 18th, to MoAver Hospital, at Philadelphia. He was mustered out of service on July 18th, 1865, with a pension of six dollars a month. In December, 1867, Howard was living at Shippensburg, Pennsylvania. He writes that he suffers greatly from dizziness, and that there have been several exfoliations from the parietal bones since he went to his home. . Hoxey, Martin B., Private, Co. B, llth Connecticut Volunteers. Fracture of the outer table of the left parietal bone by a sabre-cut. Antietam, Maryland, September 17th, 1862. Admitted to hospital at Frederick, Maryland, October l§t. Insanity was subsequently developed, and he was discharged from service December 23d, 1862. Hulston, John A., Private, Co. H, Trestoe's Cavalry, aged 20 years, received a sabre fracture of the occipital bone, with penetration of the skull, at Independence, Missouri, October 22d, 1864. Admitted to hospital at Fort Leavenworth, Kansas, October 25th. Died November 5th, 1864. Kautnkr, Charles H., Private, Co. E, 55th Pennsylvania Volunteers, aged 20 years. Sabre fracture of the cranium. Drury's Bluff, A'irginia, Alay 16th, 1864. Admitted to Chesapeake Hospital, Fort Monroe, May 18th. Transferred, June 5th, to De Camp Hospital, David's Island, New York Harbor. Furloughed July 6th, 1864, and did not return. Lambert, Joseph C, Corporal, Co. G, 21st Pennsylvania Cavalry. Sabre fracture of the cranium, and incised wound ofthe left hand. Jettersville, A'irginia, April 5th. 1865. Admitted to Cavalry Corps Hospital, April 12th. Transferred to Second Division Hospital at Annapolis, Maryland, April 15th. Returned to duty May 8th, 1865. Lawler, David E., Sergeant, Co. E, 3d Missouri Cavalry, aged 29 years. Sabre-cut of the left side of the skull, with fracture of the cranium. Little Blue River, Missouri, October 2lst, 1864. Admitted to hospital at Fort Leavenworth, Kansas, October 27th, and transferred, on November 13th, 1864, to Post Hospital. He subsequently recovered and Avas released. Lucas, Philip, Private, Co. G, 1st New York Cavalry, at Winchester, Virginia, June 13th, 1863, received a sabre fracture of the anterior edge of the occipital bone; also a sabre-cut of the right shoulder, fracturing the head of the scapula. He was discharged from the service on August 24th, 1864, and in Alay, 1865, was examined by Dr Charles Rowland, Pension Surgeon at Brooklyn, NeAV York, who reported that there Avas an extensive indentation of the skull, and that Lucas suffered from partial loss of memory, and frequent attacks of vertigo, resulting from his injury. Mahoney, Dennis, Private, Co. C, 132d New York Volunteers, aged 20 years. Incised wound four inches in length, extending from frontal protuberance along the temporal ridge, with fracture of the cranium; also a cut tAvo and one-half inches long in the left parietal region, and the little finger severed, by a sword in the hands of the officer ofthe guard, April 4th, 1863. Admitted to Foster Hospital, at Newberne, North Carolina, April 5th. Tetanus supervened, and death resulted on April 25th, 1863. Marshall, Thomas, 7th Virginia Cavalry, aged 34 years. Sabre-cut of the scalp, with fracture of the cranium. Orange Court House, Virginia, August, 1862. Admitted to Old Capitol Prison, Washington. Exchanged September, 1862. McGee, William. Orderly Sergeant, Co. F, 1st New York Mounted Rifles. Sabre-cut ofthe scalp, with fracture ofthe external table ofthe cranium. Suffolk, Virginia, May 17th, 1863. Admitted to Regimental Hospital, and returned to duty during the same month. * Catalogue of the Surgical Section of the United States Army Medical Museum, AVashington, 1866, p. 34. INCISED FRACTURES OF THE CRANIUM. 21 McIntosii, FRANCIS, Private, Co. B, 80th Illinois Volunteers. Sabre-cut of the cranium at the vertex. Day's Gap, Alabama, April 30, 1863. Admitted to First Division Hospital, Annapolis, Maryland, July 3d. Returned to duty September 7th, 1863. Mosier, Jacob, Private, Co. G, 86th NeAV York Volunteers, aged 21 years. Sabre fracture of the left parietal and occi- pital bones, Avhile on picket dutv at Petersburg, Virginia, October 2d, 1861. Admitted to Armory Square Hospital, Washington, October 29th. Died November 5th, 1864. Mullen, Charles, Private, Co. D, 69th Pennsylvania Volunteers, received a sabre-cut on the left side of the head at South Alountain, September llth, 1862. The bloAV of the sabre Avas directed obliquely, and inflicted a wound commencing near the left frontal protuberance, extending tAvo inches backwards along the parietal ridge, and downwards over the squamous por- tion of the temporal, the scalp, muscles, and periosteum, and possibly a portion of the external table being included in the flap. The man fell to the ground senseless. After a primary dressing he Avas placed in a field hospital, and thence, on October 2d, he was conveyed to Frederick, and admitted to Hospital No. 5, under the charge of Surgeon H. S. Hewit, U. S. Vols. The Avound Avas suppurating profusely at this time. The patient lay in a stupor, and Avas unable to articu- late. It Avas supposed that he had traumatic meningitis, and the treatment was conducted in accordance with this diagnosis. There was a very gradual amendment; but after several months the mental hebetude disappeared, and the poAver of speech returned. On January 2d, 1863, the patient was transferred to Hospital No. 1, at Frederick, under the charge of Assistant Surgeon R. F. AA'eir, U. S. A. At this date, there was an open granulating Avound, at the base of which dead bone Avas exposed; the pericranium was separated from the bone near the margins of the wound. In the middle of Alarch the cranium was exposed to a much greater extent. The patient complained much of headache, and there Avas partial hemiplegia of the right side. The bare portion of the parietal Avas necrosed, and was felt to be partly detached. Cataplasms Avere applied continuously for a feAV days, Avhen it Avas decided that the necrosed portion of bone was sufficiently detached to Avarrant an attempt to remove it. On March 28th, Acting Assistant Sur- geon Paullin performed the operation. The entire necrosed part was exposed by an L incision connecting with the wound. The fragment was then seized by forceps, and, by gentle traction, Avas readily removed. The lips of the Avounds were then approximated by adhesive plasters, over Avhich compresses dipped in cold water were applied. The case progressed satisfactorily until April 2d, when the patient had spasmodic movements of the muscles. These ceased upon the removal of a detached, blackened bit of bone, half an inch square, from the anterior portion of the wound. Another small scale of dead bone Avas extracted on April 10th. In May the patient's general condition Avas excellent, and the Avound Avas healing rapidly; in the latter part of the month it had closed except at one small point, from which there was a constant puru- lent discbarge. On June 8th, Mullen Avas -discharged from service on account of hemiplegia. His mental faculties were much impaired. The exfoliation Avhich was removed is represented in Fig. 7. Mullen was pensioned at the rate of eight dollars per month. On September 4th, 1867, the examining surgeon of the Pension Office reported that the hemiplegia continued, and that the disability would probably be permanent. O'Hare, Barney, Private, Co. A, 6th NeAV York Cavalry, aged 35 years, of robust constitution and health, received at the hands of a sentinel, at Camp Scott, Staten Island, New York, November 13th, 1881, a sabre-cut on the left side of the head, extending from near the outer angle of the eye across the temporal region nearly five inches. The squamous portion of the temporal and the parietal Avere incised for about two inches, and, in the middle of the incision, the bone and subjacent mem- branes were penetrated. Nearly two drachms of brain substance escaped. The wound was immediately dressed, and there being much cerebral disturbance, and the pulse full and bounding, fifteen grains of calomel were given and twenty-one ounces of blood was taken from the arm, and the eighth of a grain of tartarized antimony was giveu every two hours. Next morning the man was sitting up, and stated that he was quite comfortable. Surgeon A. P. Clark, 6th NeAV York Cavalry, who reports the foregoing particulars, proceeds to state that the scalp wound healed by first intention, and that on November 22d, 1861, nine days after the reception of the injury, the man returned to duty, and that no subsequent untoAvard symptoms appeared. O'Hare's name does not appear on the Pension Lists. In October, 1884, he was employed as a blacksmith at the Headquarters of the Army of the Potomac. Pistorius, William, Private, Co. E, 5th Pennsylvania Cavalry, aged 39 years. Sabre-cut, with fracture and depression of the parietal bone. Petersburg, Virginia, June 9th, 1864. Admitted to hospital at Hampton, Virginia, June 11 th. Died June 18th, 1864, from compression of the brain. Reed, James T., Private, Co. C, 1st Vermont Cavalry, aged 29 years, was wounded in a charge at Boonsboro, Maryland, July 6th, 1863, 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 tAvo and a half inches in length and an inch and a quarter in breadth, while the portion including the diploe and internal table Avas much smaller. The integumental flap was not entirely 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 sepa- rated from the flap, and the integument was replaced and secured by adhesive straps. Water dressings Avere applied to the wound ofthe elbow,-and the arm Avas placed in a sling. On July 16th, the patient Avas admitted to Hospital No. 1, Frederick, Maryland. The wound ofthe head had almost entirely healed. The elboAV Avas swollen and painful. On July 20th, there Avas an attack of erysipelas of the arm. This subsided, and the limb was placed, flexed at a right angle, in a starched bandage, the Fig. 7.—Exfoliation from the left parietal, resulting from a sabre wound.—.Spec. 3863, Sect. I, A. M. M., natural size. 22 WOUNDS AND INJURIES OF THE HEAD, wound being exposed. There was a copious discharge of pus mixed with synovial fluid. At this date the wound of the scalp was completely healed. On September 20th, the patient had recovered with anchylosis of the elbow. He suffered from head- ache, and from fixed pain at the seat ofthe head injury, especially when he was exposed to the sun. On January 23d, 1864, he was transferred to the 1st Battalion of the Veteran Reserve Corps, and on September 26th, 1864, he was discharged from service on account of disability. Rick, Marcus M., Corporal, Co. K, 1st Vermont Cavalry, aged 39 years, received a sabre fracture of the frontal bone, and a wound of the right thigh, at Gettysburg, July 3d, 1863. Admitted to hospital at Brattleboro, Vermont, August 5th. Returned to duty November 24th, 1863, and mustered out with his regiment on February 22d, 1865. Rogers, Thomas E., Private, Co. C, 5th Alabama Infantry, aged 41 years, was wounded near Petersburg, Virginia, April 2d, 1865, by a sabre-cut over the left supra-orbital ridge extending upwards and backAvards two inches, and fracturing the frontal bone. On April 8th, he was admitted to Lincoln Hospital, Washington. A feAV days after his admission his photograph Avas taken for the collection of Photographs of Surgical Cases of the Army Medical Museum. The picture is No. 6 of Volume 3 of that series. It is Avell copied in the right-hand figure of the group in Plate I. On April 20th, the patient showing symptoms of compression, Surgeon J. Cooper McKee, U. S. Army, applied the trephine about one inch above the supra-orbital ridge and elevated the depressed bone. On Alay 27th, the patient was recovering rapidly, having manifested no bad symptoms since the removal of the bone. The large incision in the integument was cicatrizing favorably, covering the dura mater, so that pulsation Avas no longer visible. On June 14th, 1865, the patient had completely recovered, and, upon taking the oath of allegiance, he was released. Royall, William B., Captain, 5th U. S. Cavalry, received several sabre wounds on June 13th, 1862, near Old Church, Hanover county, Virginia. While posted, in observation, on the extreme right of General McClellan's army, his small com- mand was overAvhelmed by the Confederate cavalry column of General J. E. B. Stuart. Captain Royall made a stubborn resistance with his squadron. Though surrounded, and grievously wounded, he escaped from the field. On joining the main body, his injuries were examined by Surgeon C. M. Ellis, 6th Pennsylvania Cavalry. There were tAvo sabre contusions on the right side of the head, a cut tAvo inches long on the forehead through the scalp only, along cut on the left cheek which bled pro- fusely, a cut on the right wrist dividing the tendon of the extensor proprius pollicis, and an incised fracture four inches long of the left parietal, dividing the outer table and diploe. Entire rest and restricted diet, with cold applications to the head, were enjoined; but after a feAV days the patient Avas removed to Washington. Here he was attended by Surgeon General C. A. Finley, and Surgeon G. E. Cooper, U. S. A., wlm directed a continuance ofthe antiphlogistic regimen. The flesh wounds soon cicatrized; but the incised fracture continued to suppurate for almost three months, after which the wound firmly healed. A condition of extreme nervous irritability persisted for many months, with attacks of headache and vertigo which incapacitated the sufferer for active service. In May, 1862, Captain Royall Avas brevetted Major, and in June Lieutenant Colonel, and, in October, he Avas assigned to duty as mustering officer at Louisville, Kentucky. He was promoted Major December 7th, 1863, and brevetted Colonel March 13th, 1865. In April, 1866, he was examined at the Surgeon General's Office. His health was still impaired from the effects of his injuries, but was gradually improving. In 1869, his health was good. Shaaa , John Henry, Private, Co. I, 10th New York Cavalry, received a sabre-cut of the left side of the scalp, with fracture of the outer table of the frontal bone, at Brandy Station, Virginia, June 9th, 1863. He was admitted to First Division Hospital at Annapolis, Alaryland, on June 13th, and returned to duty June 30th, 1863. Shurey, Amos, Saddler, Co. H, 21st Pennsylvania Cavalry, was wounded by sabre-cuts at the affair at Jettersville, Alrginia, April 5th, 1865. The outer tables of the parietal bones were fractured, and also the ulna and fifth metacarpal bone. He was admitted to First Division Hospital, Annapolis, Maryland, April 15th, and on May 9th he was transferred to the Second Division Hospital at Annapolis. He died May 12th, 1865. Siders, Hiram, PriA-ate, Co. H, 21st Pennsylvania Cavalry, aged 18 years. Sabre-cut of the skull, producing a com- minuted fracture of the left parietal bone. Amelia Court House, Virginia, April 6th, 1865. Admitted to Carver Hospital, AVashington, April 16th. Discharged from service Jure 21st, 1865. Steele, Jacob, Private, Co. E, 1st Michigan Cavalry, aged 20 years, received at the battle of Gettysburg, Pennsylvania, July 1st, 1863, three sabre-cuts of the head, fracturing the cranium ; also a cut on the neck, a gunshot wound penetrating the left lung, and a wound of the right arm. He was found lying in a barn in a state of insensibility. The ball was removed from the lung, the wounds were dressed, and he was admitted to Camp Letterman Hospital, at Gettysburg, on July 6th. Transferred to Jarvis Hospital, Baltimore, July 19th; thence to West's Buildings, July 21st, and finally to" Carver Hospital, Washington, on the 25th. He recovered and returned to duty October 20th, 1863. Strandburg, Andrew, Private, Co. H, 5th Minnesota Volunteers, aged 42 years, was admitted on December 18th, 1864, to the Cumberland Hospital, at Nashville, Tennessee, for a gunshot wound ofthe scrotum, received at the battle on the previous day before that city. The wound was not dangerous; but the man had epileptic fits, and it was remarked that there were Beveral depressions in the cranium on the right frontal and parietal regions. The patient stated that he had been wounded several years previously by a sabre blow upon the head, and that he had ever since been subject to convulsions, which were commonly slight, but occasionally severe and frequent. A wounded captain of his regiment stated that the patient's fits had rarely disqualified him for duty. After his admission to hospital, Strandburg had recurrences of epileptic seizures, at first every two or three days, and then at shorter intervals, until at last the intermissions between the attacks were of half an hour's dura- tion only. The intensity of the attacks increased with their frequency. He died in one of the convulsions, January 3d. 1865. At the autopsy, the upper portion of the anterior lobe of the right hemisphere was found to be softened. There was a collection of about two ounces of limpid serum above the right orbital plate of the frontal bone. The brain, in this vicinity, was darker in color than natural. Over the right frontal and parietal regions the dura mater Avas very firmly attached to the skull. The INCISED FRACTURES OF THE CRANIUM. 23 right orbital plate Avas fractured. The calvaria, which Avas contributed to the Army Medical Museum by the attending medical officer. Surgeon S. C. Ayres, U. S. A'ols., exhibited multiple united sabre fractures ot the os frontis, and united linear fractures of both parietals, and disjunction ofthe coronal suture on the right side. Most of the fractures had penetrated the lamina vitrea, Avhich Avas much thickened in the vicinity of the fractures. Several detached fragments ofthe inner table had reunited, and exhibited an eburnated appearance. Along the sagittal and coronal sutures, and in the neighborhood of the incised fractures, there Avere osseous deposits of long standing. An internal and external view of the calvaria is presented in the accompanying lithograph. Saveeney, D., Private, Co. D, 2d United States Artillery, received several severe sabre-cuts of the scalp, one of Avhich fractured the cranium. November, 1863. Admitted to Douglas Hospital, Washington, November 23d. Returned to duty December 9th, 1863. Vernor, Foster, Private, Co. E, 1st NeAV York Mounted Rifles, receiv-ed a sabre-cut ofthe left parietal region tAvo and a half inches in length, Avhich partially fractured the outer table of the skull. Smithfield, Virginia, May 17th, 1863. Admitted to First Division Hospital, Annapolis, Maryland, May 25th. Returned to duty August 9th, 1863. Of the forty-nine patients with incised fractures of the cranium above enumerated, forty-four were Union and five Confederate soldiers. Of the Avhole number, thirteen died, ten Avere discharged, four were paroled, two deserted, and twenty were returned to duty. In the thirteen fatal cases, death resulted from epilepsy, several years after the reception of the injury, in one instance* in another, tetanus was the cause of death; and, in a third, pysemia. In the ten remaining fatal cases, death resulted from inflammation of the brain or its membranes, or from compression. In three of the thirteen fatal cases, the fractures were incomplete, extending through the external table and diploe.only. Of the ten patients who were discharged for disabilities resulting from sabre fractures of the skull, one became insane, one lost vision in an eye, three suffered from attacks of vertigo or dizziness, and, in lavo of these, the mental faculties were impaired, loss of memory being particularly noticeable. A sixth patient was hemiplegia, and his mind was much deteriorated. The other four men discharged, and the four paroled men, suffered only from occasional head- aches or from slight disabilities. In eleven of the forty-nine patients, fragments of bone were removed by the forceps, elevator, Hey's saw, or trephine. But one of these eleven cases terminated fatally. In thirty-seven cases, the site of fracture is definitely described. The frontal bone was principally involved in seven cases. Two of these terminated fatally; from tetanus, in one instance; in the other, with fracture of the outer table only, secondary encephalitis and abscess of the brain supervened. There were two fractures of the temporal region, which recovered. In twenty-two cases, one or both parietals were fractured, and six of these cases resulted fatally. Of six .patients Avith incised fractures in the occipital region, three recovered and three died. These statistics corroborate the obser- vation of Hennen1 and others, that sabre wounds on the top of the head are not, by any means, so dangerous as those of the sides. Boyer2 insisted emphatically on this distinction, citing cases from La Motte, (Traitf de Chir. Paris, 1732, T. II, p. 238, Obs. 139,) Marchetti, and Bohn, of numerous recoveries from very free incisions of the upper part of the skull, with injury of the membranes or to the brain. He pronounced incised fractures of the lateral parts of the head, with penetration of the brain tissue, far graver, and, indeed, almost invariably fatal accidents. Of two cases of recovery from sabre fractures in the temporal region mentioned in the foregoing return, (Lawler, p. 20, and O'Hare,-p. 21,) the contents of the cranium were uninjured in one instance, and in the other, the incision ran across the squamo-parietal suture, and the hemisphere was probably wounded at its upper portion. . The very rapid recovery in the latter case is sufficiently surprising. In the three cases of reco\Tery from sabre fractures of the occipital region, (Bradley, p. 17, ' HENNEN, Principles of Military Surgery, 3d ed. London, 1829, p. 286. 2 BOYER, Traite des Maladies Chirurgicales, 5e ed. Paris, 1847, T. IV, p. 256. 24 WOUNDS AND INJURIES OF THE HEAD, Engklkee, p. IS, Lucas, p. 20,) there was no evidence of lesions of the enccphalon, and in two of these three cases, the incisions appear to have implicated only the outer table and diploe. The seat of injury is specified in eleven of the thirteen fatal cases of incised fractures of the cranium, and was low down laterally or posteriorly in nine. In five, of the eleven instances in which operative interference was employed in the treatment, it consisted in the early removal of detached or depressed fragments; in three cases, in the extraction pf loose exfoliations at a later period; and, in three cases, in the formal application of the trephine.* The five patients treated by the early removal of fragments recovered, and three were returned to duty; one of them, however, suffering from deafness and dullness of intellect; while two were invalided, partly on account of disabilities unconnected with the head injuries. The three patients who had exfoliations removed, eleven, seven, and thirty-two months, respectively, from the date of the reception of their injuries, also recovered, and one was returned to duty, and two were discharged and pensioned; in the former, and one of the latter, necrosis involved the outer table only; the third patient suffered from hemiplegia and mental dullness. Two of the three patients subjected to trephining, on the first and eighteenth day, respectively, recovered; and the third, trephined on the sixth day, survived the operation ten days. These cases will be further considered in the discussion of the results of trephining for gunshot injuries. When sword-cuts slice away parts of the skull and the detached fragments of bone adhere to flaps of integument not entirely separated from the scalp, the treatment to be pursued has been a subject of discussion from an early period,1 and is still a disputed question. Denonvilliers and Gosselin,2 Legouest,3 and Jamain,4 advise that the isolated fragment of bone should be removed from the integument, and that the latter should then be replaced and kept in position by adhesive straps if possible, or else by sutures inserted at such inter\Tals as to admit of the free discharge of pus. They follow the teaching of Dupuytren,5 based on the dangers of protracted suppuration, of necrosis of the detached fragment, and of secondary meningitis, from leaving the bone to act as a foreign body. But these dangers would appear to be overrated, and John Bell, Hennen, Guthrie, and Macleod, were in favor of the practice of Pare, the re-application of the flap, bone and all. Berengarius de Carpiensis, [Opera Omnia, p. 640,) Fallopius, [De Vulner. Capitis, Cap. XXII,) and Magatus, report instances of recovery after the removal of the detached section of bone and the re-application of the flap of integument. Larrey and Lombard, (Bemarques sur les .Lesions de la Tete, Strasbourg, 1796,) followed successfully the prac- tice of Berengarius, and cite many interesting cases of recovery from sword cuts in the head,-through the bone. Pare [CEuvres Completes, ed. Malgaigne, Book VIII, Chap. 7) advises that the osseous flap should be re-applied and kept in place by a few stitches, a practice which he successfully adopted in the case of 'Captain Hydron," and he quotes * Since the foregoing sheets were in print, some additional information has been obtained in relation to the case of S. L. BROWN, (p. 17.) The sabre cut ran along the lower border of the left parietal for two and a half inches, and produced a depressed fracture. The patient was conveyed, in an insensible condition, to a field hospital, and was trephined, a button of bone and a detached fragment of both tables, an inch and a half in length being removed. He was completely unconscious until July 8th, when he recovered from his profound stupor and was perfectly rational. He was kept on a strict antiphlogistic treatment for ten days longer, and was then conveyed to a hospital at York, Pennsylvania. 1 Thesavrvs Chirvrgice, continensprcestantissimorvm Avtorvm, vtpote Ambrosii Parei Parisiknsis, Ioannis Tagavlth Amblvni AriMACi, Alphonsi Ferrii Neapolitan, Ga'ILELMI Fabiuth Hildani, etc., Opera Chirurgica, nunc vere in vnum collect a per Petri: M L'fiexbachiu.ai. Francofvrti, anno A1DCX, p. 199. - Compendium de Chirurgie Pratique, T. II, p. 570. 3 Traite de Chirurgie d'Armee, p. 319. 4 Manuel de Pathologic et de Clinique Chirurgicales, 2d ed. Paris, 1867, T. 1, p. 580. b Clinique Chirurgicale, T. VI, p. 151. INCISED FRACTURES OF THE CRANIUM. 25 Celsus (De re medica, Liber VIII, Cap. IV) in support of his precept. Sabatier (De la Med. Opcratoire, ed. 1832, T. \\, p. 18) cites other examples of successful results by Pare's plan from Leaulte,1 Le Dran, (Observations de Chirurgie, T. I, p. 156, Paris, 1731,) and Plainer, (Opuscula, Lipsiae, 17-18.) In the Museum of the Royal College of Surgeons, at London, there are ten skulls, which have suffered from severe slicing cuts. The large portions of bone cleft from these crania have reunited, often a little out of their proper places. The fissures are all in a state of progress towards being filled up by bone; and the patients must haATe survived their respective injuries months, if not years. These crania are said to have been collected from a cemetery near a military asylum in Germany. Several remarkable examples of the reunion of osseous flaps sliced off by sabre-cuts are preserved in the Museum of the School of Val de Grace. Hennen (Principles of Military Surgery, 3d ed., p. 286) saw, in the Peninsula, many cases of this nature successfully treated by replacing the parts Avith the aid of a few stitches and of a supporting bandage. Macleod records (Sur- gery oj the War in the Crimea, p. 181) the case of a Russian soldier under his charge, who recovered perfectly, the osseous flap being left undisturbed. Guthrie (On Injuries of the Head affecting the Brain, p. 96) adduces examples of recovery under both methods of treatment, and teaches that when the detached portion of bone adheres firmly to the pericranium or integumental flap, it should be reapplied; but if it has but little adher- ence, it should be removed. The reports of these slanting cuts of the head, with detachment of a flap of bone, in the records of the American war, are insufficient in number and details to decide this question. In the case of Bedel, (ante p. 17,) an osseous flap from the occiput, attached to the integu- ment, and partially adherent at its base to the skull, was reapplied, and had nearly reunited through the deposition of new bone, at the date of the man's death, forty-two days after the reception of the injury. Evidently, the presence of the slice of bone in the flap had not been injurious; the fatal issue haAang been due to the irritation caused by the splinters of the inner table, driven in on the right side. In the case of Strandburg, (p. 22,) illustrated by Plate II, detached fragments had completely reunited, the man surviving his injuries for years. On the other hand, in the cases of S. L. Brown, (p. 17,) and Reed, (p. 21,) the fragments of bone sliced off were removed from the integumental flaps, which were then replaced and retained, and both men made excellent recoveries. Little is known of the practice of Confederate surgeons in this particular. Dr. Chisolm2 advises that all sabre-cuts should be closed by adhesive strips or sutures, followed by cold water dressings. Dr. E. Warren3 suggests that the osseous flap should be reapplied; but 1 Observations in Surgery, written originally in French, by H. F. Le Dran, Senior Master of the Company of Surgeons at Paris. Translated by J. S., 2d ed., Loudon, 1770, p. 77. The XXII Observation, reported by M. Leault6, SAVorn surgeon at Paris, relates to a sabre-cut ofthe occiput, "taking off about the extent of a shilling from the first table ofthe occipital bone, and from the internal table the bigness of a silver groat, Avithout offending the dura mater, only leaving it uncovered." Leaulte' attempted "the reunion ofthe teguments and the bone." M. Le Dran, "being at Tuernoy with the Mareschal de Villiers, came to visit the patient, and apprehended that it would be necessary to separate the bone from the teguments entirely; but, upon second thoughts, we concluded," says Leaulte, " that I had ahvays time enough to propose this operation, if my former intentions did not succeed; and therefore Ave agreed to continue the same manner of dressing, which afforded me the satisfaction, in a few days, of approximating the pieces, and securing them so well to the neighboring parts that they perfectly reunited, forming a cicatrix in the space of tAventy-five days, Avithout the least accident." 2 A Manual of Military Surgery for the use of Surgeons in the Confederate States Army; by J. Julian Chisolm, M. D., 3d ed., Columbia, S. C, 1864, p. 213. 3 An Epitome of Surgery for Field and Hospital; by Edward AVarren, M. D., Richmond, Virginia, 1863, p. 353. 4 26 WOUNDS AND INJURIES OF THE HEAD, does not present facts in support of the recommendation. The other Confederate surgical writers are silent on the subject. Although the dangers from permitting the flap of bone adherent to the scalp to remain have, perhaps, been exaggerated, yet it is probably safer to remove it, if it can be detached Avithout much difficulty. That the dangers are not altogether imaginary, is proved by the examples of necrosis of the segment of bone cited by Ravaton and Baerwindt. Should the bone fragment comprise only the outer table and diploe, it seems useless to preserve it; for the brain cavity remains closed by the vitreous table, and a flap of scalp alone has, incontestably, a tendency to reunite more promptly than an osseous surface. If the portion of bone sliced off includes the entire thickness of the cranial wall, and is reapplied with the integumental flap,'cicatrization must be necessarily slow, and there will be a period of many Aveeks, during which complications are liable to arise.1 Had it been practicable, the cases of incised fractures of the skull Avould have been arranged in accordance with the classification proposed by Mr. J. Adams,2 viz: "First, the simple section of the outer table, in which a mere superficial mark is left; secondly, the division of both tables by a perpendicular section; thirdly, an oblique or horizontal cut, Avhere both tables are divided, but not completely detached; and, fourthly, the entire ablation of a piece comprising both tables, in Avhich the bone adheres to the soft parts, or is completely removed with them." But the records are so incomplete that it has been possible to determine these distinctions in only 'The literature of the subject has only been glanced at above. The question seems to have been a favorite topic ol discussion Avith the older surgeons. La Motte (Traite complet de Chirurgie. Paris, 1771, pp. 534, 535, 556, 597) recorded four cases (Obs. 140, 141, 157, 161) of slanting sabre-cuts producing osseous flaps, which, in three cases, included both tables of the skull, and in the fourth, the outer table only. In all four cases, the fragments of bone Avere removed, the integumental flap reapplied, and recovery promptly ensued. Bilguer, J. M., (Chirurgische Wahrnehmungen in denem Eoniglich Preussischen Feld Lazarethen, Berlin, 1763, pp. 89,114, 113, 145, 147,) cites five cases of the same nature, all of which recovered after the removal of the detached flap of bone, (Obs. 15, 23, 35, 36, 37). D. J. Larrey reports, altogether, eleven cases of this description. (Relation Historique et Chirurgicale de I'Expedition de I''Armee d'Orient. Paris, 1803, p. 290 ; Clinique Chirurgicale, Paris, 1829, T. I, pp. 140, 183, 2S6, 306, et T. V, pp. 11, 40, 322; Men. de Chir. Mil. et Campagnes, Paris, 1812, T. Ill, pp. 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 flap of bone Avas reapplied, and tAA-o patients recovered, and two died. Al. H. Larrey (Relation Chirurgicale des Evenemens de Juillet, 1830, Paris, 1831, p. 35) cites the case of a locksmith, Avho, supposing himself to be folloAved by a large body of insurgents, rushed upon a squadron of grenadiers and received eight or ten sabre cuts on his head. There were several flaps; one, including a large portion of the parietal, fell over the right ear, exposing the dura mater over a space tAvo inches long and an inch broad. Another, behind and above the left ear, contained a detached fragment of bone. M. Magistel dressed the Avounds, removing entirely the fragments of bone, and adjusting the flaps by sutures and adhesive strips. The patient was then placed in the Beaujon Hospital, under the care of Marjolin and Blandin. Complete recovery followed in about six weeks, and the man Avas presented to the Academy of Medicine. H. Meyer (Heilung von Sckadverletzungen, in Langenbeck's Archiv., B. II, S. 91 und 101. Berlin, 1862) cites tAvo cases of this nature; in one, the severed segment of bone Avas removed and the patient recovered; in the other, it Avas replaced, and the patient died of meningitis. The pathological preparation from the latter case is specimen 1052, at the Museum of the University of Zurich. Baerwindt (Die Behandlung von Kranken und Verwundeten unter Zelten im Sommer 1866. Wiirzburg, 1867, S. 93) relates tAvo cases of replacement of the segment of bone, followed by necrosis, the patients recovering after the extraction of the exfoliation. Ravaton (Chirurgie d'Armee, Paris, 1768, p. 549) also reports, in detail, tAvo cases with a similar history. Ravoth und Vocke (Chirurgische Klinik, Berlin, 1852, S. 437) record two examples of recovery after removal of the osseous flap. B. Beck (Kriegs-Chirurgische Erfahrungen Wdhrend des Feld- zuges, 1866, in Silddeutschland. Freiburg, 1867, S. 161) cites a very interesting case of recovery after the removal of a large segment of bone and the reapplication ofthe flap of integument. On the other hand, Wepfer (Observations Medico- Practicw de Affectibvs Capitis, Scaphusii, 1827. p. 34, Obs. 16) reports a very successful case in Avhich the osseous flap was reapplied. Another is cited by Baudens, (Clin, des Plaies d'Armes a Feu, Paris, 18:56, p. 122,) a complicated and very unprom- ising case at the outset. Theden (Xeue Bemerkungen und Erfahrungen, 1782, Thiel. I, S- 77) approves of replacing the bone. Chopart and Desault (Traite des Maladies Chirurgicales et des Operations, Paris, 1796, p. 70,) are of the same opinion, and C. J. AI. Langenbeck (Xosologie und Therapie Chirurgischen Krankheitcn, Gottingen, 1830. S. 57) inclines in that direction. The authorities are about equally divided; but the facts adduced seem to favor the practice of removing the detached or partially detached segment of bone. 2 Additions to the Eighth Edition of Cooper's Dictionary of Practical Surgery, London, 1861, Arol. I, p. 8S5. INCISED FRACTURES OF THE CRANIUM. 27 thirtv-one of the 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 Avhich were fatal, under the third; and tAvo 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 Avith the integument, the connections of the flap with the head being entirely severed In this case, the complications Avere so grave that the ques- tion Avas of little interest. It is not impossible that, if the portion of scalp shorn off, the fragment of bone being removed, Avere immediately replaced, and secured by stitches, reunion 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,1 renewed by Dr. Macleod,2 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, while in several there was loss of brain tissue. In addition to those figured in previous pages of this section, the Army Medical Museum possesses eleATen crania affording excellent illustrations of almost every 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.4 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 1 Report of Observations made in the British Military Hospitals in Belgium after the battle of Waterloo, Edinburgh, 1816, p. 50. Thomson cites a remarkable case of removal ofthe upper part of the occipital bone along with the dura mater, in which " a tendency to protrusion of the brain took place during an attack of inflammation; 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, the stupor went off, and the memory returned." Further on, he remarks : "Ave had frequent opportunities of seeing the upper, and the lateral parts of the cerebrum exposed by sabre Avounds; but, in no case, except that which I have mentioned, did any tendency to protrusion of the brain present itself to our notice." 2 Notes on the Surgery of the War in the Crimea, by George H. B. Macleod, M. D., London, 1858, p. 181. 3Report of the Operations of the Medical Department at the Battle of Pea Ridge, Arkansas, on March 6th, 7th, and 8th, 1862. Bound MSS., S. G. O., Div. Surg. Rec, A. 125. 4 Specimens 970 and 971, Section I, are crania of Araucanian Indians, killed by Chilian troops. No. 970 sIioavs nine sabre-cuts, illustrating almost every variety of such injuries. It is figured at p. 33 of the Catalogue of the Surgical Section of Army Medical Museum. No. 971 shoAvs four cuts, Avhich have sliced off a large portion ofthe left parietal. No. 5107 is a skull obtained at Waterloo, by Professor AVilliam 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 the vault 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 cleanly divided. The last nine specimens will be fully described in the next edition of the Surgical Catalogue. 2S AVOUNDS AND INJURIES OF THE HEAD, Avntien Others are alluded to by medical officers, but so indefinitely that identification has been impracticable. Thus, for example, Surgeon D. S. McGuigan,3 3d Iowa Cavalry, in his report after the battle of Pea Ridge, refers to several sabre fractures of the skull, Avhich do not appear upon the casualty lists, nor on any of the nominal or numerical returns of AVounded: "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 bloAV with this rude Aveapon 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 Avho Avere severely AVounded by it." * * * " The cavalry were wounded more frequently on the upper part of the trunk or the face, upon the head or upper extremities." * * * "Here, too," [at LeetoAvn, 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 AVounded were carried America^AVan*0' ^ to CaSSville, MisSOUri."1 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 Avas twenty-one thousand four hundred and forty-four, with one hundred and ninety-six deaths; but it is impossible to determine how many of these 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, 61st Illinois Volunteers, aged 23 years, received an incised Avound on the left side of FIG. 8.—Knife or hang- er worn by Indian and other savages in the Confederate service in 1 There is no regimental surgical register of the 3d Iowa Cavalry on file, at the Surgeon General's Office, for the dates referred to. No monthly sick reports for Alarch and April, 1862, were received from the medical officer in charge of the regiment. There are no records on file from Cassville, Alissouri, prior to February, 1865. The records of the military hospitals at Rolla, Springfield, Jefferson City, and St. Louis, Missouri, and of Keokuk and Davenport, IoAva, whither AVounded were conveyed after the battle of Pea Ridge, have been carefully searched and found not to contain, at the period mentioned, the name of a single wounded man from the 3d IoAva Cavalry. The ''Death Registers" and the Casualty Lists of the Medical Director are equally silent respecting the killed and Avounded of this regiment at the battle of Pea Ridge. The regimental officers of cavalry had peculiar difficulties in making prompt and accurate returns. WThen 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; Avhen they were engaged in expeditions in large columns, or raids, the marches were so rapid that there Avas little time for clerical Avork. * Similar Aveapons Avere carried by a large number of the Cofederate soldiers captured at Roanoke Island, February 8th, 1862. These knives Avere styled by those who wore them : " Yankee-killers." They Avere from eighteen inches to twenty-four inches in length, and Avere made from scythe-blades or long files, sharpened to an edge, and set in Avooden hilts They Avere not used offensively at Roanoke Island, no disposition for hand-to-hand combat being manifested after the intrenched position Avas carried. The wood-cut is copied from Iavo specimens procured at Roanoke Island, by the compiler of this work. INCISED AVOUNDS OF THE SCALP. 29 the head by a knife, at Murfreesboro, Tennessee, Alarch 4th, 1865. He Avas admitted to hospital on the same day, and returned to duty, cured, on April llth, 1865. Jackson, John. Freedman, Avas cut on the scalp by a knife, in an affray at Vicksburg, ^Mississippi, Alay 8th, 1864. He Avas received itito the Freedman's Hospital, whence he deserted on Alay 12th, 1864. Leavis, John. Private, Co. K, 13th New A'ork Artillery, aged 22 years, received an incised Avound of the scalp by a a knife, on April 25th, 1865. He was admitted to Balfour Hospital, Portsmouth, Virginia, on the folloAving day. He Avas discharged from service on June 17th, 1865. McFarland, John, PriA'ate, Co. I, 8th Ohio Cavalry, aged 25 years, received an incised wound of the scalp by a Woav from a knife, on January 7th, 1H05. lie was admitted to Island Hospital, Harper's Ferry, Virginia, on January 9th, and returned to duty on Alarch 6th, 1865. Sciiuala, Joseph, Private, Co. K, 12th New Jersey A'olunteers, 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 Avas discharged from service on July 31st, 1865. Green, F. AL. Private Co. II, 45th Kentucky A'olunteers, aged 19 years, received an incised wound of the scalp over the superior angle of the parietal bone by a 1)1oav from an axe, on December 16th, 1864. He Avas admitted to hospital at Lexington, Kentucky, on December 21st, and returned to duty on April 1st, 1865, for muster-out of service Avith his regiment. Lenhikn. Danikl, Private Co. F, 20th NeAV York A'olunteers, on November 3d, 1864, received a Woav on the head from an axe, which produced an incised scalp wound. He was admitted to Lincoln Hospital, \Arashington, on November 15th, and returned to duty-on December 17th, 1864. Smith, Joel, Private, Co. I, 127th NeAV York A'olunteers, aged 21 years, Avas admitted to No. 1 Hospital, Beaufort, South Carolina, on February 21st, 1865, Avith an incised wound of the scalp, produced by a blow from an axe. He was trans- ferred to hospital at Hilton Head on Alay 28th, and discharged from service on June 8th, 1865. AA'yon, Frederick, Private, Co. G, 6th AVisconsin A'olunteers, aged 17 years, received an incised wound OA-er the left parietal and occipital regions, by a bloAV from an axe, on Alarch 5th, 1865. He Avas admitted to Lincoln Hospital, Washington, on April 4th, transferred thence to Mower Hospital, Philadelphia, on April 7th, and, on Alay 31st, he Avas received into the Harvey Hospital at Madison, AVisconsin. He Avas discharged from service on July 13th, 1865. In the folloAving examples of incised Avounds of the scalp, the nature of the Aveapon by AA'hich the wound Avas inflicted is not reported: Able, Henry, Private, Co. A, 107th U. S. C. T., aged 27 years, Avas admitted to Crittenden Hospital, Louisville, Ken- tucky, on July 30th, 1865, with an incised Avound of the scalp. He returned to duty on July 31st, 1865. Atlas, George, Private, Co. I, 32d North Carolina Regiment, aged 37 years, received an incised Avound of the scalp at Spottsylvania, Virginia, May 10th, 1864. He Avas received into the Second Division Hospital at Alexandria, on May 14tb, and transferred to Lincoln Hospital, AA'ashington, on May 26th, whence he Avas sent to the Old Capitol Prison on June 1st, 1864. Bolton, James, Private, Co. 1,5th Alissouri Cavalry, was received into the Post Hospital, Schofield Barracks, St. Louis, Missouri, on September 28th, 1864, with an incised wound of the left side of the head. He returned to duty on October 3d, 1864. Bowers, J., Private, Co. H, 12th New York Cavalry, aged 34 years, was admitted to Foster Hospital, NeAvberne, North Carolina, on September 25th, 1863, AA-ith an incised scalp wound. He Avas returned to duty December 9th, 1863. Butterfield, S. H., Unassigned Substitute, aged 18 years, received an incised scalp-wound, and was admitted to hospital at Pittsburg, Pennsylvania, on May 20, 1865. He was discharged from service on May 27th, 1865. Dinne, Michael, Private, Co., B, 19th Pennsylvania Cavalry, received an incised wound of the scalp on February 22d, 1864, at AVest Point, Mississippi. He Avas admitted to Washington Hospital, at Memphis, Tennessee, on February 27th, and returned to duty March 28th, 1864. Gaffney, J., Private, Co. B, 169th New York Volunteers, aged 36 years, received an incised wound of the scalp at Fort Fisher, North Carolina, on January 15ht, 1865. He Avas admitted to McDougal Hospital, Fort Schuyler, New York, on January 25th, and discharged from service on Alay 25th, 1865. Hall, A., Private, Co. A, 169th NeAV York Volunteers, aged 51 years, received an incised Avound of the scalp, and Avas admitted to McDougal Hospital, Fort Schuyler, NeAV York, on June 6th, 1865 He was discharged from service on July 18th, 1865. Howard, John, Private, Co. B, 3d Ehode Island A'olunteers, aged 23 years, was admitted to Sickel Hospital, Alexan- dria, Virginia, on May 5th, 1865, with an incised wound of the scalp. He returned to duty on May 18th, 1865. Johnson, F., Private, Co. E, 39th Ohio Volunteers, aged 19 years, was admitted to Crittenden Hospital, Louisville, Kentucky, on June 25th, 1865, Avith an incised scalp wound. He was returned to duty on July 18th, 1865. Kelly, J., Private, Co. D, 2d Louisiana Cavalry, aged 30 years, received, in an affray, a severe incised wound of the scalp. He Avas admitted to hospital at Baton Rouge, Louisiana, on May 25th, and returned to duty June 13th, 1864. McCracken, W. N., Private Co. M, 5th Pennsylvania Heavy Artillery, aged 18 years, received an incised wound of the scalp on October 7th, 1864. He Avas admitted to 3d Division Hospital, Alexandria, A'irginia, on October 10th, and returned to duty January 24th, 1865. 30 AVOUNDS AND INJURIES OF THE HEAD, McDonald, F., Private, Co. G, 55th Kentucky A'olunteers, aged 29 years, Avas received into Alain Street Hospital, Covington, Kentucky, on April llth, 1865, Avith an incised wound of the scalp, not received in action. He died on May 8th, l.S!5. Satterwhite, M., Private, Co. A, 44th North Carolina Regiment, received an incised-Avound of the scalp on June 26th, H63. He Avas admitted to Hospital No. 4, Richmond, Virginia, and furloughed on July 6th, 1863. Strihe, John J., Private Co. K, 178th NeAV A'ork Volunteers, aged 20 years, received an incised scalp-Avound, and Avas admitted to Jefferson Barracks Hospital, St. Louis, Missouri, September 20th, 1864. He Avas returned to duty on September 27th, 1864. A'arble, Henry, Private, Co. C, 22d Indiana Volunteers, aged 21 years, received an incised scalp wound at Franklin, Tennessee, on November 30th, 1864. He was admitted to Btoavii Hospital, Louisville, Kentucky, on June 21st, 1865, and mustered-out of service July 24th, 1865. Williams, A. M., Private, Co. G, 7th Pennsylvania Cavalry, was admitted to Cavalry Corps Hospital at Gallatin, Tennessee, on January llth, 1865, with an incised Avound of the scalp. He was transferred to Nashville on February 25th, and discharged from service July 28th, 1865. AA'yaian, Joseph, Lieutenant, Co. H, 9th Alinnesota Volunteers, received an incised scalp-Avound, and Avas admitted to Post Hospital, St. Louis, Missouri, on May 19th, 1864. He returned to duty on Alay 30th, 1864. Young, H. C, Private, Co. F, 20th Kentucky A'olunteers, aged 28 years, received an accidental incised scalp Avound, on February 28th, 1865. He was admitted to Brown Hospital, Louisville, Kentucky, on June 7th, 1855. He was furloughed, and returned to duty on July 29th. 1865. Of these twenty-eight cases of incised wounds of the scalp by various Aveapons, one resulted fatally. Fifteen of the patients \vere returned to duty, one deserted, and eleven Avere 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 acquired in the late Avar 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, are 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 Avith 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 are recorded. Nine Avere inflicted by sentinels, or received in broils or attempts to desert. Nine Avere received in action. Armstrong, Ebenezer, Private, Co. K, 86th Illinois Infantry. Bayonet wound of the scalp. Kenesaw Mountain Georgia, June 27th, 1864. Eeturned to duty. Ball, Patrick, Private, Co. H, 49th Pennsylvania Volunteers, aged 37 years. Bayonet Avound of the scalp. Wilder- ness, A'irginia, May 8th, 1864. Admitted to Emory Hospital, AVashington, May 13th. Returned to duty Alay 16th, 1864. Blake, Thomas, Private, Co. B, 9th NeAV Hampshire Volunteers. Bayonet wound ofthe scalp, in an attempt to desert. Admitted to post hospital at Albany, Ncav York, December 26th. Deserted, December 30th, 1863. Call. John W., Private, Co. D, 8th Regiment, 1st Army Corps, aged 24 years. Bayonet wound of occipital region and of left eyebroAV. May 23d, 1865. Admitted to post hospital at Camp Stoneman, May 25th. Returned to duty June 7th, 1&65. Davis, John, Private, Co. G, 2d Alaine A'olunteers, aged 21 years. Bayonet Avound ofthe right temporal region. Falls Church, A'irginia, July 16th, 1861. Patient remained unconscious for eight days. AVas returned to duty in October, 1861. On June 27th, 1862. constitutional symptoms Avere manifested, and he Avas admitted to Pennsylvania Hospital, Philadelphia, and again returned to duty. On November 18th, 1862, he Avas admitted to Eckington Hospital, AA'ashington, and discharged the service December 2)!d. 1862, for partial imbecility and such symptoms as dizziness, faintness, and sensitiveness to pressure over the seat of the wound. He was pensioned at four dollars per month, and on September 13th, 1867, his pension Avas increased to six dollars per month. The pension examiner at Bangor, Maine, Dr. Jones, reported, February 15th, 1867, that dizziness had increased and Avas constant, and that the pensioner often fell, and became unconscious. He dreAv his pension on March 4th, 1869, but his condition at that time is not reported. * The total number of incised Avounds returned during the four years of the Avar, on the monthly reports of white troops in the United States service, Avas tAventy-one thousand four hundred and forty-four (21,444,) Avith one hundred and ninety-six (196) deaths; but there is no means of determining how many of these Avere injuries of the head. PUNCTURED AVOUNDS OF THE HEAD. 31 Dunmore, George, Private, Co. E, 4th NeAV Hampshire A'olunteers, aged 22 years. Bayonet wound of the scalp. Cold Harbor, Virginia, June 5th, 1864. Admitted to Knight Hospital, New Haven, Connecticut, June 19th. Deserted, June 25th, 1864. Fox, Joseph. Sergeant, Co. G, 148th Pennsylvania A'olunteers. Bayonet wound of the scalp. August 25th, 1864. Admitted to Lincoln Hospital, AA'ashington, August 30th. Returned to duty September 21st, 1864. Koschico, Gultill, Private, Co. C, 13th Connecticut Arolunteers. Bayonet wound of the scalp. March 25th, 1864. Admitted to University Hospital, NeAV Orleans, Louisiana, March 26th. Returned to'duty July 1st, 1864'. Lahey. Andreav, Private, Co. C, 10th Tennessee Volunteers. Bayonet Avound ofthe scalp. May 4th, 1864. Admitted to Hospital No. 2, Nashville, Tennessee, Alay 6th. Died from inflammation of the brain, May 6th, 1864. Lkntemar, Frederick, Corporal, 4th Ohio Battery, aged 27 years, received a punctured Avound of the scalp on March 10th, 1865, and was received into Hospital No. 2, at Nashville, Tennessee, on the folloAving day. He recovered, under simple dressings, and Avas returned to duty March 18th, 1865. McCarty, Georgk, Private, Co. G, 23d Pennsylvania Volunteers, aged 18 years. Bayonet wound of the scalp. Cold Harbor, A'irginia, June 2d, 1864. Admitted to South Street Hospital, Philadelphia, June 13th. Returned to duty July 10th, 1864. McDonald, Joseph AAr., Private, Co. D, 75th Illinois Volunteers, aged 35 years. Bayonet Avound ofthe scalp. Colum- bus. Georgia, November 24th, 1864. Admitted to Hospital No. 5, Quincy, Illinois. December 8th. Returned to duty February 7th, 1835. AIcGinpsey, Hugh AA'., Sergeant, Co. E, 155th Pennsylvania A'olunteers, aged 22 years. Bayonet wound of the occipital and parietal regions. October 6th, 1864. Admitted to hospital at Pittsburg, Pennsylvania, the same day. Returned to duty February 25th, 1865. AIcGoa-ern, Philip. Private, Co. B. 158th New York Volunteers, aged 25 years. Bayonet wound ofthe scalp. March 28th, 1864. Admitted to hospital, Beaufort, South Carolina, Alarch 28th. Returned to duty April 27th, 1864. Meade, Michael, Private, Co. B, 60th Nbav A'ork Volunteers, aged 22 years. Bayonet wound of the scalp. Chicka- mauga, Georgia, September 20th, 1863. Admitted to Hospital No. 1, Louisville, Kentucky, February 17th. Returned to duty February 22d. 18S4. Tomoney, Edward F., PriA-ate, 100th Pennsylvania Volunteers, aged 38 years. Bayonet Avound of the scalp. Peters- burg, A'irginia, April 2d, 1865. Admitted to Slough Hospital, Alexandria, Virginia, April 27th. Deserted May 15th, 1865. Turney, James, Private, Co. K, 105th Pennsylvania A'olunteers, received a bayonet Avound of the side of the scalp at Fair Oaks, Alrginia, Alay 31st, 1862. He Avas sent to the rear and admitted to the Hospital at Mills Creek, on June 4th, 1862. The patient died on June 13th, 1862. The particulars of the treatment are not recorded. The case is reported by Surgeon A. P. Heichhold, 105th Pennsylvania A'olunteers. Warner, George, Private, Co. I, 1st A'eteran Reserve Corps, aged 21 years. Bayonet Avound of the scalp. March 25th, 1865. Admitted to hospital at Elmira, New York, April 4th. Returned to duty. Of the eighteen patients with punctured scalp wounds, eleven Avere returned to duty; three deserted; one was discharged for disability; and two died. Punctured wounds of the scalp, when made by a weapon directed perpendicularly to the skull, are necessarily slight in depth; when made obliquely, the point of the weapon soon penetrates from within outAvards, on account of the convexity of the cranial vault They are occasionally complicated by erysipelas, burroAving of pus under the occipito-frontalis aponeurosis, or by haemorrhage; but are commonly trivial in extent and importance. When uncomplicated, the treatment consists in shaving the surrounding scalp and keeping the Avound covered with a compress saturated with cold water or some resolvent lotion. The complications which existed in the two fatal cases above noted are not reported in detail. Punctured Fractures of the Cranium.—Only six examples of punctured frac- tures of the skull, by sharp-pointed weapons, have been reported. Five of these were inflicted by the bayonet, and one by a sword. Allen, D. K, Private, Co. F, 50th Ohio Volunteers, aged 20 years, received a punctured bayonet wound of the scalp, with fracture and depression of the left parietal bone, at Franklin, Tennessee, November 30th, 1854. Admitted to Dennison Hospital, Cincinnati, Ohio, January 18th, 1865, from Madison Hospital, Indiana. Temporary insensibility, paralysis of right arm, and aphonia, folloAved the injury. A portion of the bone, one and a half inches in length and three-fourths of an inch in breadth, was removed. The wound healed, the scalp adhering to the dura mater. Furloughed March 16th, 1865, and never returned to hospital. He was examined by Surgeon John C. Hupp, at Wheeling, West Virginia, July, 1865. There was 32 AVOUNDS AND INJURIES OF THE HEAD, a depressed cicatrix over the solution of continuity of the skull. The aperture in the parietal seemed to be about an inch in leiiLrth, by three-fourths of an inch in breadth. The patient's speech was interrupted and stammering. There Avas defective sensation in the right hand, and numbness over a tract extending from the seat of the Avound to the left side of the bone. Exer- cise of body or mind occasioned pain in the cicatrix and left temporal region. Any jolting, or stooping, effort in lifting, or any sudden or loud noise produced a sensation as of straining of the brain substance through the aperture. The patient described this sensation as very painful. In Alarch, 1839, this pensioner resided at Bridgeport, Belmont county, Ohio, and the examining surgeon ofthe Pension Bureau reported that he was totally and permanently disabled, and required cautious and Avatchful care by night and day. Buckley, John B., Corporal, Co. D, 62d Pennsylvania \7olunteers, aged 24 years, received a bayonet wound of the forehead, through the right superciliary ridge, at Chancellorsville, A'irginia, Alay 3d, 1863. It Avas found, on examination, that the Aveapon had penetrated the frontal sinus, and passed horizontally baclvAvards into the brain. The patient Avas transferred to AVashington, and Avas admitted to Finley Hospital on the 9th, in a perfectly conscious condition, Avith a natural pulse and free- dom from febrile excitement. Acting Assistant Surgeon LeAvis Heard passed a bougie along the track of the Avound into the right anterior lobe ofthe brain the distance of four inches, Avithout force, and without the least pain to the patient. The perfo- ration in the skull barely admitted the point ofthe index finger. There Avere found a feAV small fragments of bone still hanging at the inner edge of the orifice. There was no haemorrhage. Perfect quietness Avas strictly enjoined, a saline laxative Avas ordered, and cold Avater dressings Avere applied. The diet Avas light. On May 14th, he continued conscious and comparatively comfortable, complaining of but little pain in the head. Temporizing treatment was continued. For the next tAvo days signs of mental disturbance were noticeable, and partial loss of vision, with optical illusions. He complained of headache, and a febrile movement arose, Avith intense thirst. The boAvels were kept open by Epsom salts. Pus and disorganized brain tissue Avere dis- charged from the wound. At noon, on the 16th, he moved his arms about tremulously, catching at imaginary objects, arousing, occasionally, from the stupor into which he had fallen, complaining of increased pain in the head, and then talking incoherently. The skin Avas of natural temperature, and the pulse at 80. On May 17th, the patient had passed a quiet night. The pulse aa as at 125 ; there Avas greater tremulousness of the arms, Avith increased stupor, and vision Avas nearly extinct. The patient had great thirst, but no appetite. The discharge of pus and disorganized brain substance continued. Slight convulsions occurred in the afternoon, and the patient sank gradually, and died at six o'clock p. M., thirteen days after the reception of the injury. At the post mortem examination, made fourteen hours after death, the sinuses and the dura mater Avere found to be highly engorged Avith blood. The right hemisphere of the brain was sliced off, and over the right lateral ventricle a slight prominence Avas observed, Avhich, on being punctured, gave exit to a quantity of pus. The wound penetrated through the anterior lobe of the brain under the right edge of the corpus cadosum, opened the right lateral ventricle, and extended back to the posterior crus ofthe fornix, Avhich seemed to have sustained injury. The two lateral and third ventricles Avere filled Avith pus, and pus was also found in the fourth ventricle, and beneath the cerebellum around the medulla oblongata. Acting Assistant Surgeon LeAvis Heard reported the case.* G------, Thomas, Private, Co. B, 90th Ohio A'olunteers, was admitted, on November 27th, 1853, to Hospital No. 1, Nashville, Tennessee, Avith a bayonet Avound behind the left parietal eminence, inflicted by a sentinel. For several days the patient Avas in a state of stupor, and Avas obstinately constipated. Both of these conditions Avere removed by the use of powerful purgative medicines. Meainvhile the cicatrization ofthe Avound progressed rapidly, and on December 8th it had nearly closed. On this day the patient complained, for the first time, of severe headache. A probe, passed through the small orifice of the Avound, indicated denuded and detached bone at its base. A "T-shaped incision was made, and several fragments of dead bone were extracted. On the llth, there was somnolence and cephalagia, and in- creased stupor, Avith slight intolerance of light and sound; the pulse Avas full and sIoav, forty-eight beats per minute. The scalp Avas tumid; the wound gaped, and Avas filled with fungous granulations. The incisions in the scalp were ex- tended, and some of the loose bits of bone Avere removed. An ice bladder Avas applied to the head, and purgatives, Avith purgative enemata, Avere administered. On the 12th, the patient had some little appetite. The pulse was 44 and feeble. There had been no alvine evacuations, notwithstanding repeated doses of calo- mel and rhubarb, epsom salt, podophyllin, with terebinthinate enemata. In the forenoon, pills containing half a drop of croton oil were ordered to be given every hour until the bowels movea. On the 13th, the patient was freely purged. A fungus began to protrude from the Avound. On the llth, the headache Avas slight but constant, the skin cool, the pulse 42 and feeble. The cerebral hernia, tense and elastic, and indolent on pressure, still covered by the meninges, Avas steadily increasing in size. He was ordered half an ounce of Avine every hour, Avith beef tea. On the 15th, the membranes covering the hernia sloughed, and the fungous appeared Avith a dark red granulated surface, not sensitive to the touch, nor bleeding readily. When the patient, in his restless sleep, rolled over upon the fungous groAvth, he Avould aAvake with a start. For the next tAvo days he took wine in gradually augmented doses. His pulse became more feeble, and rose to 90 pulsations. Respirations 13, sighing. On December 19th, the Avhole fungous mass sloughed aAvay. There was delirium and subsultus tendinum. The other symptoms Avere unchanged. Death took place on December 23d, 1833. At the autopsy, an abscess of the left hemisphere, and diffused arachnitis, Avere observed. The bayonet had penetrated an inch or more into the cerebrum. The calvaria Avas forAyardtd to the Army Medical Museum by Assistant Surgeon C. J. Kipp, U. S. Volunteers, Avith Fig. ft.—Perforation of the left parietal by a bayo- net.— Spec. 2179, Surg. Sect. A. M. M. * American Medical Times, June 10, 1&63, A'ol. VI, r- 292. PUNCTURED WOUNDS OF THE HEAD. 33 the foregoing notes of the case. It is represented in the adjacent Avood-cut, (Fig. 8.) It sIioavs a perforation of the left parietal behind the protuberance. The opening is egg-shaped ; but the edges suggest its original triangular outline. The edges are rounded, and the texture of the bone near the solution of continuity is porous, particularly on the inner table. A slight fissure exists in the outer table. H------, Joun, Private ofthe Hospital Guards at the Lovell General Hospital, Portsmouth Grove, Rhode Island, aged 25 years, \yas confined four hours on the night of February 28th, 1863, as a punishment for bringing spirits into the camp and attempting to run the guard. AA'hen released from his cell by order of the officer of the guard, he rushed upon the latter and struck him in the face, whereupon the sergeant dreAv his sword, and, stepping back a pace, put himself in guard, holding the gripe of his SAVord firmly against the right hip, with the point slightly elevated. AVhile in this position the prisoner again rushed upon the sergeant; but the ground being uneven, and the grass covered Avith a heavy frost, the assailant slipped and fell on the point ofthe sword, and then heavily fonvards on the ground. When taken up he Avas insensible, and breathed heavily. On Avashing from his face the blood, AAhich had floAved copiously from a slight Avound in the right nostril, the officer ofthe day, an acting assistant surgeon, who Avas immediately summoned, detected no other injury than the trivial incision of the right ala of the nose. The man had been drinking freely, and, under the supposition that he Avas suffering only from the stupefying effects of liquor, increased by the fall upon his head, the surgeon remanded him to the guard-house, where he laid in a state of stupor until the folloAving morning, Avhen he Avas removed to one of the Avards of the hospital. He was found to be still unconscious, and breathed stertorously, and moaned occasionally. The pulse was full and slow. The eyelids Avere closed, showing, when forcibly opened, the pupils dilated and immovable. The remedies usually employed in cases of apoplexy were directed, but consciousness could not be restored, and the patient died on the succeeding morning, March 2d, 1863, thirty-one hours after the reception of the injury. An autopsy Avas made nine and a half hours after death. Rigor mortis Avell pronounced. No external mark of violence Avas perceptible, except a Avound five-eighths of an inch in length and one-eighth of an inch in depth on the external edge of the right nostril. The nostril was filled Avith coagulated blood. There was no sign of fracture ofthe nasal bones. On remoA-ing the calvarium, the blood vessels of the membranes of the brain were found to be engorged, and upon reflecting the membranes, the convolutions over the Avhole of the right hemisphere were found to be covered Avith extravasated blood. This extravasation extended along the Avhole. of the base of the right side, and, to a slight degree, on the left, covering the whole surface of the cerebellum, increasing at the base and toAvards the medulla oblongata. The brain was then removed, and the posterior clinoid process of the sphenoid Avas found to be fractured transversely, and the middle and lower part of the superior turbinated bone was pierced. A small indentation, corresponding with the point of the SAVord, was found in the right clinoid process. The lungs were considerably engorged, but healthy and crepitant throughout. There Avas a slight adhesion found at the apex of the posterior part of the left lung. A portion ofthe sphenoid bone was removed to exhibit this very rare and interesting fracture. Unfortunately it was somewhat injured during maceration, but still gives a good illustration of this unusual form of injury. The portion ofthe sword Avhich inflicted the injury was filed off, and Avas found to fill exactly the perforations ofthe ethmoid and sphenoid bones. The sword had penetrated about four inches from the nasal Fig. 10—Transverse fracture ofthe posterior m, -,.. r.i c ,, -iji-Ax- a • j. j. o clinoid procoss by a sword thrust.—Spec. 1612, spine. Ihe history of the case was carefully compiled by Acting Assistant Surgeon Sect j ^ M M/ E. Seyffarth, and the specimen, represented in the accompanying Avood-cut, (FiG. 10,) Avas forwarded by Surgeon L. A. EdAvards, U. S. A., in charge of Lovell Hospital, to the Surgeon General. Saunder, G. W., Private, Co. D, 7th North Carolina Regiment, received at the battle of Gaines Mills, June 26th, 1862, a bayonet thrust in the forehead, which probably penetrated the frontal bone. He Avas conveyed to Richmond, and admitted, on June 27th, into Ward No. 3 of Chimborazo Hospital. He died on July 5th, 1862. Surgeon E. H. Smith, C. S. A., reports the case. Woodbridge, William T, Musician, Co. F, 15th Indiana Volunteers, received on October 15th, 1863, a punctured wound of the skull from a bayonet thrust, which perforated the left parietal bone near its posterior superior angle. Tavo days after the injury he Avas received into the City Hospital at Indianapolis, Indiana, suffering Avith convulsions, and symptoms of meningitis and inflammation of the brain. On October 21st, several small fragments of bone Avere extracted; but the symptoms were not alleviated, and the patient died on October 27th, 1863, from abscess of the brain. Acting Assistant Surgeon J. M. Kitchen reports the case. Of the six patients with punctured fractures of the cranium, one survived, though permanently disabled; and five died, with extravasation of blood in one case, cerebral hernia in one, encephalitis in one, and abscess of the brain in two cases. The very intractable and fatal nature of such injuries is well known. The diagnosis is commonly difficult, the small dimensions of the external Avound forbidding satisfactory exploration. If the external table only is punctured, it is true that there is not much more danger than in a wound of the soft parts; and recoveries take place \vhen both tables are pierced, if there is no extravasation of blood, or wound of the membranes or the brain by the weapon, or by depressed splinters of the vitreous table. But when the puncture is small and M WOUNDS AND INJURIES OF THE HEAD, I U narroAV, it is very difficult to determine its depth. The information obtained by the probe is unsatisfactory, and its use is not unattended by danger. When the brain is wounded, svmptoms of cerebral mischief are frequently delayed until extravasa- tion or the pent-up products of inflammation produce pressure. Thus the surgeon is restrained from interference until a period when inter- ference is likely to be of little benefit. When arrows and lances were commonly used in warfare, this class of injuries were not uncommon, and many interesting examples of them are reported by authors.1 The Indian hostilities in the west- ern part of the United States still afford examples of punctures of the cranium by arrows.2 In the late war, the lance was not used to any extent, and no cases were reported of wounds of the head by this weapon. Two regiments Avere armed with it; but the nature of the country which was the theatre of war was regarded as ill adapted to the manoeuvres of lancers; and, after serving for a while on escort duty, the regiments changed their equipment. A very grave complication of punctures of the cranium consists in the breaking off of the penetrating weapon, Avhich is sometimes so firmly wedged that its removal is a matter of great difficulty. The treatment of punctures of the cranium will consist of the ordinary simple dressing of Avounds of the scalp, until symptoms of cerebral disorder arise demanding mechanical interference. Recognizing the great probability of dangerous complications, the surgeon will insist on strict precautionary measures, and will incise the scalp, and expose the fracture, and remove spiculae or foreign bodies, or elevate depressed bone as soon as he is satisfied that the brain or its membranes are injured. Besides the six examples of puncture of the cranium by sharp-pointed weapons, reported on the preceding pages, the Army Medical Museum has specimens of punctures of the skull by arrows and tomahaAA'ks.3 These preparations will be fully described in the next edition of the Museum Catalogue. u 1 2 FIG. 11.—1. Lance carried by the U. S. Lancers, il. Lance cur- ried by o'th Pennsylvania Cav- alry. Scale one-tenth to one inch. From specimens furnished the A. M. M. by <'apt. T. G. Benton, Ordnance Corps. 1 See Par6, GZuvres Completes, ed. Alalgaigne, livre 8e); Morgagni, (De Causis et Sedibus Morborum, Vol. I); Briot, (Histoire de I'Etat et des Progress de la Chirurgie Militaire, Besancon, 1817, p. ill); Percy, (Manuel du Chirurgien d'Armee, Paris, 1830, p. 101); Desport, (Traite des Plaies d'Armes a Feu, Paris, 1749, p. 374); Larrey, (Relation Med. de Camp, et Voyages, Paris. 1841, p. 381; et Clinique Chirurgicale, Paris, 1829, T. I, pp. 156 et 192; et T. V, Paris. 1836, p. 323); Hennen, Princi- ples of Military Surgery, London, 1829, p. ;2S4); Rogers, Transactions of the Royal Medico-Chirurgical Society, Vol. XIII); South, (Cheliush System of Surgery, Am. ed., Vol. I, p. 437); Hewett, (Dublin Med. Jour., 1851, p. 347) ; Legouest, (Chirurgie d'Armee, p. 277); Bonnefous, (Jour, de Med. de Montpellier, 1860); Bruns, (Die Chirurgischen Krankheitcn, Tubingen, 1854, S. 32, u. s. v.); Hyrtl, (Handbuch, S. 86); A7elpeau, (Dietionnaire de Medecine, Paris, 1844, 2L;me ed. T. XXIX, p 559); Fritze, (Xassauische Jahrbiicher, Heft. VII, S. 64); Schneider, (Die Kopferletzungen in Medicinish-gerichtlicher Hinsicht, Stuttgart, 1848, S. 58.) 2 For a very interesting account of arrow Avounds, Avith numerous illustrative cases and judicious suggestions as to treat- ment, based on extensive observation of such injuries, the reader is referred to an article by Assistant Surgeon [doav Surgeon and Bvt. Lieut. Colonel] J. H. Bill, U. S. Army, in the American Journal ofthe Medical Sciences, N. S., A'ol. XLIV, p. 365. 3 No. 5528. Section I, A. AI. Ai., is the cranium of a Tonkaway warrior, with two punctures in the right parietal by the sharp point of a tomahaw-k. It Avas obtained near Fort Cobb, AA'ashita Eiver, I. T., by Dr. E. Palmer. No. 5531, is a cranium penetrated through the left antrum and orbit, by a stone-headed arrow. It Avas obtained from a grave in Alameda county, Cali- fornia, by Dr. C. Yates. No. 5644, is a segment of the anterior portion of the skull of a Aiexican herder, Avith a perforation of the frontal, above the left superciliar ridge, by an iron arroAv head, Avhich had been driven deeply into the brain, in an Indian fight, seventy miles north of Fort Concho, in the summer of 1868. It was presented by Bvt Major AV. Ai. Notson, Assistant Surgeon. U. S. Army. CONTUSIONS AND LACERATED AVOUNDS OF THE SCALP. 35 Section If. MISCELLANEOUS INJURIES. In this section such injuries of the head as are common to the soldier and the civilian will be considered. These comprise the results of railroad accidents, of falls, of blows from blunt weapons, of kicks from horses and mules, of the falling of trees or masonry, and other accidents. It is impracticable to determine the total number of cases that should have been referred, during the Avar, to this category. On the monthly reports of sick and wounded, the contusions and lacerated wounds, and simple fractures, were entered numerically, without indication of the seat of injury. Cases of concussion and compression of the brain were returned separately, but these statistics were vitiated, because instances of gunshot Avounds were oftentimes included. The information that can be gleaned from this source will be recorded at the end of this section. Abstracts of a few cases, cited from special reports, or from the histories of specimens in the Army Medical Museum, will illustrate the principal varieties of injuries of this class.. In movements of large bodies of troops by rail, the men crowded upon platforms and roofs of cars, contusions and lacerations of the scalp, concussions of the brain, and fractures of the skull, were not infrequent. Railroad Accidents.—The following are examples of contusions from this cause: Case.—Second Lieutenant John H. Alasterson, Co. E, 100th U. S. C. T., aged 38 years, Avas throAvn from a railroad car and received a severe contusion ofthe scalp, July 1st, 1864. He entered the Officers' Hospital at Nashville, Tennessee, the following day; recovered, under simple treatment, and was returned to duty July 25th, 1864. Case.—Private John Jenkins, Co. G, 15th U. S. C. T., aged 28 years, fell from a railroad car at Nashville, Tennessee, December 26th, 1864, and received a severe contusion of the head. He was treated at Hospital No. 16, at Nashville, by cold applications, and Avas returned to duty, well, on January 4th, 1865. Case.—Private Ganin AlcCoy, Co. C, 16th Veteran Reserve Corps, aged 57 years, recei\Ted at Petersburg, Arirginia, August 14th, 1863, a severe contusion of the forehead and right side of the head, by falling from a car in motion. He Avas admitted to York, Pennsylvania, Hospital, and discharged from service on January 8th, 1864, on account of persistent pain in the head. Case.—Sergeant J. C. Williams, Co. B, 1st AVisconsin Heavy Artillery, aged 20 years, received in a railroad collision, on August 19th, 1864, a contused Avound of the sealp. He recovered, under simple dressings, at the hospital at Lexington, Kentucky, and returned to duty August 22d, 1864. Case.—Private L. J. Learned, Co. B. 1st AVisconsin Heavy Artillery, aged 22 years, was similarly injured at the same time and place, but Avith greater severity. He Avas transferred to Park Hospital, Alihvaukie, AVisconsin, on September 18th, and \A-as discharged from service December 26th, 1864. Case.—Private S. Croyton, Co. G, 6th Virginia Cavalry, aged 17 years, received near Carlisle, Illinois, June 21st, 1865 several severe contused wounds of the scalp, in a railroad accident. He was treated Avith cold local applications at the Marine Hospital, St. Louis, Missouri, and recovered, and Avas discharged from service July 19th, 1865. 36 WOUNDS AND INJURIES OF THE HEAD, The following men also received, in railroad accidents, contusions of the head, of a slight nature, probably, as all were speedily returned to duty: Cases.—Private J. Burns, K, 71st New York A'olunteers, near Wilmington, DelaAvare, September 21st, 1864. Captain D. Cornelius, C, 212th Pennsylvania A'olunteers, near Baltimore, September 17th, 1864. Private Peter Daly, G, 140th New York Volunteers, near York, Pennsylvania, January 7th, 1865. Private L. P. Daniels, I, 2d Ohio Artillery, near Knoxville, January 29th, 1865. Private AV. Fogarty, A, 21st New York Cavalry, near Grafton, AVest A'irginia, July 22d, 1864. Private J. H. Fritton, A, 33d Illinois Volunteers, New Orleans, Alarch 2d, 1865. Private J. Jaide, E, 1st Alissouri Militia, near St. Louis, April 29th, 1864. Private D. Jones, A, 145th Ohio A'olunteers, near AVashington, Alay 21st, 1864. Private AY. Kennan, E, 14th Areteran Reserve Corps, near Baltimore, Alarch 24th, 1864. J. T. Langston, Alilitary Train, near Summit Point, Maryland, November 16th, 1864. Private J. N. Moore, C, 100th Pennsylvania Volunteers, near Pittsburg, Alarch 23d, 1864. Private A. Russell, I, 2d Ohio Heavy Artillery, near Knoxville, January 29th, 1865. Corporal S. Shipman, F, 88th Illinois Volunteers, near Jeffersonville, Indiana, December 16th, 1864. J. Slacher, Unassigned Recruit, near Elmira, New York, April 26th, 1865. Sergeant F. Wright, B, 16th New York Cavalry, near York, Pennsylvania, January 7th, 1865. Corporal C. Zuraff, A, 33d Illinois Volunteers, near New Orleans, Louisiana, March 3d, 1865. In the following cases of contusions of the head, the injuries were of a severe character, probably, since the patients were discharged from service for disability: Cases.—Private G. A. Campbell, I, 2d Ohio Art'y, near Knoxville, Tenn., January 29th, 1865. Discharged May 12th, 1865. Private J. Carney, C. 43d NeAV York Volunteers, near Albany, N. Y., March 7th, 1865. Discharged July 6th, 1865. Private P. Coyne, A, 1st N. Jersey Artillery, near AVashington, D. C, June 13th, 1865. Discharged July 10th, 1865. Private T. Little, F, 122d Ohio Volunteers, near AA'ashington, December 3d, 1864. Discharged January 23d, 1865. Lacerations of the scalp were produced in the following cases: Case.—Private Philip A. Adams, Co. G, 8th Indiana Cavalry, aged 39 years, received June 30th, 1864, near Chatta- nooga, Tennessee, a severe lacerated Avound of the scalp, by falling from a railroad car. He was admitted to Hospital No. 3, Nashville, Tennessee, on June 30th, and on January llth, 1865, he was transferred to Gallatin, Tennessee. He was discharged the service for disability on June 5th, 1865. Case.—Private Clifford Allen, Co. I, 2d Ohio Heavy Artillery, aged 16 years, received a contused and lacerated wound of the left temporal region on January 29th, 1865, near Knoxville, Tennessee, from a railroad accident. He was admitted to the Asylum Hospital, at Knoxville, and recovered, under simple treatment, and was returned to duty on February 16th, 1865. Case.—Private Richard Bogles, Co. G, 20th Pennsylvania Cavalry, aged 21 years, received on April llth, 1864, a severe lacerated Avound of the right side of the scalp, by falling from a railway car, and was admitted to Grafton Hospital, AA'est A'irginia, on the same day. The wound did Avell under cold water dressings, and he was returned to duty on June 2d, 1864. Case.—Private Robert Boyd, Co. F, 8th New Jersey Volunteers, fell from a railavay car near Wilmington, DelaAvare, on June 21st, 1864, and received a lacerated wound of the scalp. He Avas immediately conveyed to the Tilton Hospital. Simple dressings Avere applied, and he was returned to duty July 8th, 1864. Case.—Private Albert Edgar, Co. G, 20th Pennsylvania Cavalry, aged 18 years, was wounded on the same occasion, and the preceding history applies to his case. Case.—Private L. J. Frence, Co. I, 2d Ohio Heavy Artillery, aged 21 years, received a severe contusion, Avith a lacerated wound of the scalp, on the same occasion as the preceding, and returned to duty at the same date. Case.—Private John B. Glynn, Co. H, 24th Alissouri Volunteers, received a severe scalp wound by a fall from a rail- Avay car, on Alarch 1st, 1863. He was admitted to Lawson Hospital, St. Louis, Missouri, and returned to duty June 1st, 1863. Case.—Private G. AA'. Haines, Co. I, 2d Ohio Heavy Artillery, aged 36 years, was wounded in the same accident, and Avas treated in the same hospital. He had a Avound of the scalp, with a very severe contusion, and recovered sloAvly. He AAas discharged from service on May 21st, 1865. Surgeon F. Meacham, U. S. V., reports the case. Case.—Private G. AA'. Marvin, Co. I, 2d Ohio Heavy Artillery, aged 20 years, was Avounded at the same time and place, rece'iA-ing a laceration ofthe scalp, extending from behind the left ear to the occipital protuberance. He recovered, under simple treatment, and Avas discharged from service May 24th, 1865. Surgeon F. Meacham reports the case. The following were returned to duty after receiving, in railroad accidents, slight lacerations of the scalp: CONCUSSION OF THE BRAIN FROM RAILROAD ACCIDENTS. 37 Cases.—Private G. AA'. Francis, C. 112th Pennsylvania A'olunteers, near Philadelphia, November 7th, 1864. Private G. Gormer, K, 2d Alaryland P. H. V. B., near Cumberland, Maryland, October 20th, 1864. Private AV. Gunnin, 2d Alassachusetts Volunteers, near Albany, Ncav A'ork, June 8th, 1864. Sergeant J. H. Jackson, G, 149th Indiana Arolunteers, near Indianapolis, Indiana, August 25th, 1865. Sergeant A. Mitchell, 27th Michigan Volunteers, near Cincinnati, Ohio, April 13th, 1863. Private L. H. Palmer, K, 97th Illinois Volunteers, Algiers, Louisiana, November 1st, 1863. Private T. \A'. Peverlcy, A, 33d Illinois Arolunteers, near New Orleans, Louisiana, March 2d, 1865. Private T. PoAvers, H, 97th Illinois A'olunteers, near Algiers, Louisiana, November 1st, 1863. Private D. Swinger, A, 19th A'eteran Reserve Corps, near Baltimore, September 3d, 1864. Private J. AA'illiams, L, 193d NeAV A'ork A'olunteers, near Baltimore, May 18th, 1865. The following Avere discharged from service on account of lacerations of the scalp of a graver description: Cases.—Private J. Fallon, A, 1st NeAV Jersey L. Artillery, near Washington, June 13th, 1865. Discharged July 10th, 1865. Private R. S. Harper, A, 1st A'irginia Artillery, near Columbus, Ohio, February, 1865. Discharged May 29th, 1865. Private A. Kimball, G, 10th A'ermont Arolunteers, near Brattleboro, Vt., June, 1865. Discharged July 14th, 1865. Private AI. Rice, G, 86th NeAV York A'olunteers, at Bristol, Pa., Alarch 7th, 1865. Discharged June 7th, 1865. In four of these forty-nine cases of contusions and lacerations of the scalp, erysipe- latous inflammation supervened, and others were complicated by sloughing and burrowing of pus. The patients all ultimately recovered. In the following cases, concussion of the brain was the most important feature: Case.—Captain AA7". W. Cushing, Co. I, 125th Ohio Volunteers, aged 27 years, was admitted to the Officers' Hospital, Nashville, Tennessee, on March 12th, 1865, laboring under concussion of the brain, resulting from a railroad accident on March 1st. He was furloughed on Alarch 13th, 1865, and did not report subsequently. Case.—Private A. Faigue, Co. B, 153d NeAV York Volunteers, received, in a railroad accident, near Harper's Ferry, Virginia, April 20th, 1865, a severe contusion of the head, accompanied by concussion, and probably laceration, of the brain. He was admitted on the same day to the Island Hospital, at Harper's Ferry, and survived but a few hours. Acting Staff Sur- geon N. F. Graham reports the case. Case.—Joseph M. Grace, unassigned recruit, aged 16 years, jumped from the cars while in motion, near Bowling Green, Kentucky, on November 4th, 1864. He Avas admitted to Hospital No. 3, at Nashville, Tennessee, on November 5th. There was a severe contusion on the head, and signs of grave concussion of the brain. He recovered from the head symptoms, but died on April 5th, 1865, from some pulmonary complication. Surgeon J. R. Ludlow, U. S. V., reports the case. Case.—Patrick King, aged 23 years, a laborer in the employ of the subsistence department, fell from a railroad car July 22d, 1863, and Avas admitted to the General Hospital at Frederick, Maryland, on the folloAving day, in a semi-comatose condi- tion, in consequence of a severe contusion of the forehead, Avith concussion of the brain. As the stupor passed off, there was mild delirium ; but the patient gradually improved under the use of saline cathartics and a low diet, and yvas returned to duty, August 14th, 1863. Case.—Corporal T. J. Smith, Co. G, 6th Virginia Cavalry, aged 20 years, was AVounded, on the night of June 21st, 1865, by a collision of trains, on the Ohio and Mississippi Railroad, near Carlisle, Illinois. The regimental surgeon, Dr. A. H. Thayer, reports that there were very grave symptoms of concussion of the brain. The patient was conveyed to the Marine Hospital, St. Louis, where Assistant Surgeon E. AI. Horton, U. S. A., reports that arteriotomy was performed without any beneficial result. The patient died on June 23d, 1865. Case.—Private John Taft, Unassigned Recruit, received, in an accident on the Philadelphia and Baltimore Railroad, March 30th, 1865, near AVilmington, Delaware, a severe contusion of the head, with concussion, and probably laceration, of the brain. He was conveyed to Tilton Hospital, at Wilmington. Every effort to bring about reaction Avas unavailing, and the case terminated fatally on the following day, Alarch 31st, 1865. No autopsy was held. The case is reported by Surgeon E. J. Bailey, U. S. Army. Case.—Sergeant T. Wise, Co. K, 134th Ohio Volunteers, aged 35 years, received, in a railroad accident, June 6th, 1864, near Point of Rocks, Virginia, a severe concussion of the brain. He Avas admitted to Judiciary Square Hospital, and after reaction had taken place, he Avas treated by purgatives, rest, and Ioav diet. He recovered, and Avas furloughed for forty days, and failed to return, but joined his regiment "of three months men," on October 20th, 1864, to be mustered out. Assistant Surgeon Alexander Ingram, U. S. A., reported the the case. In the following cases, without injury to the walls of the cranium, there appears to have been some obscure injury to its contents: Case.—Private James Buckland, Co. H, 2d Missouri Artillery, received, in a railroad accident near St. Louis, August 13th, 1864, a severe contusion of the head. He Avas received into Schofield Barracks Hospital on the same day, Avith symptoms of severe concussion of the brain. His condition Avas relieved in a short time, but, after a feAV days, paralysis of the motor nerves of the loAver extremities was observed, and symptoms indicative of softening of the brain ensued. The case terminated fatally, September 14th, 1864, from ramollissement. Assistant Surgeon E. M. Powers, U. S. V., reports the case. 38 WOUNDS AND INJURIES OF THE HEAD, Case.—Lieutenant William Harrington, 29th Pennsylvania Volunteers, aged 28 years, fell from a railway car in motion, near Chester. Pennsylvania, March 1st, 1864. He Avas admitted to the Citizens' Volunteer Hospital, in Philadelphia, on the folloAving day. There Avere signs of severe concussion of the brain; but no evidence of fracture could be detected. He died on Alarch 4th, 1864. The relatives refused to permit an autopsy. Surgeon R. S. Kenderdine, U. S. A'., reports the case. CAse.—Private Edward AIcKeeby, Co. C, 19th Illinois Volunteers, aged 30 years, on June 12th, 1864, Avhile riding on a railroad car, received a contusion of the right side of the occiput, by striking violently against a bridge. He was admitted, on June 13th, into Hospital No. 8, Nashville, Tennessee, at which time there Avere no external marks of violence, and no pain. Occasional delirium was the only indication of mischief to the contents of the cranium. On the third day the symptoms Avere greatly aggravated. Coma supervened, Avith involuntary discharges : and death took place on June 25th, 1864. At the autopsy, there was found upon the superior surface of the right cerebral hemisphere, and beneath the pia mater, a small collection of pus, and upon the left side a coagulum of blood. The inferior surface of the cerebellum, medulla oblongata, pons varolii, and optic commissure, were covered with a thick coat of pus. The right lateral ventricle and choroid plexus were likeAvise covered with pus. A clot of blood was found interposed between the dura mater and cranium, below the right lobe of the cerebellum. There Avas a contusion, Avith extravasation of blood, beneath the scalp on the right side of the occiput. No fracture could be detected. The thoracic and abdominal organs were normal in appearance. Surgeon R. R. Taylor, U. S. V., reports the case. Case.—Sergeant S. AVarner, Co. C, 34th New Jersey Volunteers, aged 31 years, near Beverley, NeAV Jersey, July 15th, 1864, fell from a raihvay car in motion, and received a very severe contusion of the head. He was taken to the Beverley Hospital, and presented the symptoms of severe concussion, but, in addition, the pupils Avere quite irresponsive to light, and vision was extinct. The symptoms of compression were speedily relieved, but vision did not return. On April 4th, 1865, the patient Avas transferred to Satterlee Hospital, Philadelphia, and was discharged from service Alay 24th, 1865, for traumatic amaurosis, completely, and probably permanently, blind. Assistant Surgeon Dallas Bache, U. S. A., reports the case. The following cases of railway accidents were attended by fractures of the skull: Case.—Sergeant Charles Dougherty, Co. C, 69th Pennsylvania Volunteers, aged 38 years, while in an intoxicated condition, fell from a railroad car, on April 16th, 1864, receiving a severe contusion ofthe left temporal region, and a compound fracture of the right humerus. He Avas admitted to Cuyler Hospital, GermantoAvn, Pennsylvania, on April 18th. The arm was dressed in an angular splint, and stimulants Avere administered. There was much ecchymosis about the temple and orbit. The general symptoms approached those of delirium tremens. There Avas apparent improvement for the first tAventy-four hours, Avhen obstinate vomiting began, and recurred with brief intermissions. On the morning of the fifth day, the patient Avas in a moribund condition, pulseless at the wrist, bathed in a cold perspiration, and delirious. There was a general capillary congestion amounting to cyanosis almost, and an excessive dilatation of both pupils, with insensibility to light. Coma grad- ually came on, and death on April 20th, 1861. The autopsy revealed extensive congestion of the membranes and substances of the brain, softening and laceration of the spleen, Avith extravasation of blood in the abdominal cavity, congestion of the base of the right lung, and a multiple fracture ofthe right humerus. Assistant Surgeon H. S. Schell, U. S. A., reports the case. Case.—AA'alter Fitch, in the employ of the Quartermaster Department, aged 19 years, received a fracture of the vault of the cranium, by being throAvn from a railroad car in motion, May 18th, 1864. He was admitted to the field hospital at Bridgeport, Alabama, on Alay 19th, Avith symptoms of compression ofthe brain. Death took place on Alay 26th, 1864. Assistant Surgeon H. T. Legler, U. S. V., reports the case. Case.—PriA-ate EdAvin French, Co. F, 3d Delaware Volunteers, aged 18 years, was thrown from a raihvay car, on June 21st, 1862, and the fall produced a linear fracture of the skull near the vertex. He AA-as admitted to hospital at Frederick, Maryland, August 22d, 1862. The treatment Avas expectant. He was transferred to Race Street Hospital, Phil- adelphia, on September 27th. The case is entered on the register as one of "general debility." He was transferred on January 14th, 1863, to MoAver Hospital, Philadelphia, and complained of great dizziness and pain in the head. On February 15th, he had a severe chill, due apparently to malarious influences, since quinine prevented the recurrence of other paroxysms. In Alay he was well enough to perform duty as a nurse in the ward. He was transferred to the A7eteran Reserve Corps on August 27th, and was sent to modified duty on September 3d, 1863. Case.—Private George H------, Co. I, 3d Delaware A'olunteers, fell from a railroad car, on June 22d, 1862, his head striking the ground Avith great violence. He was taken up in a stunned and insensible condition, and Avas conveyed to the neighboring post hospital at Winchester, A'irginia. Acting Assistant Surgeon AA'. Draine found a severe contusion over the right parietal eminence, and, as grave symptoms of com- pression ofthe brain Avere apparent, he made a free crucial incision through the scalp, with the expectation of finding a depressed fracture of the skull. But, although the skull was freely exposed by reflecting the flaps of integu- ment, no evidence of fracture was observed. The patient lingered, comatose, for a feAV days, and died on June 26th, 1862. At the autopsy, a fissure seven inches in length Avas discoA-ered, commencing in the squamous portion ofthe right temporal bone, passing through the right parietal protuberance, crossing the sagittal suture at right angles, and running forward on the left parietal bone. The specimen (FiG. 12) Avas forwarded by Dr. Draine to the Army Aledical Museum, and the facts above recorded Avere reported by Surgeon (•eorge Suckley, U. S. V. Fig. 12.—Fissure of the vault of the fall from a rail-ear in motion.—Spec. 130. ranium from a 'ent. I. A.M.M. FRACTURES OF THE SKULL FROM RAILROAD ACCIDENTS. 39 Case.—PriA-ate A. Mitchell. Co. E, 6th Indiana Cavalry, aged 28 years, received, in a raihvay accident, near Murfreesboro, Tennessee, on October 30th, 1804, a severe lacerated wound of the head, with fracture of the right parietal bone. He also had a compound fracture of the right fore-arm. He Avas conveyed to Nashville, and subsequently was transferred to Jefferson Barracks, St. Louis, on December 6th, 1864. There had not been, at any time, signs of compression, and, on his arrival at St. Louis, the cerebral symptoms had disappeared. After undergoing an amputation at the arm, he recovered, and was discharged from service, well, on April 5th, 1865. Case.—Private G. Spancell, Co. A, 105th Illinois Volunteers, in a railroad accident near Murfreesboro, Tennessee, Sep- tember 10th, 1863, received a compound fracture of the skull. He was placed in hospital under the care of Surgeon W. Threl- keld, U. S. A'. The ease Avas complicated by laceration of the brain, and extravasation of blood within the cranium, and death took place Avithin a feAV hours after the accident, September 10th, 1863. Case.—Private Zachariah AVard, Co. H, 139th Indiana A'olunteers, aged 17 years, fell from the cars in motion, near Mumfbrdsville, Kentucky, July 4th, 1864. He was taken to the military hospital at Mumfordsville, Avhere a simple linear fracture of the frontal bone Avas diagnosticated. There Avere no symptoms of compression, and the treatment was of the expectant nature. On August 14th, he was transferred to Clay Hospital, at Louisville, Kentucky, and again, on September 10th, to the City Hospital, at Indianapolis, Indiana. AVith the exception of slight vertigo and headache, he had quite recovered at this date, and tAvo Aveeks subsequently, September 24th, 1864, he Avas returned to duty Avith his regiment. Case.—Private MattheAv Young, Co. I, 1st Ohio Artillery, aged 39 years, received a compound fracture of the left parietal bone, with a terrible laceration of the scrotum, on November 29th, 1864, in a railroad accident, near Knoxville, Tennessee. He was taken to the Asylum Hospital, at Knoxville. It was found that the symptoms did not justify operative interference. The testes had been quite torn aAvay. and the constitutional depression was great. The patient lingered in great suffering until December 16th, when he died. The case is reported by Surgeon B. Barnum, 25th Michigan Volunteers. The next case appears to furnish an example of fracture of the base of the cranium by contre-coup : Case.—Private Joseph AA'eber, Co. C, 6th New York Cavalry, fell, or jumped, from a railroad car in motion, near Newark, NeAV Jersey, on January llth, 1865. He was carried to the Centre Street Branch of the AV'ard Hospital, at NeAvark. It Avas found that there was a compound comminuted fracture of the frontal bone. He Avas sensible, and conversed with readiness, and walked up stairs to his bed. Meningitis soon supervened, indicated by nausea, rigors, contracted pupils, with intolerance of light, and severe headache. These symptoms were unavailingly combatted by cold applications to the head, purgatives and revulsives. The case terminated fatally on January 15th, 1865 At the autopsy, it was found, on removing the scalp, that the frontal bone Avas badly fractured, being comminuted near the right frontal eminence, while fissures, penetrating both tables, extended backwards, nearly to the coronal suture, and downwards, quite into the right orbit. On removing the calvarium, a large clot was found on the dura mater, below the right frontal eminence. The membranes Avere much congested, and were covered in places with fibrinous exudations, and elsewhere were strongly adherent to the calvarium. The cerebrum, and particularly the right hemisphere, Avas found in the same highly congested state. The removal of the encephalon disclosed a second simple fracture, of the base of the cranium, extending through the basilar process of the occipital bone, nearly to the foramen magnum. The case is reported by the late Assistant Surgeon J. T. Calhoun, U. S. A., the report of the postmortem examination being furnished by Acting Assistant Surgeon W. S. Ward. Falls.—Injuries of the head by falls were not uncommon, especially in the cavalry. The following are examples of contusions or lacerations of the scalp from this cause: Cases.—The men named in this category, by being thrown from their horses, or falling from heights, received injuries of the scalp of sufficient severity to be admitted into General Hospitals, whence they were returned to duty, after intervals of from two to one hundred and thirty-six days : Private F. Albrecht, Co. F, 7th Michigan Cavalry, Alexandria, Virginia, October 20th, 1863. Private B. F. Alsop, 3d Iowa Cavalry, near Vicksburg, Mississippi, March 10th, 1864. Private F. AndreAvs, A, 12th Ohio Cavalry, Lexington, Kentucky, April 15th, 1864. Private R. F. Barton, L, 1st Kentucky Cavalry, near Knoxville, Tennessee, July 6th, 1864. Private F. Beal, 1st Provisional Cavalry, Washington, D. C, December llth, 1865. Corporal J. Blethune, 37th Co., 2d Battalion Veteran Reserve Corps, near Washington, D. C, January 31st, 1865. Private S. S. Burridge, E, 9th New York Volunteers, Alexandria, Virginia, September 28th, 1863. Private F. Campbell, H, 6th United States Infantry, Hilton Head, South Carolina, November 1st, 1865. Private A. B. Chamberlain, H, 4th Vermont Volunteers, Philadelphia, Pennsylvania, March 13th, 1863. Private P. Crow, C, 1st Missouri Artillery, Rolla, Missouri, May 21st, 1863. Private J. Dailey, E, 30th Alassachusetts Arolunteers, New Orleans, Louisiana, September 19th, 1863. Private H. Egbert, D, 7th Illinois Volunteers, Fayetteville, North Carolina, Alarch 14th, 1865. Private AI Fesby, F, 29th U. S. C. T., Point of Rocks, Virginia, March 31st, 1865. Private J. Haley, 18th Alassachusetts Volunteers, near Boston, Massachusetts, December llth, 1864. Sergeant T. Haley, 1st Delaware Volunteers, Gettysburg, Pennsylvania, July 3d, 1863. Private J. A. Hern, E, 12th NeAV A'ork Volunteers, near Alexandria, Virginia, December 20th, 1862. Lieutenant D. Hillis, I, 3d New York Artillery, NeAvberne, North Carolina, May 22d, 1864. Private T. Marin, I, 3d NeAV Jersey Battery, near Fort Monroe, Virginia, August 1st, 1864. First Lieutenant J. D. McBride, H, 44th Missouri Volunteers, Nashville, Tennessee, December 1st, 1864. 10 WOUNDS AND INJURIES OF THE HEAD, Private, S. McCarty, B, 10th Ncav Jersey A'olunteers, near Philadelphia, Pennsylvania, January 7th, 1864. Private P. McDougal, 61st Massachusetts A'olunteers, near Galloup's Island, Alassachusetts. January, 1865. Private J. McFarland, K. 2d Ncav Jersey Cavalry, Memphis, Tennessee, December 28th, 1864. Private G. L. AIcKenzie, A. 10th NeAV York Cavalry, York, Pennsylvania, July 6th, 1863. PriA-ate G. Meyers, G, 41st Alissouri Cavalry, St. Louis, Missouri, June 30th, 1865. Private F. Alunch, B, llth Indiana Arolunteers, Columbia, Tennessee, January 14th, 1835. Private P. ODonald, F, 15th New York Cavalry, near Alexandria, A'irginia, June 30th, 1865. Private P. Palmer, I, 1st A'eteran Reserve Corps, AA'ashington, D. C; February 13th, 1864. Private AV. Pomperi, F, 71st Ncav York A'ohmteers, Shipboard, February 2d, 1864. Private J. Regan, C. 50th Pennsylvania A'olunteers, Harrisburg, Pennsylvania, April llth, 1864. Private M. Rigel, B, 20th Pennsylvania Cavalry, Alartinsburg, A'irginia, June 2d, 1861. Private B. L. Roberts, K, 39th Kentucky Volunteers, Lexington, Kentucky, June 12th, 1864. Private S. Smith, C. 1st Iowa Cavalry, Memphis, Tennessee. March 26th, 1865. Private J. Steves, E, 91st NeAV York Arolunteers, Baltimore, Alaryland, February 23d, 1865. Private E. Sullivan, AI, llth Kentucky Cavalry, Lexington, Kentucky, November 18th, 1864. Private F. Tarbox, H, 14th Pennsylvania Cavalry, Harper's Ferry, A'irginia, April 20th, 1865. R. Taylor, Government employe, near Harper's Ferry. A'irginia, June 10th, 1865. Private J. E. Thomas, G, 115th Pennsylvania A'olunteers, near Philadelphia, Pennsylvania, June 1st, 1863. Private L. Turrier, H, 29th Illinois Volunteers, near Mobile, Alabama, March 27th. 1865. Private T. Trempeman, E, 16th Illinois Cavalry, Camp Butler, Illinois, July 29th, 1863. Private P. A'incentio, B, Native California Cavalry, San Francisco, California, January 20th, 1864. Private J. N. Wise, B. 1st Pennsylvania Artillery, AVashington, D. C, May 4th, 1861. Private E. York, G, 3d Ohio A'olunteers, Columbia, Tennessee, January 14th, 1865. Private J. Yorkman, B. 23d Michigan A'olunteers, Columbia, Tennessee, November 26th, 1864. The folloAving are examples of severer contusions of the head, resulting from falls. Many of them terminated in such disabilities as to disqualify the patients from further active service: Case.—Private AA'. Alentharpe, Co. M, 9th Indiana Cavalry, was thrown from his horse at Vicksburg, Mississippi, May 18th, 1865, and fell upon his head. He Avas admitted to AlePherson Hospital, and waslfound to have a severe lacerated Avound of the right parietal region, Avith grave symptoms of concussion ofthe brain. He partially recovered, and was discharged from service June 15th, 1865. Assistant Surgeon J. A. AVhite, U. S. A'., reports the case. Case.—Prh'ate A. Alteman, Co. G, 1st Pennsylvania Artillery, aged 40 years, fell from his horse July 1st, 1864, striking his head on the left temporal region. He received a severe concussion ofthe brain. He was admitted to hospital at Chambers- burg, Pennsylvania, and Avas returned to duty on September 2d, 1864; but instead of rejoining his regiment, he proceeded to the A'ork Hospital, Avhere he remained until January 18th, 1865. Avhen he was transferred to the military hospital at Pittsburg. Here he remained until June 5th, 1865, Avhen he Avas transferred to Chester, Pennsylvania, \A-hence he Avas discharged from service for disability July 26th, 1865. The disability appears to have been due to chronic rheumatism, rather than the effects of the injury. Surgeon T. H. Bache, U. S. V., reports the case. Case.—Private J. C. Baumbach, Co. E, 65th Ohio, was admitted to hospital at Camp Chase, Ohio, December 23d, 1864. He had been throAA-n from his horse, and, falling upon the left side of his head, had suffered a severe concussion ofthe brain. There Avas entire loss of vision of the left eye, and the vision of the right eye was impaired. After a time deafness of the right ear supervened. The patient was discharged from service Alay 17th. 1864, for disability. The case is reported by Surgeon S. S. Schultz, U. S. V. Case.—Private Frank Clune,- 15th New York Cavalry, Avas thrown from his horse at Louisville, Kentucky, July 20th, 1865. and fell violently upon his head. He was admitted to Crittenden Hospital immediately after the accident, and died in a feAV hours, July 20th, 18.65, from the effects of concussion and probable laceration of the brain. No fracture or extravasation of blood Avas detected. It was impossible to bring about reaction from the condition of extreme depression resulting from the concussion. Assistant Surgeon J. C. G. Happersett, U. S. A., reports the case. Case.—Private Dexter Cole, Co. I, 25th Alichigan Volunteers, in October, 1862, received a severe Moav upon the head by a fall, and Avas admitted into Stanton Hospital at Washington, on February 1st, 1863, completely deaf, in consequence ofthe commotion or concussion of the brain. Every method of treatment for the restoration of his hearing having been employed unavailingly, he was discharged from service February 26th, 1863, on the certificate of Surgeon John A. Lidell, of his total disability. Case.—Private J. D. Davis. Co. F, 10th Indiana A'olunteers, aged 42 years, was admitted to Cumberland Hospital, Nashville, Tennessee, December 6th, 1864, on account of a fall from a horse on the previous day. He had a bad contusion of the scalp and concussion of the brain. He recovered, and was sent to Jeffei sonville Hospital on Januarv 7th 1865. He Avas treated for chronic rheumatism till February 22d, when he Avas transferred to Hospital No. 15, at Nashville Avhere he was tieated for asthma until Alay 24th, 1865,. when he was finally discharged from service. The case is reported by Surf-eon AV. Ai. Chambers, U. S. A'. Case.—Private Henry Drimeyer, Co. C, 28th Ohio Volunteers, aged 28 years, a somnambulist, fell from a second story window while walking in his sleep, in July, 1863, and, striking on his head, received a severe contusion and concussion of the CONTUSIONS AND CONCUSSIONS FROM FALLS. 41 brain. He Avas admitted to the Marine Hospital, Cincinnati, Ohio. He recovered from the immediate effects of the accident, but his idiosyncrasy Avas regarded as such a dangerous one for a soldier, that he was discharged from service August 16th, 1863. Acting Assistant Surgeon John Davis reports the case. Case.—Sergeant D. H. Gleason, Co. H, 1st Afassachusetts Cavalry, aged 28 years, was thrown from his horse in a charge at Gettysburg, July 1st, 1863, and received a very severe concussion of the brain. He Avas sent to the hospital at the Cavalry Depot at Camp Stoneman, AA'ashington. After recovering from the symptoms of concussion, he suffered from persistent pain in the head, and on Alarch 7th, 1864, he was sent to Finley Hospital, AA'ashington. He recovered, and returned to duty October 1st, 1864. The case is reported by the late Surgeon G. L. Pancoast, U. S. V. Case.—Private P. Goodman, Co. C, 13th NeAV York Cavalry, aged 46 years, received a severe injury of the head, by being throAvn from his horse, February 13th, 1864. He Avas admitted to Campbell Hospital, and was discharged from service, Avith complete loss of vision in his right eye, March 6th, 1864. Surgeon A. F. Sheldon, U. S. V., reports the case. Case.—Corporal J. B. Hefler, Co. D, 7th Pennsylvania Cavalry, aged 25 years, was thrown from his horse, at Louisville, Kentucky, April 15th, 1864, falling betAA-een his OAvn horse and that of a comrade, and striking upon his head. His injury was supposed to be of a slight character; but he suffered from constant headache until the 29th of August, when an abscess commenced to form over the right parietal. The abscess was opened on November 30th. The patient Avas then transferred to the hospital at Madison, Indiana. On his admission, his pulse Avas ninety, his skin dry, his tongue coated, and bowels consti- pated. On examining the seat of injury the parietal bone was found to be denuded, and externally necrosed for a space one and a half inches in width, by two and a half inches in length. On December 21st, the scalp was freely divided and the flaps reflected, with a vieAV of removing the necrosed bone; but upon examination the necrosed portion did not seem to be sufficiently separated to justify operative interference. On January 1st, 1865, very marked symptoms of compression were ushered in suddenly, convulsions recurring in rapid succession for two days, when a comatose condition supervened, which lasted until the patient's death, on January 13th, 1865. At the autopsy, a large abscess was found in the right hemisphere of the cerebrum communicating with the lateral ventricle, and containing several ounces of pus. There Avere evidences of inflammation of the - cerebellum and meninges of the brain. The necrosed portion of bone was, in two or three places, perforated. It was observed that the Avails of the cranium.were very thin. The thoracic and abdominal viscera were normal in appearance. The notes of the case were furnished by Acting Assistant Surgeon H. F. Bosworth. Case.—Lieutenant J. Hendriek, Co. H, 6th Pennsylvania Cavalry, was thrown from his horse in August. 1863, and his head struck the ground Avith such violence as to produce a severe concussion of the brain. He was admitted to the Officers' Hospital at Philadelphia, with partial hemiplegia of the right side, and occasional attacks of delirium. AA7ith rest and restricted diet, these symptoms gradually disappeared, and this officer was returned to duty, well, on February 5th, 1864. Acting Assistant Surgeon W. Camac reports the case. Case.—Private C. S. Miller, Co. I, 18th Connecticut Volunteers, aged 30 years, fell from a bridge at Harper's Ferry, Virginia, October 27th, 1864, and received a severe contusion of the scalp with concussion of the brain. He was sent to the hospital at Sandy Hook, Maryland, on the following dav, and Avas transferred to Frederick, on November 2d. He gradually recovered his physical health, but dullness of intellect persisted, and he was discharged from service for disability, on May 21st, 1865. Assistant Surgeon T. H. Helsby, U. S. A., reported the case. Case.—Private John Aliller, Co. E, 4th PennsyhTania Cavalry, aged 31 years, fell from a tree, on June 16th, 1863, aud struck upon the left side of his head, and upon his shoulder, fracturing the left clavicle. He was admitted, a few hours afterwards, to Lincoln Hospital, Washington, in a semi-conscious condition, partially insensible, the surface pale and cold, with other symptoms of severe concussion of the brain. Stimulants Avere administered. He failed to react. On the folloAving day his respiration became more labored, and, failing gradually, he died on June 18th, 1863. Surgeon G. S. Palmer, U. S. V., reports the case. Case.—Private J. P. Schneider, Co. L, 1st Missouri Engineers, aged 30 years, was thrown from a wagon, near New Madrid, in November, 1863, and, striking on his forehead, was badly stunned, and received a contused and lacerated wound of the integuments. He was treated in several hospitals, at Chattanooga, Cumberland, and Jeffersonville, and is reported as suffering from indigestion, hernia, neuralgia, and other ailments, and finally, at Mound City Hospital, Illinois, on December 1 st, 1864, with ulceration of the frontal bone, over the sinuses. He was discharged the service on account of incurable disease of the frontal sinuses and turbinated bones, on March llth, 1865. Surgeon IL Wardner, U.'S. V., reports the case. Case.—Private Charles Sherman, Co. A, Todd's Scouts, yvas throAvn from his horse, on August 18th, 1863, and, striking upon the right side of his head, received a severe concussion of the brain. He was admitted to Camp Dennison Hospital, Ohio, a few hours after the reception of the injury, at which time respiration Avas almost extinct, pulse soft and feeble, and extremities cold. Complete insensibility existed, although he could swallow stimulants in small quantities. Sinapisms were applied to the back of the neck and to the extremities, and reaction Avas slowly established. On August 19th, he remained unconscious, with irregular and labored respiration, pulse 60, full, slow, and incompressible, with involuntary discharge of urine, and partial paralysis of the right arm. During the evening of the same day symptoms of improvement and returning consciousness Avere * manifest. At 9 p. m. the pulse was 110, and full. HeAvas bled, and the pulse increased in frequency, but afterwards fell to 112. Upon the application of cold to the head the respiration became natural. On August 20th, he opened his eyes when sharply spoken to, his respiration was natural, pulse 78, and compressible. He continued in this condition until August 26th, when his symptoms improved still more, and he replied to questions readily. He had no paralysis, and took liquid nourishment freely, He recovered completely, and was returned to duty on October 22d, 1863. Surgeon B. Cloak, U. S. V., reported the case. 6 42 WOUNDS AND INJURIES OF THE HEAD, Case.—Private F. Tillotson, Co. B, 7th Kansas Cavalry, aged 25 years, received a severe concussion of the brain by a fall from his horse, near Memphis, Tennessee, and was transferred from a hospital at that city to the Marine Hospital at St. Louis, on September 16th, 1864. He Avas furloughed on November 20th, and on December 24th, 1864, he deserted. Surgeon A. Hammer, U. S. A'., reports the case. Case.—Private T. J. Wittermode, Co. I, 14th Indiana A'olunteers, Avas admitted to MoAver Hospital, Philadelphia, Alarch 16th, 1*63, Avith a very severe contusion of the scalp, occasioned by a fall. A puffy tumor of the scalp, which subsided under the use of evaporating lotions, while persistent pain at the seat of injury continued. The patient was transferred to McDougal Hospital, New A'ork, on April 22d, thence to Fort Wood, thence to NeAV York City, Avhere he Avas transferred to the Veteran Reserve Corps, on July 27th, 1863, in accordance Avith G. O. No. 235, AVar Department, A. G. 0., 1863. The next series consists of abstracts of thirteen cases of simple or compound fractures of the cranium produced by falls: Case.—Private John W. Anderson, Co. E, 19th Alichigan Volunteers, fell doAvn stairs in the court-house at McAIinns- ville, Tennessee, February 2d, 1864, and, striking his head, produced a fracture of both tables of the left temporal bone. He av.is admitted to hospital under the charge of Surgeon John Bennett, 19th Michigan A'olunteers, Avho records the accident upon bis regimental monthly report. The case terminated fatally on February 6th, 1864. At the autopsy, intense congestion of the cerebral vessels was observed, Avith effusion of serum in the cavity ofthe ventricles; but no extravasation of blood was observed. Case.—Private J. J. Brooks, Co. G, 9th Illinois Cavalry, aged 28 years, was thrown from his horse on April 5th, 1864, and fell upon his head. A fracture, involving the frontal, temporal, sphenoid, ethmoid, and upper maxillary bones, was pro- duced. The patient was taken to the Adams Hospital at Memphis, Tennessee. He died a few hours after his admission, and it av..s found that the brain had been extensively contused and lacerated. Acting Assistant Surgeon F. Impey reports the case. Case.—Private James Carr, Co. G, 6th United States Cavalry, aged 21 years, fell from his horse on July 6th, 1863, receiving a wound of the frontal region with fracture, and depression of the inner table of the skull. He was admitted to Carver Hospital, Washington, on July 24th, in an irritable, morose, and restless condition. Three days subsequently he Avas slightly delirious, and respiration was difficult. In the afternoon he became completely unconscious, with insensible pupils and stertorous breathing, and death ensued in a few hours, on July 27th, 1863. The autopsy revealed a depression of the inner table of the frontal bone, and an abscess immediately beneath, filled with sanious pus, and surrounded with plastic lymph. Many of the sulci were adherent, and patches of lymph were distributed on the anterior and middle lobes of the brain. Surgeon O. A. Judson, U. S V., reports the case. Case.—Private AA'illiam Day, Co. C. 57th Illinois Volunteers, aged 44 years, an epileptic subject, a deserter from his regiment, had a severe fall, April 1st. 1864, and was admitted, in a delirious state, to the Marine Hospital at Chicago, Illinois. Acting Assistant Surgeon R. M. Isham, who reports the case, does not describe the symptoms, or the appearances at the autopsy ; but states that there Avas a fracture of the base of the cranium, and that compression of the brain, consequent upon a large extravasation of blood Avithin the skull, Avas the cause of death. The patient died April 3d, 1864. Case.—Private Hugh Donelly, Co. K, 38th NeAV York Volunteers, received at the battle of Williamsburg, May 5th, 1862, a flesh wound of the shoulder. He was made a prisoner. While confined at Richmond he had a fall in prison, striking his head, and producing a depressed fracture of the right parietal bone. He was exchanged, and received into hospital at Camp Parole, Annapolis, on February 5th, 1S63. He Avas deaf, and his mental faculties were very sluggish and obtuse. He Avas discharged from service for total disability on February 18th, 1863. Surgeon James Norval, 79th N. Y. S. M., reports the case. Case.—Sergeant Albert K------, Co. A. 4th Pennsylvania Cavalry, falling violently upon his head, in April, 1862, in Washington, D. C, had a fracture of the left side of the occipital bone, attended with laceration ofthe brain. He entered the Judiciary Square Hospital in an in- sensible condition, Avith stertorous breathing, dilated pupils, slow pulse, and relaxed sphincters. Cold applications to the head, purgatives, and derivatives, were em- ployed unavailingly. The patient passed into a condition of profound coma, and died April 28th, 1832, from compression of the brain. Acting Assistant Sur- geon C. G. Page made the autopsy, and found a partially organized coagulum in the substance of the posterior lobe of the left hemisphere, and in the cavity of the left ventricle. The clot is not recent, and the brain substance in the A-iciuity is firmly contracted around it. It is of a dark broAvnish-yelloAV color, and spongy in texture, and measures one inch in diameter by one-fourth of an inch in thickness. On the surface of the brain there is a more recent clot, black in color, and partially disorganized, measuring nearly the same as the first., The specimen was contributed by Dr. Page to the Army Medical Mu- seum. A vieAV of the clot in the ventricle is given in the accompanying wood- fig. 13.—Portion of left hemisphere ofthe brain cut (Fl(J 13) containing a coagulum.—Spec. 505, Sect. I, A.M.M. Case.—Sergeant J. J. Kent, Co. L, 1st AA'isconsin Cavalry, aged 29 years, was thrown from his horse February 18th, 1SG4. and falling on his head, had a depressed fracture of the left parietal bone near its coronal suture. It can only be learned of the early history of the case that it Avas treated on the expectant plan. The patient Avas admitted to Harvey Hospital, at Madison, AVisconsin, on July 27th. He made a very good recovery, returning to duty October 10th, 1864. Case.—Sergeant Alexander N------, Co. B, 13th NeAV York Cavalry, was throAvn from his horse while riding in the Streets of Washington, on August 10th, 1865, his head striking violently upon the pavement. He Avas taken to the hospital at CONTUSIONS AND LACERATIONS BY BLOWS FROM MUSKETS. 43 Camp Barry in an insensible condition, and, in a few hours, became delirious. He remained so until his death, which took place on August 14th, 1865. There was no external evidence of depression or fracture of the skull, but simply a severe contusion o the forehead. The autopsy revealed a three-branched linear fracture of the frontal bone. Its direction is indicated in the accompanying wood cut. (Fig. 14.) Externally one line of fracture passes from the centre of the superior border of the bone doAviiAvard and outAvard through the right frontal eminence. From the upper third of this fissure a second fissure passes nearly at right angles dowmvard through the left frontal eminence. This last fissure involves the external table only. The inner table is fissured to correspond Avith the first line of fracture, and there is also a short fissure branching upAvard. The inner table opposite each frontal eminence is reticulated, and in the centre of the perforated plate on the left side there is a small nodule of bone of the size of a grain of wheat. The specimen, with a mem- Fl0. i4._Fracture of the frontal bone without orandum ofthe case, Avas foi-Avarded to the Army Medical Aluseum by Surgeon displacement, from a fall from a horse.—Spec. 297 J, J. M. Homiston, 3d NeAV A'ork Provisional Cavalry. Case.—Lieutenant J. M. Ragan, Co. E, 1st Tennessee Artillery, aged 30 years, was thrown from his horse, June 18th, 1865, and Avas admitted into the Officers' Hospital, at Knoxville, Tennessee, on the following day, laboring under very grave symptoms of compression of the brain. He died, June 25th, 1865, from extravasation of blood, consequent upon the fracture of the skull. Surgeon F. Aleacham, U. S. \.. reports the case. Case.—Private E. G. SteA-ens, Co. D, 8th Arermont Volunteers, aged 18 years, fell from a second story window, in NeAV Orleans, on June 10th, 1864, his head striking the ground. He Avas conveyed to the University Hospital, and Surgeon Samuel Kneeland, U. S. A7., recognized the usual signs of fracture of the base of the cranium. There was also a contused and lacerated Avound of the vertex. The case terminated fatally June llth, 1864. Case.—Private C. Timberman, Co. C, 2d NeAV Jersey Cavalry, aged 19 years, received, April 22d, 1864, a severe fall. He Avas admitted to Gayoso Hospital, at Memphis, Tennessee, on April 30th, and was found to have a compound fracture of the occipital bone. There Avere no symptoms which were thought to justify operative interference, and the treatment consisted of cold applications to the bead, and purgatives. Death took place on May llth, 1864. Surgeon F. N. Burke, U. S. V., reports the case. The tAvo following were belieA7ed to be examples of fracture by contre-coup: Case.—Private John H. BoAvker, Co. A, 3d Maine Volunteers, Avas thrown from a horse, March 26th, 1862, at Fort Monroe, Virginia, and, falling upon his head, received a fracture of the base of the skull. He was immediately conveyed to the Hygeia Hospital, with marked symptoms of compression of the brain. He died, March 27th, 1862. Brigade Surgeon R. B. Bontecou, U. S. V., reported the case. Case.—Private Peter Flynn, Co. H, 2d Ohio Heavy Artillery, was admitted to the Post Hospital at Munfordsville, Kentucky, January 3d, 1864. with a fracture of the skull. He had every symptom of grave compression of the brain, and blood was passing from his mouth and ears. He Avas comatose, and died two hours after his admission. The man had received a heavy blow upon the left supra-orbital ridge, whether by a weapon, or fall, could not be ascertained; but no evidence of fracture could be discovered at this point. Surgeon S. Albright, 2d Ohio Heavy Artillery, who reports the case, believed that there must be a fracture of the base of the skull by contre-coup. The post mortem examination proved the correctness of this diagnosis. There was a fissure running across the petrous bone, diastasis of the sutures between the occipital and left temporal, Avith a large coagulum of blood in the left cranial fossa. Blows.—Contusions and lacerations of the scalp, concussion of the brain, and frac- tures of the cranium, were produced by a great variety of blows. When received in action, such injuries were commonly inflicted by clubbed muskets, falling trees or branches cut down by artillery, or by kicks from horses or mules. In affrays in camp or on the street, similar injuries were more generally produced by blows from clubs or axes, slung shot, and various other blunt weapons, or by bricks or stones: Cases.—The nineteen following named patients were admitted to hospital for contusions or lacerations of the scalp by blows from muskets, and were returned to duty, the average duration of treatment being about one month: Private J. W. Anderson, H, 19th Massachusetts Volunteers, in action, at Gettysburg, July 2d, 1863. Private D. W. Butler, A, 92d Illinois Volunteers, at Nashville, Tennessee, November, 1864. Deserted. Private C. Chamberlain, A, 34th New Jersey Volunteers, November, 1863. Private H. W. Jones, K, 9th New Hampshire Volunteers, in action, near Jackson, Mississippi, July 14th, 1863. Private R. Lauutz, C, 54th Pennsylvania Volunteers, in action, at Piedmont, Virginia, June 5th, 1864. Private P. Leonard, G, 2d Michigan Cavalry, in action, near Nashville, Tennessee, December 7th, 1864. Private J. Linebacker, F, 13th Missouri Volunteers, accidentally, at Rolla, Alissouri, December llth, 1864. Private M. J. Loud, A, 2d Rhode Island Volunteers, in action, near Appomattox, Virginia, April 6th, 1865. Private J. McCracken, A, 5th Tennessee, accidentally, Cincinnati, Ohio, January 22d, 1865. Private H. McLaughlin, G, 16th New York Cavalry, near Alexandria, Virginia, July 31st, 1864. Private W. Magee, L, 2d Iowa Cavalry, in action, near Nashville, Tennessee, December 18th, 1864. 44 WOUNDS AND INJURIES OF THE HEAD, Private Conrad Osman, Co. I, 108th Ohio Volunteers, Marietta, Georgia, November 13th, 1864. Private W. A. Palmer, A, 146th NeAV l'Ork Volunteers, in action, near Spottsylvania, Arirginia, May 5th, 1864. Corporal T. Robb, A, 2d District of Columbia ATolunteers, AVashington, D. C, August, 1865. Corporal J. Schinkel, D, 28th Ohio Volunteers, near Beverly, AVest Virginia, February 7th, 1864. Private J. Snowdon, F, 30th United States Colored Troops, in action, near Petersburg, Virginia, July 30th, 1864. Private J. SAyeeney, G, Second Battalion, 14th United States Infantry, near Annapolis, Maryland, June 9th, 1863. Private AA'. J. True, K, 2d Illinois Volunteers, near Memphis, Tennessee, March 10th, 1865. Private A. AA'olf, D, 59th New York Volunteers, in action, at Gettysburg, July 2d, 1863. Deserted. Cases.—The twelve following received injuries of the head, of a more severe nature, from blows from muskets: Private Andrew Berry, Co. B, 14th Pennsylvania Cavalry, aged 54 years, at Snicker's Gap, Virginia, April 1st, 1865, in action. Was sent to Satterlee Hospital, Philadelphia; thence to McClellan Hospital, July 16th; thence to MoAver Hospital, July 20th, and Avas discharged from service August 24th, 1865, in accordance with G. O., War Department, A. G. O., Alay 3d, 1865. Private AI. BroAvn, B, 140th New York Volunteers, in action, at Spottsylvania, May 12th, 1864. Private W. B. Burns, A, 22d North Carolina Regiment, Avas admitted to Farmville Hospital, Virginia, August, 1864, and Avas discharged from the Confederate service for total deafness, resulting from a blow received, in action, from a musket. Private J. Hewett, Co. B, 2d Vermont Volunteers, aged 28 years, received, May 5th, 1861, a lacerated wound of the scalp, with concussion of the brain, by being struck with the butt of a musket at the battle of the AVilderness. He Avas treated at the University Hospital, Baltimore, and at the Smith Hospital at Brattleboro, Vermont, and returned to duty July 29th, 1864. Private M. Leisure, 173d Ohio Volunteers, aged 30 years, accidentally, at Nashville, Tennessee. Transferred July 1st, 1865. Not accounted for. Private Otis J. Libby, Co. H, 16th Maine Volunteers, was struck on the head by a musket, at the battle of Fredericks- burg, December 12th, 1862, and was sent to Alexandria, December 19th, and was discharged from service, totally disabled, on March 30th, 1863. The case Avas recorded by Surgeon E. Bentley, U. S V. Private J. Logan, Co. C, 6th Maine A'olunteers, aged 28 years, received a lacerated wound of the scalp, July 21st, 1861, at the first battle of Bull Run. He Avas treated at the Mason Hospital, Boston, and returned to duty, and was subsequently discharged from service on account of epileptic fits, January llth, 1865. Private J. O'Donnell, Co. K, 12th Alaine Volunteers. Insubordination, December 9th, 1862. In 1863 and 1864, he was serving out his sentence by Court Alartial, at Ship Island, Mississippi, and Tortugas, Florida. Private J. Parker, Co. K, 2d Ncav Hampshire Volunteers, aged 23 years, March 12th, 1864. Partial paralysis of left arm. Recovery, and returned to duty, Alay 6th, 1864. Private Sampson Turner, Co. F, 66th Ohio A'olunteers. was admitted into the Twentieth Army Corps Hospital, on July 6th, 1864, much debilitated by malarious attacks. While in hospital, a musket fell upon his head, producing a concussion of the brain, and almost instant death, on August 26th, 1864. Private W. Walter, 3d Pennsylvania Reserve Volunteers, June 26th, 1864, lacerated wound of the scalp, at the battle of Gaines' Mills, 1862. Examined for 44th Regiment V. R. C, January, 1867. Private Robert M. Young, Co. D, 107th Illinois Volunteers. Laceration of the scalp by a blow from the butt of a gun. Admitted to Douglas Hospital, Washington, July 17th, 1863. He was transferred to the Invalid Corps, September 16th, 1863. The seven following abstracts refer to examples of fracture of the skull resulting from blows from muskets: Case.—Private Michael B------, Co. F, 9th Massachusetts Volunteers, while sleeping on the ground after the battle of Gettysburg, Pennsylvania, July 4th, 1863, Avas struck on the head by a musket in the hands of a felloAV soldier. The hammer of the musket inflicted a wound of the left temple and a depressed fracture at the middle ofthe lower border of the left parietal and adjoining portion of the left temporal bone. The patient Avas conveyed to Baltimore. He was admitted, on July 5th, into Jarvis Hospital, in a comatose condition There was a hernia of the brain of the size of a walnut. The patient retained voluntary motion of the lower limbs. The pupils were irregular and insensible to the light. Con- sciousness Avas never restored, and death took place on July 6th, 1863, forty- four hours after the reception of the injury. At the autopsy, made fourteen hours after death, the left side of the calvarium Avas removed, and a number of long fragments were found imbedded in the middle lobe of the left hemisphere, the brain tissue being broken up as far as the left lateral ventricle. Two frag- ments, one of the outer and one of the inner table remained attached; the latter froFmIGa ^^7p£ui*lZ?TZtX & ^ and one of the former having their free edges depressed one-fourth of an inch. The oval opening made in the skull is represented in the adjacent wood-cut, (Fig. 15.) The pathological specimen and notes of the case Avere contributed by Surgeon D. C. Peters, U. S. Army. Case.—Private James H. Burns, Co. F, 9th New Hampshire Volunteers, was struck, at Petersburg, Virginia, July 30th, 1864, AA-ith the butt of a musket, and received a contused wound of the scalp, with fracture and depression of the right parietal bone, tAvo and a half inches anterior to the lambdoidal, and two inches external to the sagittal suture. On June 1st, 1865, he was transferred to the 6th NeAV Hampshire Volunteers. Cephalalgia, upon exposure to the sun, was the only troublesome nvmptom. He Avas mustered out of service on July 17th, 1865. CONTUSIONS AND LACERATIONS FROM FALLING TREES OR BRANCHES. 45 Case.—PriA-ate AA'm. Mclntire, Co. K, 2d DelaAvare Volunteers, received a blow from, the butt of a pistol in a s#eet brawl, at AA'ilmington, DelaAvare, November 21st, 1863. He Avas conveyed to Tilton Hospital, where Surgeon E. J. Bailey, U. S. Army, Avho reports the case, found that there Avas a compound fracture Avith depression of the left parietal, causing grave injury to the brain. Operative interference was deemed inexpedient, and the patient died, November 25th, 1863. Case.—Private Jarvis Nunn, Co. A, 12th Kentucky Volunteers, aged 18 years, was admitted into the Old Hallowell branch of the military general hospitals at Alexandria, Virginia, February 1st, 1865, with a compound fracture of the skull by a blow from the muzzle of a musket in the hands of a comrade. The wound and fracture were situated a little above and to the outside of the left frontal eminence. There was no disturbance of the mental faculties, and no especial derangement of the physical functions at the date of the patient's admission, except slight constipation, which was overcome by a cathartic. On February 4th, a slight febrile movement, Avith a dull frontal headache and swelling of the left parotid gland was observed; but there Avas no obtuseness of intellect. On the following day, the left side of the face Avas cedematous. The eyes, particularly the left eye, being Avatery. The bowels Avere soluble. The wound had now commenced to suppurate, the discharge being foetid. Cold applications Avere made to the bead. On the 7th, the pupils Avere dilated, and the tongue was protruded with difficulty. On February 8th, the patient was delirious, deaf, unable to articulate, or to protrude his tongue. He could be roused with difficulty from his comatose state. The respiration Avas at 44, and the pulse thready at 115. It was necessary to evacuate the urine by a catheter. On the 9th, the coma became profound; respiration 36; pulse 128; pupils widely dilated, and irresponsive to light. On February 10th, the respiration was very labored, the face and neck cedematous; the eyelids firmly closed; but, when forcibly separated, revealing the pupils dilated to almost the extent of the iris. The urine and faeces were discharged involuntarily. The surface was covered by a profuse SAveat. The radial pulse was imperceptible. Death took place at three o'clock in the afternoon of February 10th, 1865. At the autopsy there was found, on the left side of the sinciput, a Avound covered Avith yelloAV pus, and beneath, a depressed fracture of the frontal bone; and on removing the skull-cap a dark coagulum. The dura mater Avas not inflamed, but was separated from the bone for some distance around the fracture. The anomaly of the right lung being divided into two lobes only Avas noticed. This lung was emphysematous, and the bronchial mucous membrane on this side was thickened and discolored. The tissue of the left lung was crepitant, but red and slightly softened. The structure of the spleen was softened. The case was reported by Surgeon E. Bentley, U. S. V. Case.—Private Joseph Richards, Co. G, 13th Wisconsin Volunteers, aged 52 years, received, at Paint Rock, Alabama, December 31st, 1864. a lacerated Avound of the scalp, with fracture of the right parietal, by a blow from a musket. He was sent to the hospital at HuntsA-ille, Avhere he recovered from the symptoms of concussion at first manifested, and was so far convalescent that, on March 31st, 1865, he was transferred to Nashville, Tennessee. On April 13th, he Avas sent to Crittenden Hospital, at Louisville, Kentucky, and thence to SAvift Hospital, at Prairie du Chien, Wisconsin. He recovered from his injury, and Avas discharged from service, on June 30th, 1865. Case.—Private David Smith, Co. K, 113th Ohio Volunteers, aged 23 years, was struck on the head by a musket, August 4th, 1864, in a private quarrel, and received a partial fracture of the frontal and left parietal bones. He was received into Adams Hospital, at Memphis, Tennessee, August 17th, 1864. He recovered perfectly, under expectant treatment, and was returned to duty December 10th, 1864. Surgeon J. G. Keenon, U. S. V., reports the case. Case.—Private E. J. Tripp, Co. B, 77th New York Volunteers, aged 42 years, in the battle of Spottsylvania, May 10th, 1864, was struck upon the head with the butt of a musket which produced a severe contusion of the scalp, and a simple fracture of the cranium. These injuries seem to have led to no very serious derangement of the cerebral functions since the patient was able to return to duty in October, and to go into action at the battle of Cedar Creek, October 19th, 1864, when he received a flesh wound in his groin, for which he Avas treated in the field hospital of the Second Division of the Sixth Corps, and afterwards at Martinsburg, Alrginia, whence he was furloughed, on February 1st, 1865, to report at Ira Harris Hospital, Albany, New York, on March 12th. He was discharged from service August 7th, 1865, on account of loss of power in the lower extremities, and impairment of the mental faculties, resulting from the injury of the head. Assistant Surgeon James H. Armsby, U. S. V., rated his disability at two-thirds. The following men received injuries of the head from falling trees or'branches: Cases.—The seventeen men named in this series had contusions or lacerations from the above cause of sufficient severity to require treatment in general hospitals. They were all returned to duty after a few days or weeks of treatment, with the exception of a feAV who were mustered out of service, or who deserted: Private W. R. Bradstreet, Co. B, 19th Maine Volunteers, in action, Wilderness, Virginia, May 9th, 1864. Drummer D. Cain, Co. H, 20th Massachusetts Volunteers, Brandy Station, Virginia, May 2d, 1864. Corporal G. Chase, Co. H, 4th Vermont Volunteers, March 23d, 1865. Private J. Cozzens, 14th Co. Unattached Massachusetts Volunteers, June 22d, 1864. Private F. Freeman, Co. I, 25th AA'isconsin Volunteers, October 10th, 1864. Lieutenant D. B. Greeley, Co. B, llth Iowa Volunteers, in action, at Corinth, Mississippi, October 4th, 1862. Private T. Lee, Co. H, 20th Indiana Volunteers, January 13lh, 1865. Private J. Mclntyre, Co. B, 157th NeAV York Volunteers, Fillifinny, South Carolina, December 6th, 1864. Private J. McNulty, Co. D, 26th Massachusetts Volunteers, August 23d, 1864. Private J. Alaine, Co. K, 162d NeAV York Volunteers, Winchester, Virginia, February 22d, 1865. Private J. D. Mansfield, Co. B, 16th Maine Volunteers, February 7th, 1865. Private J. Miles, Co. C, 16th Illinois Volunteers, February, 1865. Private G. H. Miller, Co. B, 23d United States Colored Troops, Petersburg, Virginia, October, 27th, 1864. 16 WOUNDS AND INJURIES OF THE HEAD, • Private E. B. Mitchell, Co. K, 15th A'irginia Arolunteers, Cumberland, Alaryland, August 9th, 1864. Private T. Mount, Co. D, 77th Illinois A'olunteers, March 27th, 1865. Private J. Naylor, Co. D, 52d Illinois A'olunteers, Rome, Georgia, November 1st, 1861. Private J. Talbot, Co. I, 189th NeAV York A'olunteers, June 1st, 1865. Cases—The fourteen named in this series were dischargedfrom service on account of disabilities, produced by more severe injuries, from the same cause: Private EdAvard Harris, Co. H, 120th New York Volunteers, in action, at Hatcher's Run, A'irginia, February 8th, 1865. Private Peter Hollahan, Co. G, 73d New A'ork Volunteers, January 4th, 1865. Private John AA'. Hudson, Co. A, 60th Ohio Volunteers, June, 1865. Private John Larkin, Co. D, 88th NeAV York Volunteers, April, 1865. Private AVilliam Loveland, Co. F, 21st Ntnv York Cavalry, Alarch 23d, 1865. Corporal Arthur McCune, Co. D, 7th Indiana A'olunteers, January, 1865. Private Patrick Alaloney, Co. D, 46th NeAV York Volunteers, Petersburg, Virginia, November 3d, 1864. Private Otto Nestler, Co. B, 7th New York Volunteers, February 5th, 1865. Private Joseph AA'. NeAvland, Co. G, 80th, NeAV York A'olunteers, Rochester, NeAV York, November 13th, 1864. Private D. Rogers, 29th United States Colored Troops, Petersburg, A'irginia, October 25th, 1864. Private Christian Smith, Co. E, 7th NeAV York A'olunteers, April, 1865.. Private Patrick Sullivan, Co. H, 73d New York Volunteers, May, 1865. Private Stephen Twelves, Co. A, 116th Pennsylvania Volunteers, Chancellorsville, Virginia, May 3d, 1863. Case.—Lieutenant John A. Porter, Co. C, 36th Illinois Volunteers, aged 23 years, in the engagement at Resaca, Georgia, May 15th, 1864, was struck on the head by a limb of a tree which had been cut off by a solid shot He fell, senseless, the blood gushing from his mouth and nostrils. He remained in an unconscious state for forty-eight hours, when he was con- veyed to the hospital at Chattanooga, Tennessee. On admission, he was speechless, and completely paralyzed in the upper extremities and in the muscles ofthe head and face. On June 18th, he Avas transferred to Hospital No. 1, at Nashville, Avhence he Avas furloughed on August 1st, 1864. At this date "the entire upper part of his body was paralyzed." He remained at his home* until November 10th, when, having regained his strength, and, in a measure, the use of his upper extremities, he returned to the hospital, and thence to duty with his regiment at Pulaski, Tennessee. He participated in the engagements at Spring Hill and Franklin, Tennessee, on November 29th and 30th, hoping that the excitement would restore his voice. He stated that the sound of musketry and artillery firing " almost burst his head." In the early part of December, 1864, after violent and repeated efforts to utter a sound, a copious haemorrhage took place from the fauces, and possibly the upper portion of the larynx, preceded by a feeling of " cracking and bursting," and a sense of " rushing upward in the head." The haemorrhage was followed by complete return of his voice, seven and one-half months after the reception of the injury. During this period tinnitus aurium and vertigo existed, at times, to such extent as to deprive him of sight and hearing. He was mustered out of service on October 8th, 1865, with his regiment. On June 13th, 1866, he was pensioned, to date from October, 1865. The examining surgeon reporting a concussion of the right hemisphere ofthe brain, Avhich caused "general debility, affecting the right leg, arm, and eye" He drew his pension at the Quincy Agency, Illinois, Alarch 4th, 1869, and was then reported as permanently disabled. He resided at Little York, AVarren county, Illinois, and wrote thence, in the spring of 1866, a very detailed account of his acci- dent, from which the above abstract is partially compiled. He stated that he suffered so much from dizziness, from Aoav of blood to the head, that he supposed he would never recover his health, and concluded: " I am unable, entirely, for manual labor; yet my wound was received in a glorious cause, and one that I was willing to sacrifice my life for." In the next two cases, falling trees produced fractures of the cranium: Case.—Private James AI. Logan, Co. K, 106th Illinois A'olunteers, was, in January, 1863, struck by a falling tree, which fractured the cranium at the vertex, just posterior to the coronal suture, involving both tables. He was admitted to the hospital at the provisional encampment at Fort Pickering, Tennessee, where he remained under treatment until August 4th, 1863, Avhen he was discharged from the service. On August 8th, 1863, Pension Examining Surgeon Thomas B. Henning, examined the case, and reports that a portion of the bone was lost, and that the pulsations of the brain were visible. An abscess had formed in the left temporal region, and was then discharging. The man Avas debilitated, and when exposed to the sun, or exertion, Avould suffer from vertigo and headache. Case.—Private John Tyler, Co. K, 30th United States Colored Troops, was injured, on December 27th, 1864, by a falling tree, which produced a linear fracture of the cranium, extending from the sagittal suture obliquely through the left parietal and temporal bones to the middle foramen lacerum. He was admitted to the field hospital of the Twenty-fifth Army Corps on the same day, in an unconscious condition, from which he never rallied. His pulse was slow and weak, respiration stertorous, and pupils insensible to light. But little nourishment could be given in consequence of impaired deglutition. AA'ith the exception of slight improvement in his pulse, he continued in the above condition until his death, on December 31st 1864. At the autopsy, effusion of blood in the left parietal and temporal regions beneath the scalp, and slight effusion internally upon the dura mater. Beneath the dura mater, on the right side, a thin coagulum extended from the upper surface of the hemisphere, doAvn into the middle fossa of the cranium, Avhere it Avas one-fourth of an inch in thickness. The convolutions of brain were flattened from pressure. The inferior portion of the right middle lobe, for a space of one and a half inches, was much ecchymosed and softened, and blended with the coagula. There were two ounces of serum in the sub-arachnoid space, and in the lateral ventricles. Avhich Avere someAvhat distended. The left hemisphere was normal; no other organs Avere examined. Sur- geon Norton Folsom, 45th United States Colored Troops, reports the case. FROM CLUBS AND OTHER BLUNT WEAPONS. 47 Kicks, from horses and mules, were a not infrequent cause of injuries of the head: Cases.—The ten named in the following list Avere received into hospital on account of contusions or lacerations of the scalp by kicks from horses or mules, and Avere returned to duty after a brief interval: Private AA'illiam BroAvn, Co. G, 21st New A'ork Cavalry, November 1st, 1864. Teamster R. Broyden, Quartermaster's Department, January 13th, 1865. Private Alonzo Cole, Co. G, 6th Pennsylvania Reserves, June 30th, 1863. Private AA'illiam Deal, Co, I, 7th Illinois Cavalry, July 28th, 1H64. Sergeant R. S. Doav, Co. C, 39th AI as sachu setts Volunteers, October 15th, 1864. Bugler Jacob Horn, Co. K, 5th United States Artillery, Buzzard Roost, Georgia, May 9th, 1864. Private Joshua LeAvis, Co. A, 5th Michigan Volunteers, July, 1863. Deserted, September 3d, 1863. Private Andreav Peters, Co. G, 3d United States Colored Troops, St. Louis, December 4th, 1862. Private Edward-T. Simmons, Co. G, 1st DelaAvare Volunteers, May, 1864. Private Calvin Starzman, Co. H, 12th Illinois Cavalry, February 21st, 1865. Cases.—The four following are reported as discharged from service on account of severe injuries of the head, without fracture, from kicks: Private John AA'. Forckers, Co. A, 3d Maryland Volunteers, March, 1865. Private AndreAV Kerr, Co. G, 1st Alichigan Cavalry, November 25th, 1833. Private Philip Seton, Co. G, 169th NeAV A'ork Volunteers, July 25th, 1865. Cases.—The four folloAving are reported as having received simple fractures of the skull from kicks; but the accidents were not followed by any very grave symptoms, since the men Avere returned to duty, or discharged, as well: Private AA'illiam N. Ehvood, Co. I, 29th Pennsylvania Volunteers. Returned to duty, June 22d, 1865. Private Peter Leiser, Co. C, 67th Ohio Volunteers. Discharged, October 1st, 1863. Private George Styles, Co. B, -iOth New York Cavalry. Returned to duty, July 12th, 1865. Private John L. Weigel, Co. I, 8th Ohio Cavalry. Returned to duty, October 29th, 1864. Case.—Private George A. Teasdale, Co. G, 36th NeAV York Volunteers, received a severe contused wound of the scalp, with fraoture of the left parietal bone, by a blow from a horse's foot, in a cavalry charge, at the first battle of Bull Run, July 21st, 1861. He Avas made a prisoner, and remained in confinement until the termination of the war, in the spring of 1865. He Avas then released, and was examined at AA'ashington for admission into the 44th Regiment Vtteran Reserve Corps. He Avas suffering from very imperfect vision, resulting from the injury he had received. The late Assistant Surgeon W. A. Bradley, U. S. Army, reported the case. Case.—Abraham, a colored teamster of the Quartermaster's train of the 20th Army Corps, received, September 14th, 1863, near Stevenson, Alabama, a kick from a mule. The blow was found to have produced a depressed fracture of the left temporal bone. Surgeon D. J. McKibben, U. S. V., avIio records the case, states that the patient died on September 17th, 1863 from compression of the brain. These cases comprise all the injuries of the head from kicks that have been reported by name, with the exception of one, which will be cited among the cases of trephining, at the conclusion of this section. Injuries of the head, requiring treatment in hospitals, were frequently produced in private quarrels, or affrays, by blows from clubs and other blunt weapons: Cases.—The forty-one named in the folloAving list received contusions or lacerations of the scalp from blows from clubs, &c, and were returned to duty after a short period of treatment in general hospital: Private Samuel Biland, Co. L, 1st Alissouri Artillery, November 26th, 1863. Private Abraham BoAven, Co. I, 16th Kentucky Volunteers, June 4th, 1864. Private B. F. BosAvell, Co. D, 1st District of Columbia Volunteers, October 2d, 1864. Deserted. Sergeant Wm. Campbell, Co. E, 33d Iowa Volunteers, March 31st, 1865. Private F. E. Conn, Co. F, 1st United States Artillery, January 5th, 1865. Private S. F. Conway, Co. D, 1st Virginia Cavalry, December 23d, 1864, Private C. C. Daggart, Veteran Reserve Corps, December 13th, 1864. Private John DoAvler, Co. G, 2d District of Columbia Volunteers, October 10th, 1863. Private S. AV. Duvall, Co. D, 12th Kentucky Volunteers, January, 1865. Private James English, Co. K, 3d Massachusetts Heavy Artillery, January 9th, 1865. Private John Fitzgibbons, Co. B, 13th NeAV York Artillery, December, 1863. Thomas Geary, Quartermaster's Department, July 15, 1864. AV. W. Hopkins, Recruit, 5th Michigan Volunteers, April 26th, 1865. Thomas Jordan, employe, Quartermaster's Department, March 31st, 1865. 4* Private AVilliam Johnson, 10th New Hampshire Volunteers, December, 183'3. Deserted. Sergeant W. Leroy, Co. G, 4tfi United States Artillery, October 25th, 1864. Private Edward LoAvry, Co. E, 1st Veteran Reserve Corps, April 21st, 1864. 48 WOUNDS AND INJURIES OF THE HEAD, PriA-ate David AIcBride, Co. A, 18th Iowa A'olunteers. October 17th, 1863. Private Aliehael AlcCabe, Co. H, 4th AVisconsin A'olunteers, January 22d, 1865. Private Jerry McCarty, Co. C. 8th Illinois Cavalry, February 1st, 1864. Private Daniel AicLaughlin, Co. E, McClellan Guard, June 27th, 1863. Deserted. Private Patrick Martin, Co. E, 88th Ncav York A'olunteers, Alay 24th, 1865. Sergeant L. Martindale, Co. G. 2d Aiaine Cavalry, August 13th, 1865. Private John Moony, Co. H, 5th Connecticut A'olunteers, November 29th, 1863. Private John Aloore, Co. D, First Battalion California A'olunteers, December 12th, 1863. Private Kenneth NeAvton, Co. K, 38th Illinois A'olunteers, December 10th, 1864. Private Edward Ormsby, Co. I, 145th NeAV York Volunteers, November, 1863. Corporal Daniel Parker, Co. D, 73d NeAV York Volunteers, February 7th, 1863. Sergeant J. D. Place, Co. F, 75th Illinois Volunteers, December llth, 1864. Corporal Jacob Paul, Co. E, 16th Illinois Volunteers, December 14th, 1864. Private AV. E. Redding, Co. G, 2d Tennessee Mounted Infantry, January 20th, 1865. Private M. J. Rice, Co. I, 110th Pennsylvania Volunteers, May, 1863. Private Peter Smith, Co. C, 1st Missouri Artillery, December 22d, 1864. Private James E. Shay, Co. F, 22d Illinois Volunteers, Alay 24th, 1864. Private John Scott, 2d Indiana Battery, January 27th, 1865. Private Jacob Smith, 110th Ohio Volunteers, October 4th, 1864. Private Silas M. Smith, Co. C, 15th Illinois Cavalry, November 14th, 1863. Private Charles Trucksiss, Co. C, 16th A'eteran Reserve Corps, September llth, 1864. Private EdAvard AA'oodruff, Ordnance Corps, January 1st, 1865. Private Francis AA'irtz, Co. L, 1st Missouri Artillery, November 20th, 1863. Private John Williams, Ordnance Corps, January 1st, 1865. Cases.—The seven following men received injuries ofthe head from blows, which were followed by grave complications: Private G. H. Cutting. Co. D, 8th DelaAvare Volunteers. BIoav from spade. Alay, 1865. Otorrhea folloAved. Mustered out July 22d, 1865. Private Joseph EdAvards, Co. A, 28th Illinois A'olunteers. Laceration of forehead by a billet of wood. May, 1864. Severe erysipelas. Duty, June 30th, 1864. Private Henry Lough well, Co. H, 15th Ohio Volunteers. Contusion of frontal region by a billet of wood, November 25th, 1864. Discharged, June 10th, 1865. Private Michael Miller, 27th Co., 7th Regiment, V. R. C, aged 52. Severe contusion of scalp and concussion of the brain from a blow by a whip handle, Alay 14th, 1865. Discharged, November 14th, 1865. PriA-ate A. Robinson, 6th Michigan Cavalry, aged 24. Laceration of forehead by a slung shot, May 23d, 1865. Dis- charged, July 3d, 1865. Corporal William AVarner, Co. F, 7th Michigan Volunteers, aged 24. Partial paralysis ofthe left arm from a blow from a fence rail, in action, Gettysburg, July 3d, 1863. Transferred to 2d Co., 1st Battalion, V. R. C, September 4th, 1863. Private James AA'hissen, Co. F, 13th Ohio Cavalry, aged 21, was struck on the head with a pick-axe, February 16th, 1864. October 1st he Avas sent to a hospital at Alexandria, Avith violent epileptic convulsions. These continued to recur, and he was discharged from service Alarch 18th, 1865. The fourteen following abstracts afford examples of fractures of the cranium by blows from various blunt Aveapons: Case.—Seaman'James R. Connor, U. S. Steamer Arietta, aged 19 years, was admitted to the Post Hospital at Beaufort, North Carolina, October 31st, 1864, on account of a blow upon his head by an iron stanchion on the previous day. The blow had caused a fracture ofthe vault ofthe cranium. The patient died November 1st, 1864. Surgeon N. P. Rice, \J. S. V., reports the case, without particulars of the treatment. Case.—Sergeant J. G. Garrabrant, Co. C, 39th New Jersey Volunteers, aged 39 years, was admitted to the Ward Hos- pital, NeAvark, New Jersey, on January 8th, 1865, in an insensible condition, with a fracture of the cranium and compression of the brain, resulting from a Woav received in a street affray a few hours previously. He never regained consciousness, and died on January 12th, 1865. At the autopsy, the arachnoid membrane was highly congested, and the smallest vessels were visible. Upon the anterior portion of the right lobe of the cerebrum, between the dura mater and arachnoid, there was a clot of blood several inches in diameter. The other portion of the brain Avas normal. The internal table of the occipital was found to be fractured in two places, extending from the torcular Herophili to the foramen magnum. The case is reported by the late Assistant Surgeon J. Theodore Calhoun, U. S. A. Case.—Private John AA'. Hogener, Co. E, 120th Ohio Volunteers, received, on board a transport steamer, a blow from an iron bolt, which caused a fracture of the frontal bone. He was admitted to Hospital No. 11, at New Albany, Indiana, on November 18th, 1863, and died, on November 21st, 1863, from compression of the brain. Acting Assistant Surgeon A. M. Clapp reports the case. Case.—David H-----, U. S. Alarine Corps, aged 35 years, was admitted to the post hospital at Vicksburg, Missis- sippi, February 24th, 1866. with all the toes frost-bitten. This seemed to constitute the only trouble, Avith the exception of a Blight headache, which was attributed to the constipated condition of his bowels for three or four days prior to admission. An FRACTURES FROM VARIOUS BLUNT WEAPONS. 49 An incised wound of the scalp, Flo. 1H.—Fracture ofthe left parietal by a blow from a blunt weapon.—Spec. '2tiHJ, Sect I, A.M. M. aperient Avas ordered, Avith simple dressings to the feet. Until February 27th, there Avas a gradual improvement in the local lesion, but the dull, heaA-y pain in the head continued, Avith poor appetite, and costive bowels. On IVbruary 28th, the patient Avas found comatose, and for the first time there Ayas noticed a slight paralysis ofthe right side. an inch or more in length, Avas discovered in front of the left parietal protu- berance. A crucial incision Avas made, and the flaps Avere reflected, Avith a view of trephining in the eyent of a fracture ofthe skull with depression, but as no lesion of the skull could be detected, the incision Avas closed. No other injury of the scalp Avas found after careful examination. The coma and paralysis were ascribed to apoplectic effusion. The patient expired at three o'clock on the morning of the folloAving day. The antecedent history of this patient could not be ascertained, and Acting Assistant Surgeon G. F. Rock- Avell, AA-ho attended and reported the case, remarks that he was restricted to inferences from the clinical history and what the autopsy revealed. On re- moving the calvarium he found a small coagulum, but its location Avas not under the site ofthe external Avound, but a little back of the coronal suture, on the left side, Avhere the internal table Avas slightly depressed. But the chief difficulty was on the right side. When the skull-cap was lifted betAveen tAvo and three ounces of blood escaped, still leaving a coagulum covering the Avhole hemisphere. There Avas a semicircular fissure of the external table just in front ofthe left parietal protuberance, and stellate Assuring, Avith slight depression ofthe inner table, including a surface one inch in diameter. From this point a fissure, involving both tables, extended to the centre ofthe left branch ofthe lambdoidal suture. There Avere no traces of attempt at repair. There must have been a rupture of some ofthe larger vessels to cause such profuse extraA-asation of blood. There Avas no external Avound ofthe scalp over the fracture ofthe left parietal. The specimen (Fig. 16) Avas contributed to the Army Aledical Aluseum by Dr. RockAvell, who believed that the weapon employed must have been a billet of Avood, or something of that nature. Case.—Private AA'illiam Horan, U. S. Marine Corps, aged 43 years, was admitted to Armory Square Hospital, Washing- ton, Alay 14th, 1865, with a bruise of the left side ofthe forehead, received in a street fight a few hours previously. The injury was regarded as a simple contusion ofthe scalp, and was treated as such. On Alay 20th, the patient suddenly became comatose, and death took place on the folloAving day, Alay 21st, 1865. The post mortem examination revealed a slight fissure of the outer, and a considerable depression ofthe inner table. An abscess of considerable size extended for some distance beneath the frontal bone. Surgeon D. AA'. Bliss, U. S. A'., reports the case. Case.—Corporal Michael Lynch, Co. H, 45th New York Volunteers, aged 33 years, Avas struck with a club July 1st, 1864. He Avas admitted into the hospital of the 2d Division 2d Corps on the same day, and Avas transferred to Stanton Hospital, in AVashington, on July 4tb. Surgeon John A. Lidell, U. S. V., who reports the case, found that there Avas a comminuted fracture ofthe right temporal bone. Cerebral inflammation supervened, and the patient died July 14th, 1864. Case.—Private E. C. M------, Co. D, 23th Alabama Infantry, a prisoner of war at Rock Island, Illinois, w-as killed by a felloAV prisoner, August 14th, 1864, by a blow on the right temporal region Avith a board. Death was almost instantaneous. At the autopsy, it was found that the skull was remarkably thin, and that a nearly vertical fissure extended through the squamous portion of the temporal, the great Aving of the sphenoid, and nearly to the median line of the frontal bone, bifurcating an inch from its termination. The right orbital plate of the frontal, which was extremely thin, was fissured either by contre coup, or by the impulse communicated through the cerebral substance. There was diastasis of -the squamo-sphenoid suture. Large branches of the meningeal arteries were ruptured, and death resulted, probably, from haemorrhage in the cavity of the cranium. But the condition of the brain and its membranes, and the extent of the intracranial bleeding, were not reported. The speci- men is delineated in the adjacent wood-cut, (FiG. 17.) By an inadvertence of the en- graver in copying the photograph, the specimen appears reversed, and represents a fracture of the left instead of the right side. Fig. 17.—Fracture of the temporal by a blow from a board.—Spec. 28ti2, Sect. I, A. M. M. Case.—Private J. M. Munroe, Co. E, 26th Massachusetts Volunteers, was admitted to St. James Hospital, New Orleans, February 23d, 1863, Avith a fracture of the skull, produced by a blow. He recovered, under expectant treatment, and was discharged from service on Alay 12th, 1863. The case appears on the report of Assistant Surgeon J. Homans, U. S. A. Case.—Private John Alurray, Co. D, 6th Illinois Cavali^-, aged 23 years, was struck on the head by a slung shot, in the streets of Memphis, Tennessee, April 7th, 1864. He Avas admitted, on the same day, to Adams Hospital, and his case is recorded on the register of that hospital as a contused wound of the scalp. He Avas furloughed on July 8th, and admitted to Knight Hospital, NeAV Haven, Connecticut, on August 24th. He was furloughed from this hospital on September 9th, and re-admitted as unable to travel, tAA-o days subsequently. He Avas again furloughed on NoA-ember 2d, 1864, and re-admitted from furlough November 15th, and, according to the monthly report of Surgeon P. A. Jewett, U. S. V., in charge of Knight Hospital, was discharged from service on November 16th, 1864, on account of total physical disability, resulting from fracture of the skull, The certificate states that the man was unfit for duty in the Veteran Reserve Corps. 7 50 WOUNDS AND INJURIES OF THE HEAD, Case.—Private Francis AI. Pettit, Co. G, 12th Kansas Volunteers, is reported by Surgeon C. R. Stuckslager, 12th Kansas Volunteers, as ha\'ing received a compound fracture of the left parietal bone, a little in advance of the protuberance, by a blow from the handle of a table fork. There Avas depression of bone, with injury of the membranes of the brain, and the patient died a feAV days after the injury, Alay 7th, 1863. A post mortem examination Avas made, which disclosed indications of softening of the brain and meningitis. Case.—Private Aiichael Smith, Co. F, 7th United States Infantry, arrived at Fort Basconi, New Mexico, August 10th, 1863, and, on August 20th, he applied to Acting Assistant Surgeon S. Rankin, to have his head dressed. Dr. Rankin found a fistulous opening on the right frontal protuberance. The man related that, six months previously, at Fort Union, he had received, in an affray, a Woav Avhich had broken his head, and that a little matter had floAved from the Avound ever since. A simple dressing was applied, and the man did not report again on the sick list until September, 1863, when, after getting on a frolic, he Avas attacked Avith grave symptoms of cerebral disorder, and died, from cerebritis, September 20th, 1863. At the post mortem examination, Dr. Rankin found a piece of bone two inches long and one inch Avide, consisting of the inner table, altogether detached, lying pressing upon the brain, which had undoubtedly been in the same situation the previous spring Avhen he received the injury. Case.—Alfred Sypole, Farrier, Co. M, 4th A7irginia Cavalry, on February 26th, 1861, Avas knocked down by a bloAV from an axe, Avhile making a furious assault upon a non-commissioned officer of his company. For several hours afterwards he was insensible, and then partially recoyTered; but remained moody and stupid. On March 2d, he was admitted into the post hospital at NeAV Creek, AVest Virginia, under the care of Surgeon S. B. Smith, U. S. Y., who reports the case. Dr. Smith found a small wound, suppurating freely, over the left temporal bone, and a fracture without depression. The mental faculties Avere confused. The patient complained of severe pain on the opposite side of the head. An emollient poultice Avas applied to the seat of injury, and a brisk cathartic Avas ordered, which promptly relieved the pain in the head, and was folloAved by a restora- tion of clearness of intellect. At this time, the patient seemed to convalesce rapidly. In tAvo days, he Avalked about and enjoyed himself, entering freely into general conversation, and expressing himself Avith ease and clearness. On the evening of the 16th, he became sullen and depressed in spirits, and had a recurrence of severe pain on the opposite side of the head from the Avound. On the folloAving morning, the patient had convulsions, and death took place in a short time, March 17th, 1864. On a post mortem examination, it was found that there Avas a fracture of the temporal bone, triangular in shape, an inch and a half in length, and about one inch in width at Ihe base. The dura mater Avas not injured, and the bone was not depressed. In the middle lobe of the left hemisphere there was an abscess near the fracture containing an ounce and a half of pus. No abnormal appearances could be detected on the opposite side of the brain, Avhere the intense pain had been experienced. There Avas but little injection, anyAvhere, of the pia mater. Case.—Private James AViggins, Co. C, 1st U. S. Cavalry, was admitted to the Balfour Hospital, Portsmouth, Virginia, April 10th, 1865, with compression ofthe brain, resulting from a fracture of the frontal bone by a blow over the left superciliary ridge, received a feAV hours before admission. The roof of the orbit Avas depressed, as Avell as the loAver part of the skull, over the anterior portion of the left hemisphere. An operation was deemed inexpedient. Cold applications to the head, blisters to the nape of the neck, and stimulants, constituted the treatment. Assistant Surgeon J. H. Frantz, U. S. A., reported the case. Case.—Private J. R. Wilkinson, Co. B, 46th Virginia Regiment, Avas struck on the head by an iron bar, used in starting a steam engine, and had a fracture of the right parietal bone. He Avas treated at the Farmville Hospital, Virginia, on the expectant plan. Epileptic convulsions ensued, and the patient Ayas discharged from service, permanently disabled, on Sep- tember 23d, 1864. Surgeon H. D. Taliaferro, C. S. A., records the case on his monthly roport. The following are examples of contused and lacerated wounds of the scalp produced by stones, bricks, and similar missiles: Cases.—An officer and eight men of the 6th Massachusetts Militia received contusions or lacerations of the scalp, by paving stones, bricks, etc., on the occasion of the memorable attack upon that Regiment by insurgents in Baltimore, on April 19th, 1861: Privates G. Alexander, C. H. Chandler, and Sergeant W. H. Lamson, of Co. D; Sergeant G. G. Durrell, Co. D; Lieut. James F. Roavc of Co. L; Privates S. Flanders, J. Porter, J. Pennell, and Charles B. Stinson, of Co. C. These patients were conveyed, by rail, to Washington, and were treated in the E Street Infirmary, under charge of Surgeon Norman Smith, 6th Massachusetts Volunteers, and the late Dr. J. Sim Smith, Assistant Surgeon, U. S. A. Cases.—The twenty-two men named below are reported as having been tceated in various hospitals for contused or lacerated scalp wounds, produced by bricks or stones, and returned to duty, after a comparatively brief period of treatment: Private James Armstrong, Co. K, 7th Pennsylvania Reserves, October 4th, 1863. Private Anthony Babano, Co. C, 46th Indiana Volunteers, April 16th, 1835. Private Wm. BoAA-les, Co. A, 1st Alichigan C. T., Septeiwber 17th, 1864. Corporal F. B. Cox, I, 22d Pennsylvania Cavalry, May 30th, 1865. Sergeant F. A. Cullin, D, 22d A'eteran Reserve Corps, July 9th, 1864. Private J. R. Davenport, H, 84th New York A'olunteers, July 1st, 1863. Private E. Enghausen, K, 1st New York Light Artillery, June 1st. 1865. Private J. Ginn, C, 36th Indiana A'olunteers. November 27th, 1863. Private F. P. Green, D, 205th, Pennsylvania A'olunteers, May 26th, 1865. Private G. AV. Hamilton, K, 86th Illinois A'olunteers, July 1st, 1864. Private R. D. Herron, A, 23d Alichigan A'olunteers, December 22d, 1864. FROM UNSPECIFIED CAUSES OTHER THAN GUNSHOT. 51 Private B. HockAvorth, I, 1st AA'est Virginia Infantry, April 18th, 1864. Private T. Kelley, A, 14th Tennessee Cavalry, December 20th, 1864. Private J. Kennedy, L, 1st Missouri Engineers, August 16th, 1861. Private W. Locke, G, 23d A'eteran Reserve Corps, March 18th, 1865. PriA-ate AI. Lope, A, 22d Ohio A'olunteers, June 29th, 1865. Private T. Alinnan, Ordnance Corps, March 10th, 1865. Private A. NeAvhauser, G, 1st Illinois Artillery, April 29th, 1865. Private P. Rhodes, D, 18th IoAva A'olunteers, October 1st, 1863. Private W. Sallee. Ordnance Corps, January, 1865. Corporal J. W. Smithers, B, 27th Massachusetts A'olunteers, May llth, 1864. Private C. H. VA'inn, I, 35th Illinois A'olunteers, Alay, 1864. The three following are cases of fractures of the skull from the causes last mentioned: Case.—Private John Aldrich, Co. K, 176th New York Volunteers, aged 29 years, in an attack of delirium, struck his head with a stone, on July 25th, 1864, producing a compound fracture of the cranium. He was admitted to the University Hospital, at NeAV Orleans, Louisiana, on the folloAving day. An abscess formed and the patient died, on August 15th, 1864, from inflammation of the brain. Surgeon Samuel Kneeland, U. S. V., reports the case. Case.—Corporal Adam Gaslein, Co. B, 6th Pennsylvania Cavalry, had a simple fracture of the vault of the cranium, in April, 1863, caused by a bloAV from a stone. He was admitted to Columbian Hospital, Washington, on April 4th, 1863. He had a very protracted convalescence, and finally recovered perfectly, and returned to duty, April 12th, 1864. Surgeon T. R. Crosby. U. S. A'., reports the case. Case.—Private Daniel T. S\A-artz, 7th AA'est Virginia Cavalry, aged 35 years, had a laceration of the forehead, and a compound fracture of the left side of the frontal bone, from a blow by a brick-bat, on April 1st, 1865. He Avas admitted to AA'ashington Hospital, Alemphis, Tennessee, Avhere the haemorrhage, which had been very profuse, was arrested, and the wound dressed simply, there being no indications of depression of bone or of intracranial extravasation of blood. On Alay 15th, the patient was transferred to Gayoso Hospital. On May 24th, he was considered cured, and returned to duty. Surgeon Daniel Stahl, U. S. A'., reports the case. Unspecified Causes —Many men. also were received into general hospital for con- tusions or lacerations of the scalp, or for concussion of the brain, or fracture of the skull, and were reported by name, but without any indication of the precise cause of their injuries: Cases.—The one hundred and tAventy-one men enumerated in the following list recovered, and Avere returned to duty or discharged from service at the conclusion of the war after a brief period of treatment for such injuries as are mentioned above: Private H. Ackerman, K, 18th Wisconsin A'olunteers, Nashville, Tennessee, January llth, 1865. Private W. H. Alexander, C, 39th NeAV Jersey Volunteers, Camp Frelinghuysen, NeAV Jersey, October 24th, 1864. Private J. Anderson, G, 4th Tennessee Cavalry, Vicksburg, Mississippi, February 20th, 1865. Bugler G. AV. Ashland, B, 12th Pennsylvania Volunteers, Sandy Hook, Alaryland, Alay 12th, 1864. Teamster C. Barachi, Indian Expedition, Fort Ridgely, Minnesota, May 31st, 1864. Private T. Barber, H, 118th New York Volunteers, Petersburg, Virginia, June 2d, 1865. Private D. Bon, C, 2d Missouri Artillery, Cape Girardeau, Missouri, December 20th, 1863. Private B. S. Boorman, G, 41st Ohio Volunteers, Nashville, Tennessee, December 13th, 1864. Private A\'. J. BroAvn, E, 14th Illinois Cavalry, Nashville, Tennessee, February 9th, 1865. B. Busa, Government Employ^, AA'ashington, D. C, February 17th, 1864. Recruit J. Cain, Merrill's Horse, St. Louis, Missouri, November 8th, 1864. Lieutenant H. D. Call, A, 76th NeAV York Volunteers, Georgetown, D. C, January 9th, 1864. Private J. Cantrell, Schofield Hussars, St. Louis, Missouri, December 8th, 1863. Private W. C. Carroll, B, 4th Tennessee Volunteers, Louisville, Kentucky, Alarch 30th, 1863. Private AI. Casey, L, 1st Illinois Artillery, New Creek, AA'est Virginia, November 10th, 1864. Private A. R. Chapman, C, 32d Massachusetts Volunteers, Washington, D. C, May 23d, 1865. Private J. Chase, G, 4th Michigan Cavalry, Nashville, Tennessee, Alarch 6th, 1864. Deserted. Private J. Christie, A, 18th NeAV York Cavalry, New Orleans, Louisiana, April 26th, 1865. Private W. M. Clare, G, 20th Missouri Regiment, Farmville, Va. Private H. AV. 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, AA'ashington, D. C, August llth, 1864. Recruit J. E. Cranfield, 63d New A'ork A'olunteers, Alexandria, A'irginia, Alay 8th, 1864. Private AV. Daly, A, 16th United States Infantry, Nashville, Tennessee, December 18th, 1865. Private AV. Danekas, E, llth Illinois A'olunteers, Alemphis, Tennes.ee, April 6th, 1865. Private L. L. Davis, C, 15th Ne^v Jersey Volunteers, AVashington, D. C, May llth, 1864. John Dugan, Government Employe, Quartermaster's Department, Nashville, Tennessee, November 28th, 1864. Private H. Dunham, I, 6th Missouri A'olunteers, Nashville, Tennessee, December 9th, 1864. 52 WOUNDS AND INJURIES OF THE HEAD, Corporal S. Eplar, C, 2d Minnesota Cavalry, Fort Ridgely, Alinnesota, April 13th, 1864. Private J. En-ay, A, 10th Alichigan A'olunteers, Knoxville. Tennessee, April 24th, 1864. Private A. C. EAving. C, 2-th Kentucky A'olunteers, Louisville, Kentucky. June 15th, 1865. Private C. FarnsAvorth, A, 3d Ohio Cavalry, Ncav Albany, Indiana, April 10th, 1864. Private J. Fitzgerald, 21st AA'isconsin A'olunteers. Nashville, Tennessee, November 2d, 1864. Private M. Flaherty, C, 49th Alissouri A'olunteers. St. Louis, Alissouri, November 17th, 1864. 1st Sergeant A. B. Francisco, F, 124th NeAV A'ork A'olunteers, Chester, Pennsylvania, May 30th, 1864. Corporal G. Gamble, A, 27th Pennsylvania A'olunteers, Nashville, Tennessee, May 13th, 1864. Private P. Gannon, K, 39th Alassachusetts A'olunteers. Boston, Massachusetts. Alay 9th, 1864. Sergeant J. X. Gilchrist, K, 5th Alabama Infantry, Richmond, A'irginia, June 4th. 1864. Corporal T. Gleason, E, 63d Ncav 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, AA'ashington, D. C, Alay 14th, 1864. Sergeant C. B. Hadley, B, 56th Massachusetts A'olunteers, Boston, Alassachusetts, April 21st, 1864. Private W. Hatsell, B, 6th Kentucky Regiment, Nashville, Tennessee, September 24th, 1863. Private H. Henning, E, 8th IoAva Cavalry, in action, Tuscaloosa, Alabama, April 3, 1865. Private J. M. Heevey, A, 56th Georgia Infantry, Nashville, Tennessee, February 16th, 1864. Private J. Hickey, D, 23d Maryland A'olunteers, Louisville, Kentucky, June 25th, 1865. Private E. B. Hieronymus, B, 7th Alissouri State Alilitia Cavalry, St. Louis, Alissouri, March 30th, 1865. Private AI. Higgins, L, 2d Alassachusetts Artillery, Portsmouth, A'irginia, July 1st, 1865. Private F. HoAve, G, 6th A'ermont A'olunteers. January 6th, 1865. Private J. Hudson, C, 2d United States Infantry, Elmira, New York, January 7th, 1865. Private J. Jenks, F, 51st NeAV York A'olunteers, Alexandria, A'irginia, April 23d, 1864. Private J. James, Unassigned Substitute, Elmira, New York, Alay 7th, 1865. Sergeant AV. A. Johnson, A, 15th Indiana Battery, Washington, D. C, February 17th, 1865. Private J. Kanally, K, 35th Indiana A'olunteers, 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 A'olunteers, Nashville, Tennessee, Alay 29th, 1864. A. Kruse, Contract Nurse, AA'ashington, D. C, May 15th, 1864. C< rporal T. Langley, E, 10th United States Colored Troops, Portsmouth, A'irginia, May 27th, 1865. Private A. J. Little. H, 5th Alissouri State Alilitia Cavalry, Rolla, Missouri, July 4th, 1864. Private J. S. Lockwood, A, 17th Connecticut A'olunteers, St. Augustine, Florida, June llth, 1864. Private J. McAldee, 2d Indiana Battery, Nashville, Tennessee, February 16th, 1865. Private B. McCarty, B, 21st Connecticut A'olunteers, Portsmouth, Virginia, May 5th, 1865. Private R. McCarty. B, 40th Alissouri Volunteers, St. Louis, Missouri, November 6th, 1864. Private C. McDonald, C, 19th Massachusetts Volunteers, in action, Wilderness, Virginia, May 6th, 1864. Private N. McEnroe, F, 2d New York A'olunteers, NeAvark, New Jersey, June 6th, 1864. Private P. AIcGevi, B, 10th Tennessee Volunteers, Nashville, Tennessee, November 6th, 1864. Private M. McKenney, I, 1st United States Artillery, Gettysburg, Pennsylvania, July 3,1863. Private C. McAIahon, I, 5th Missouri State Militia Cavalry, St. Louis, Alissouri, January 1st, 1865. Private P. Mahon, F, 20th Connecticut A'olunteers, Aquia Creek, Virginia, Alay 4th, 1863. Private F. Marrais, 7th Massachusetts Battery, New Orleans, Louisiana, March 18th. 1864. Private J. Marity, G, 1st Alichigan Engineers, Louisville, Kentucky, Alarch 15th, 1864. Private M. Miller, C, 2d Ohio Heavy Artillery, Bowling Green, Kentucky, October 22d, 1863. Private AA'. Alissor, G, 87th Illinois A'olunteers, St. Louis, Alissouri, December 18th, 1862. Deserted. Private S. AA'. Morgan, G, 1st Indiana Artillery, NeAV Orleans, Louisiana, January 8th, 1864. Private AA'. J. AIoAvry. K, llth Illinois Cavalry, A'icksburg, Alississippi, February 24th, 1864. Sergeant J. Alurphy, D, 2d Alaryland Cavalry, Annapolis, Alaryland, August 27th, 1863. Private M. Murray, C, 6th Ncav York Heavy Artillery, Washington. D. C, August lQth, 1864. Private J. F. Neal, F, 55th Kentucky A'olunteers, Louisville, Kentucky, May 26th, 1865. Private T. New-ell, D, 6th Kentucky Cavalry, Louisville, Kentucky, March 18th, 1864. Private J. O. Barker, H, 9th United States Colored Troops, Portsmouth, Virginia, Alay 27th. 1865. Private J. O'Hara, D, 2d Massachusetts Heavy Artilley, Boston, Alassachusetts, September 12th, 1865. Private W. Palmer, B, 26th A'irginia Infantry, June 17th, 1864. Sergeant A. M. Parmenter, E, 29th Alichigan A'olunteers, Louisville, Kentucky, October llth, 1864. W. Parker, Substitute, 16th Kentucky A'olunteers, Nasln-ille, Tennessee, December 9th, 1864. Deserted. Orderly Sergeant T. Pepper, United States Army, Covington, Kentucky, June 18th, 1865. Private AA'. H. Perry, K. 6th Illinois A'olunteers, Nashville, Tennessee, July 28th. 1865. Private J. M. Pierce, H, 6th Indiana A'olunteers, Chattanooga, Tennessee, November 25th, 1863. Private L. E. Porter, H, 109th NeAV York Volunteers, Baltimore, Alaryland, August 23d, 1864. Private J. Riley, 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, Ncav York, January 7th, 1865. Deserted. A. Rosa, Blacksmith, L, 1st Illinois Artillery, A'icksburg, Mississippi, May 29th, 1864. Private R. Scerter, G. 30th Indiana A'olunteers, Nashville, Tennessee, May 19th, 1864. FROM UNSPECIFIED CAUSES OTHER THAN GUNSHOT. 53 Private J. Scribner, D, llth Missouri Cavalry, St. Louis, Alissouri, December 28th, 1864. Corporal L. Seiper, E, 40th Missouri Volunteers, St. Louis, Missouri, November 7th, 1864. Private D. Smalhvood, C, 15th United States Colored Troops, Nashville, Tennessee, August 19th, 1865. First Lieutenant A. Smith, D, 51st NeAV York A'olunteers, Alexandria, A'irginia, May 18th, 1865. Recruit C. Smith, 14th New A'ork Artillery, Elmira, NeAV York, December 29th, 1863, Private D. Smith, D, 1st AA'isconsin Cavalry, Nashville, Tennessee, Alarch 9th, 1864. Private H. Smith, A, 68th New York A'olunteers, Nashville, Tennessee, December 16th, 1864. Private I. Smith, D, 31st Alaine Volunteers, Boston, Alassachusetts, April 18th, 1864. Private J. Smith, A, 9th NeAV A'ork A'olunteers, New York, July 20th, 1863. Deserted. Private J. Smith, B, 18th NeAV A'ork Cavalry, AA'ashington, D. C, February 14th, 1864. Deserted. Private J. Smith, C, 10th Tennessee Mounted Infantry, Nashville, Tennessee, Alay 4th, 1864. Private AA'. A. Smith, F, 1st Delaware A'olunteers, AA'ilderness, Virginia, May 5th, 1864. Private J. Spencer, A, 179th Ohio A'olunteers, Louisville, Kentucky, October 6th, 1864. Private T. Sullivan, F, 52d Illinois A'olunteers, Louisville, Kentucky, June 21st, 1865. Corporal J. Suter, E, 7th A'eteran Reserve Corps, Louisville, Kentucky, July 19th, 1864. Private J. Sutter, K, 1st Alichigan Cavalry, AA'ashington, D. C, March 2d, 1864. Private W. C. Sicanson, K. 12th North Carolina Infantry, Richmond, A'irginia, April 28th, 1863. Private E. Sweat, F, 93d NeAV York A'olunteers, AA'ilderness, A'irginia, Alay 5th, 1864. Private E. Taylor, F, 3d Ohio Cavalry, Nashville, Tennessee, June 8th, 1864. PriA-ate D. W. Ticks, C, 50th Georgia Regiment, Richmond, Virginia, June 5th, 1863 Private AA'. A'isser. G, 82d Illinois A'olunteers, Ballesville, Illinois, December 18th, 1862. Deserted. Private J. Walcott, I, 50th Ohio A'olunteers, Baltimore, Alaryland, February 4th, 1865. Corporal P. AA'alton, I, lilth Pennsylvania A'olunteers, Savannah, Georgia, February 1st, 1865. Corporal C. VA'illiams, M, 2d Alassachusetts A'olunteers, Worchester, West Virginia, January 23d, 1865. Private T. AA'ilson, M, 3d United States Cavalry, Little Rock, Arkansas, February 19th, 1866. Private H. Wolf, B, 9th NeAV York Cavalry, Washington, D. C, June 26th, 1865. Private G. B. Y'oung, B, 64th United States Colored Troops, Vicksburg, Alississippi, July 31st, 1865. The following are examples of graver injuries belonging to the foregoing category: Cask.—Private Frederick Burling, Co. D, 23d New York Volunteers, aged 21 years, received a severe injury of the head, at Upton's Hill, A'irginia. Deafness and partial paralysis ensued, and he was discharged from service on March 1st, 1862. Case.—Private O. B. Cook, Co. H, llth Vermont Volunteers, received a severe injury of the head, at Fairfax Court House, A'irginia, January 4th, 1863, and Avas discharged for disability, rated at one half, on March 24th, 1863. Surgeon A. T. WoodAvard, 14th A'ermont Volunteers, records the case. Case.—Private Milton CroAvell, Co. B, 84th Illinois Volunteers, received a contused wound of the head, in May, 1863, and was admitted to Gayoso Hospital, Alemphis, Tennessee, June 1st. Cerebral complications arose, and he died on June 5th, 1863. Surgeon D. AA'. Hartshorn, U. S. V., records the case. Case.—Private EdAvard 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. 0. Abbott, U. S. Army, the Medical Director of the Department of AA'ashington, Alarch 3d, 1863. The case is recorded by Assistant Surgeon J. H. AA'ithers, U. S. V. Case.—AA'. F. Kirkland, a recruit of the 16th New York Cavalry, aged 43 years, received a lacerated wound of the scalp in the frontal region, May 4th, 1864, and Avas admitted to Camden Street Hospital, Baltimore. Erysipelas of the scalp supervened, and was folloAved by meningeal inflammation. The patient died on May 13th, 1864. Surgeon Z. E. Bliss, U. S. V., records the case. Case.—Private Thomas Alorrissey, Co. A, 2d Vermont Volunteers, aged 26 years, was admitted to Lincoln Hospital, Washington, April, 1863, under the charge of Surgeon H. Bryant, U. S. Volunteers, on account of a contusion of the head. Symptoms of arachnitis were manifested; but the patient recovered partially, was transferred to a convalescent camp near Alexandria, on March 10th. He was discharged from service on March 20th, 1863. His mental faculties were much impaired. His disability was rated at two-thirds. Surgeon S. B. Hunt, U. S. V., records the case. Case.—Sergeant Richard M. Porter, 37th Alassachusetts A'olunteers, aged 28 years, received a contusion of the scalp, in July, 1864. He was admitted into Augur Hospital, and, on August 2d, he was transferred to the 3d Division Hospital, 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 Alounted Infantry, aged 50 years, received, in camp, near Green- ville, Louisiana, June 18th, 1864, a contused Avound of the scalp. On June 20th, he Avas transferred to University Hospital, New Orleans, and on December 21st, 1864, he was transferred to the Veteran Reserve Corps. The following are abstracts of cases of simple or compound fractures of the skull, produced by causes not specified, save that it is stated that they were not inflicted by gunshot: 54 WOUNDS AND INJURIES OF THE HEAD, FIG. 18.—Section of base of cranium show- ing- depressed fracture.—Spec. 4351, Sect. I, A. M. M. Case.—Private Robert Bibb, Co. E, 4th A'irginia Regiment, Avas admitted, Alarch 31st, 1864, into the hospital at the Old Capitol Prison, AVashington, Avith a simple fracture of the skull. He died, April 6th, 1866. Case—Private James Burns, Co. B, 39th Alassachusetts A'olunteers, aged 57 years, Avas admitted to Stanton Hospital, Washington^ on July 14th, 1863, with a fracture of the cranium. He Avas transferred to Satterlee Hospital, Philadelphia, on May 10th, Ail. and returned to duty October 18th, 1864. Surgeon I. I. Hayes, U. S. V., records the case. Case.—Private Peter Cahill, Co. C, 79th Ncav York Volunteers, aged 19 years, received an accidental compound fracture of the external table of the frontal bone, June 14th, 1865, 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 AV. H. Christ, Co. I, 126th Ohio A'olunteers, aged 24 years, Avas admitted to the base hospital, at City Point, A'irginia, 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 Pctn- Clofat, Co E, 2d Louisiana Regiment, was sent to the St. James Hospital, NeAV Orleans, on May 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, Ncav York Harbor, on January 21st, 1865. It Avas found that life Avas entirely extinct. There was a contused and lacerated Avound, three inches in length, behind the left ear, and a depressed fracture on the left side of the occipital. No clue Avhatever could be obtained as to the nature of the Aveapon by which the injury Avas inflicted; nor, indeed, could it be accurately determined whether it was due to a bloAV, or to a fall. At the autopsy, it Avas found that the medulla oblongata Avas torn aAvay almost completely from the pons A'arolii. There Avas 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 process of the right temporal. Assistant Surgeon P. S. Conner, U. S. Army, forAvarded to the Army Medical Museum the notes of the case, and a section of the skull, Avhich is represented in the accompanying Avood-cut, (Fig. 18.) Case.—Captain J. B. Forcum, Co. H, 4th North Carolina Infantry, received, at Gettysburg, July 1st, 1863, a simple fracture of the cranium. He Avas 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, Avas admitted to the Seminary Hospital, GeorgetOAvn, December llth, 1862, Avith 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 Alichigan Volunteers, aged 39 years, received a fracture of the right side of the frontal bone, on October 28th, 1864. He was treated at Huntsville, Alabama; Nashville, Tennessee ; Louisville, Kentucky ; and recovered, and Avas discharged from service, June 9th, 1865. Surgeon B. B. Breed, U. S. V., records the case. Case.—Sergeant R. W. Jones, 1st A'irginia Artillery, Avas 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 Avas transferred to Louisville, thence to Camp Dennison, Ohio, and recovered, and Avas returned to duty, January 7th, 1865. Surgeon J. E. Herbst, U. S. V., records the case. Case.—Private AndreAV Mader, Co. L, 3d Pennsylvania Artillery, received a simple fracture of the right parietal, December 13th, 1864. The line of fracture passed across the middle meningeal artery, Avhich Avas ruptured, and gave rise to a large extravasation of blood. He Avas admitted to Balfour Hospital, Portsmouth, Virginia, Avith 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 AA7. Morey, Co. E, 10th Alichigan Volunteers, aged 23 years, received a contused Avound on the left side of the head, at Tunnel Hill, Georgia, in April. 1864. 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. C ase.—Sergeant John Miller, Co. I, 2d Illinois Artillery, Avas admitted to Indianapolis Hospital, in September, 1862, with fracture of the skull. He died, September 17th, 1862. Surgeon J. S. Bobbs, Brigade Surgeon, U. S. V., records the case. Case.—Private Daniel AV. Nash, Co. F, 31st Ohio Volunteers, received a simple fracture of the skull, in February, 1863. He Avas admitted to Hospital No. 10, at Louis\Tille, Kentucky, and was discharged from service, February 28th, 1863. Acting Assi:-taut Surgeon E. O. BroAvn, records the case. FRACTURES FROM UNSPECIFIED CAUSER. 55 Case.—Teamster AA'ashington Odell, Co. I, 98th Illinois A'olunteers, received an injury of the skull in 1863. He Avas admitted to Camp Dennison Hospital, Ohio, and Avas discharged from service, on August 12th, 1863. Surgeon H. C. McAllister, 98th Illinois A'olunteers, records the case. Case.—Private Stephen E. Potts, New A'ork Marine Artillery, Avas admitted to Foster Hospital, NeAvberne, North Carolina, August 23d, 1862, Avith a simple fracture of the skull. He recovered, .and was discharged from service, December 13th, 1803. Case.—Private Dennis Quinn, Co. F, llth A'eteran Reserve Corps, received, in September, 1864, a simple fracture ofthe frontal bone, with a slight depression. He aa;is admitted to Judiciary Square Hospital, AA'ashington, on September 24th, and recovered, and returned to duty on October 8th, 1864. Assistant Surgeon P. C. Davis, U. S. A., records the case. Case.—Private AA'illiam Russell, 26th Ncav York Battery, was admitted to the St. James' Hospital, New Orleans, Louisiana, on March llth, 1863, Avith a simple fracture of the skull. He recovered, and Avas discharged from service, on May llth, 1863. Assistant Surgeon John Homans, U. S. A., records the case. Case.—PriA-ate J. 0. R------. Pennsylvania Artillery, aged 22 years, was admitted, on September 30th, 1864, to Jarvis Hospital, Baltimore, Maryland, in an inebriated condition, with a contusion of the left side ofthe face, and a small contused Avound over the left malar bone. No history of the cause or circumstances attending his accident could be ascertained. Cold applications Avere made to the head, and he Avas kept quiet in bed. No symptoms of grave cerebral mischief appeared until the evening of October 5th, Avhen he became noisily delirious. He became comatose, and died the folloAving morning. Sectiocada- veris tAventy-four hours after death. There Avas ecchymosis on the left side of the face; the left ramus of the loAver jaAV bore traces of an old gunshot fracture. There Avas also a gunshot fracture invohing the light 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 tAvo 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. There Avas also a clot at the posterior surface of the posterior lobe of the right hemisphere. The cerebral substance Avas softened at this point. There Avas effusion of serum over the pons A'arolii 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 FlG ip.._Fracture of the orbital plate of the of the frontal, fissuring the ethmoid, and the body of the sphenoid. The sphenoidal frontal, the ethmoid, and sphenoid.—Spec. 3440, ' „ . , , , , n , , . ,. . . Sect. I, A. M. M. fissure on the left side Avas 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, Avas admitted to the Seminary Hospital, GeorgetoAvn, D.C, January 8th, 1862, with a fracture of the skull. He died on January 12th, 1862. Surgeon Joseph R. Smith, U. S. A., records the case. Case.—Private J. M. Sharp, Co. F, 45th North Carolina Regiment, received a simple fracture ofthe zygoma ofthe right temporal, without injury to the cranial cavity. He was admitted to the Farmville Hospital, Virginia, on June 2d, 1864. He recoveied, and was furloughed on August 9th, 1864. 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 ofthe right side of the frontal bone, at New Market, Virginia, May 15th, 1864. He was transferred in June to Frederick, Maryland, and in October to Annapolis Junction, and thence to Satterlee Hospital, Philadelphia, and finally to Turner's Lane Hospital, Avhence he was discharged on March 16th, 1885, on account of confirmed epilepsy. Case.—Private Frederick Stapley, Co. E, 92d Illinois Volunteers, was admitted to Hospital No. 19, Nashville, Ten- nessee, on June 4th, 1863, on account of a simple fracture of the skull, according to the hospital register. If the diagnosis Avas correct, the case Avas unusually successful, since the patient returned to duty on June 18th, 1863. Surgeon John AV. Foye, U. S. V., records the case. Case.—Private Frank Treber, Co. D, 10th Tennessee Volunteers, aged-38 years, Avas admitted to Hospital No. 19, Nash- ville, Tennessee, on March 21st, 1865, with a simple depressed fracture of the os frontis. He Avas transferred to Cumberland Hospital on April 20th, and returned to duty, well, on April 29th, 1865. Surgeon B. Cloak, U. S. V., records the case. Reaioa'AL of Fragments.—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. R. Spalding, fell from the spar deck into the hold, on June 20th, 1863, a distance of tAventy-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 tAvo inches, Avas produced. On his admission to the military hospital at Beaufort, North Carolina, the man Avas pale, his pulse imperceptible, and he lay groaning occasionally, his lower limbs moving spasmodically. The trephine Avas applied, but the depressed portion of bone could not be raised by the elevator. A portion of the fractured skull was then removed by Hey's saAv; after which, the remaining portion was raised to jts normal position by the eleA-ator, and the periosteum, Avhich had been carefully preserved, was brought back over the solution 56 WOUNDS AND INJURIES OF THE HEAD, of continuity of the bone. The wound Avas then dressed with cold water. The after treatment was of stimulant and tonic description, Avith careful attention to the boAvels, and occasional opiates. At the date of the report, fifteen days after the operation, the patient was AAalking about the Avard. The avouikI of the scalp was united and the small portion over the trephined part Avas healing by granulation. The case appears on the monthly report of Beaufort Hospital, North Carolina, signed by Surgeon F. S. Ainsworth, U. S. V. Case.—Private EdAvard Connors, Co. A, 9th Illinois Cavalry, aged 22 years, received in a street fight, Alarch 22d, 1864, a Woav from a stone, which struck the left side of the forehead. He was admitted into the LaAvson Hospital at St. Louis, Missouri, on the same day. There was an external Avound three inches in length, a depressed fracture involving both tables of the skull. Several small spiculae of bone Avere 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 Avas administered and low diet Avas prescribed, with cold water applications to his head. His general condition at this time was good; the pulse Avas 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 ofthe brain were manifested: the symptoms of compression, perhaps, predominating. On the folloAving 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 Avas made on the folloAving day. The external table of the frontal bone shoAved the loss of a fragment of the size of a quarter of a dollar. A fissure extended backAvards 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 Avas softened, but to an inconsiderable degree. The specimen Avas preserved, but was not forwarded to the Army Medical Aluseum. 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 NeAV York Volunteers, aged 22 years, was admitted, on January 12th, 1865, to St. Louis Hospital, NeAV Orleans, Louisiana, with tAventy other wounded men, injured on the occasion ofthe collision between the United States transport J. H. Dickey, and John Rain, on the Mississippi River, fifteen miles below Vicksburg, on January 9th, 1S65. Private Hatch Avas found to be still laboring under the effects of concussion of the brain. He had received a violent bloAV, causing a wound of the scalp and fracture of the skull. Symptoms of injury to the brain persisting, the wound in the scalp Avas 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, 1865, and from the hospital register, signed by Surgeon A. McMahon, U. S. V. Case.—Private Jonathan Leet, Co. M, 22d Pennsylvania Cavalry, aged 18 years, received, on April 4th, 1865, a com- minuted fracture of the cranium, by a blow from a glass bottle. He Avas admitted to hospital, at Cumberland, Maryland, on Alay 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. LeAvis, U. S. V., records the case. Cask.—Private Conrad Murphy, Co. E, 17th Kentucky Volunteers, Avas confined for misconduct in the guard-house, on February 15th, 1863. He Avas insubordinate, and the sentinel struck him on the head Avith the butt of a musket, with such A-iolence as to fracture the frontal bone. Murphy Avas 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 Avas made at the seat of injury, and the depressed bone was elevated, and detached spiculae were removed, but the grave symptoms Avere not modified, and death took place on February 18th, 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 upon the brain. Case.—Private------, 149th NeAV York Volunteers, received at Stevenson, Alabama, January 29th, 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 Ncav York Volunteers, ascertained that there was a fracture of the frontal bone over the right frontal sinus, Avith depression of the vitreous table. The patient had repeated convulsions and in the intervals Avas 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 Avas reported as doing well in February, the symptoms of compression being Fig. 20.—Four fragments removed from the entirely relieved, but it has been impracticable to learn the ultimate result of the case. rip-ht side of the fron'tal bone fractured by a The fragments of bone removed are represented in the adjoining wood-cut, (Fig. 20,) blow from a bottle; natural size. Spec. 2210, . r J 6 > \ '' Sect. I, A. M. M. and comprise about half a square inch of the inner table, and a somewhat larger portion of the external table. Case.—Private Charles A'. Orton, Co. L, 1st Tennessee Cavalry, in an engagement at Shoal Creek, Alabama, October 19th, 1864, received a Avound 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, Avhich produced a compound fracture of the frontal bone. The regimental surgeon, Dr. W. F. Green, reports that several fragments of bone Avere 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 Avas subsequently sent to the AA'est End Hospital, at Cincinnati, Ohio, and was discharged from service, on Alay 2d, 1865, for disability rated at three-fourths. He Avas alloAved a pension of six dollars per month from this date, and Commissioner H. Van Aernam states that he drew his pension on March 4th, 1869; but that the particulars of his condition at that time Avere not reported. REMOVAL OF FRAGMENTS AND TREPHINING. 57 Case.—At Antietam, Maryland, September 17th, 1862, a soldier, employed in entrenching, struck another, on the left side of his head, with the edge of a spade. The Avounded man fell, badly stunned, and, on examination, it was found that the Woav 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 Avith stertor, and had a slow pulse, dilated pupils, and the other signs of compression ofthe brain. The scalp was shaved, and an incision Avas made, through which a number of fragments of detached bone were removed. The patient lingered, in a state of stupor, until November 8th, 1802. 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. Ilascall, Co. C, 61st New A'ork Volunteers. The fracture extends downwards from the sagittal suture three inches, and it is an inch wide at its loAvest 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 Avood-cut, (Fig. 21.) The contour ofthe aperture in the bone represents, with exactness, the outline of the edge of the spade. The specimen was forwarded to the Army Medical Museum Fig. 21.—Segment of right fey Surgeon Vanderkieft, by Hospital SteAvard A. Schafhirt, U. S. A. The latter states that a from a blow from a spade.— detailed history accompanied ihe specimen. A careful search has failed to discover this paper, and Spec. 712, Sect. I, A. M. M. ^e registers of the Museum contain no indication of its reception. Trephining.—The folloAving eighteen abstracts of cases of fracture of the skull from various causes, other than gunshot injury, refer.to instances in which the trephine was formally applied: Case.—Private Joseph Burns, Co. C, 4th Kentucky Cavalry, aged 23 years, was struck on the head at 8 o'clock P. M., February 22d, 1864, by a slung shot, AA-hich produced a fracture ofthe skull, extending from the ATertex to the left orbit, through the parietal, frontal, and the great Aving of the sphenoid. The patient was taken to Clay Hospital, at Louisville, Kentucky, on the evening of the accident, Avith symptoms of grave compression of the brain. During the night he had frequent convulsions. Early the following 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, 1864. Surgeon Alexander T. Watson, U. S. V., records the case. Case.—Private Patrick H. Green, Co. H, 125th NeAV York Volunteers, while on furlough, received a blow on the left side ofthe 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 Avas found to be a depressed fracture of the skull. The scalp Avas laid open by an incision, and trephining was performed, and the depressed portions of bone Avere removed. The scalp wound was united by sutures, and a compress of cloths wet with tepid water were 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, Virginia, on September 27th, 1^63. in a comatose condition, with a wound on the right side of his head. He was conveyed to the New HalloAvell 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 was fractured and depressed. A crucial incision was made through the scalp, and the cranium being, freely exposed, it A\as found that the fracture Avas much more extensive than had been supposed. A disk of bone Avas removed by the trephine, and several detached pieces were removed by the elevator, so that, altogether, a portion four inches in length by tAvo 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 Avere very remarkable. In less than three minutes after the removal of the de- Fig. 22.—Section of cranium with great loss of sub- J j j i stance from the removal of depressed fragments.—Spec pressed fragments, the patient opened his eyes, and appeared to ayvake to 2673. Sect. I, A. M. M. 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, he was reported to have had no bad symptom and he complained of nothing but hunger. The sutures had been removed, and the greater portion of the incision had united by first intention. He Avas now allowed the "extra diet" of the hospital, consisting of oyster broth, rice pudding, and the like. On October 20th, the patient was up and about the ward. No untoAvard symptoms had intervened meanwhile, and the treatment had been unchanged. At this date the patient was put on "half diet," and the nearly cicatrized wound was dressed with simple cerate. He continued to do well until November 26th when he Avas visited by his brother, who brought him some bad news from home which disturbed him very much, and he immediately Avent to bed and became stupid and sullen, taking no notice of anything. Is it not possible that his brother brought 8 .YS WOUNDS AND INJURIES OF THE HEAD, him some stimulant as well? On October 27th the patient had become comatose, with every sign of compression of the brain, and on October 28th, 1863, he died. At the autopsy, twenty hours after death, there was found to be an abscess in the right hemisphere and the neighboring brain substance Avas softened. The thoracic and abdominal viscera Avere healthy. The edires of the aperture were found to be rounded off and in process of repair. The notes from Avhich the abstract is compiled Avere made by Acting Assistant Surgeon S. B. AVard, and the specimen Avas forAvarded to the Army Aledical Aluseum by Surgeon E. Bentley, U. S. A'. It is represented in the Avood-cut (Fig. 22) on the preceding page. Case.—Private John T. Jenkins, 5th Alabama Regiment, Avas received into a regimental hospital at Union Alills, Fluvanna county, A'irginia, in October, 1861, suffering from compression of the brain, produced by a Woav. The skull Avas extensively fractured. Trephining Avas 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. A'enable, C. S. A., and no further particulars can be obtained. Case.—Private AVilliam H. Low-ery, Co. C, 6th Tennessee Cavalry, aged 22 years, was wounded in an affray at Alem- phis, Tennessee, October 3d, 1864, 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 Avas 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 Brey 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 were applied to the Avound. The patient was 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 intercurrent attack of pneumonia supervened. On November 3d, there Avere signs of cerebral hernia. Protrusion ofthe cerebral substance progressed so rapidly, that on November 6th it was 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, 1864. Surgeon F. N. Burke, U. S. A'., furnished the notes of the case. Case.—Private E. Aliller, Co. G, 6th A'irginia Cavalry, aged 17 years, was wounded, in a railroad collision on the Ohio and Mississippi Railroad, near Carlisle, Illinois, June 21st, 1865. He was taken to UlinoistoAvn, under the care of his regimental surgeon, Dr. A. H. Thayer, and Avas thence sent to the Alarine Hospital, St. Louis, Missouri, where a depressed fracture of the cranium A\ras diagnosticated. Assistant Surgeon E. AI. Horton, U. S. Army, decided that the symptoms of compression of the brain demanded an operation, and applied the trephine, and removed 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.—Private Sumner H. Needham, Co. I, 6th Alassachusetts Alilitia, on April 19th, 1861, during the attack upon his regiment, by riotous insurgents in Baltimore, Alaryland, was struck on the forehead by a brick, which fractured the frontal bone. He aa as conveyed to the Baltimore University, AA-here his wound was examined by Dr. AA'illiam A. Hammond, who found symptoms of compression of the brain demanding the application of the trephine. The operation was immediately performed by Dr. Hammond, but the symptoms were not relieved, and the patient died iu a few hours, April 19th, 1861. Air. Needham, a resident of Lawrence, Alassachusetts, Avas one of the earliest victims of the rebellion.* Case.—A negro, Avhose name was unknoAvn, was brought into the E Street Infirmary, AVashington, D. C, with well marked symptoms of compression of the brain, in the latter part of February, 1864. He was examined by Assistant Surgeon J. AA'. S. Gouley, U. S. A., Avho found a wound over the right parietal pro- tuberance, caused apparently by a Moav from the head of an axe. The scalp Avas shaved, and it was found that there Avas a depressed fracture of both tables of the skull, Avith detachment of a large fragment. It was not practicable to insert the elevator to raise the depressed fragment; to alloAV this to be done, a disk of bone Avas removed by the trephine. A triangular fragment, measuring an inch by one and a quarter inches, was then removed and the flaps of the scalp Avere approximated. The symptoms of compression Avere relieved, and the patient Avas doing well three days subsequently, Avhen the specimen, rep- resented in the adjacent wood-cut, (Fig. 23), Avas forwarded to the Army Aledical Aluseum. The facts above noted are taken from a minute, made upon ^^ifP the reception^ of the specimen, by Surgeon John H. Brinton, U. S. V. It has FlG. ^l^isk and fragment of bone removed for been impracticable to learn the ultimate result of the case; but a letter from depressed fracture from a blow.—Spec. 2081, Sect. I, the late Assistant Surgeon T. G. Alackenzie, U. S. A., dated Alarch 25th, 1864, A' M" M' 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 without the supervention of cerebral hernia, and without loss or apparent impairment of the mental faculties. Case.—A. B. Parish. Quartermaster's Department, received a lacerated Avound of the frontal region, with fracture and depression of the frontal bone, by a kick from a horse, near Natchez, Mississippi, September 13th, 1-64. 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 elevator. The patient soon reacted. Tonics, stimulants, and Ioav diet, were ordered. The patient gradually improved, and Avas discharged from the hospital, entirely cured, on October 13, 1865. 'Record of the Massachusetts A'olunteers, 1861-1865. Published by the Adjutant General, under a Resolve ofthe General Court. Quarto. Boston, lso'8, pp. 793. Vol. I, p. 34. TREPHINING. 59 Case.—Private P------, 14th Tennessee Confederate Infantry, aged 25 years, small in stature, but muscular, received, in a quarrel, a Avound on the anterior portion of the parietal bone, from a stone held in the clenched fist of his adversary. He was stunned by the bloAV. 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 Avas soon relieved of this complication; but in a feAV Aveeks, became subject to epileptic paroxysms, which recurred every four or five days. He Avas discharged for disability, and went to his home, at Springfield, Tennessee. Convulsions recurred with such frequency and violence that he Avent to Nashville in May, 1862, to be treated by Dr. YA'. T. Hriggs, of the medical school in that city. His general health Avas poor, the countenance pale, the bowels torpid, the pulse quick and irritable. A depression of the skull corresponded with the cicatrix of the original Avound. There Avas 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. BoAvling and Buchanan, removed a disk of bone Avith the croAvn 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 av;is no recurrence of the convulsions. He reentered the Confederate service, as a so-called "Partizan Ranger," and .was captured and sentenced to be hung, but escaped before the sentence Avas 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 Eogers, Battery L, 4th Ohio Artillery, was struck on the head by a stone on May 3d, 1865, receiving a depressed fracture of the skull. He Avas admitted to the hospital at NeAV Creek, Virginia, on May 7th, in a comatose state. He remained in this condition until Alay 9th, Avhen he A\as placed under the influence of ether, and Assistant Surgeon S. AI. Finley, 22d Pennsylvania Cavalry, applied the trephine and elevated the depressed bone. The patient reacted well, and simple dressings were applied. Erysipelas supervened, but Avas successfully combatted by chloride of iron. The patient improved rapidly, the Avound Avas 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 throAvn at him. He was admitted to Armory Square Hospital, Wash- ington, D. C, on the following day. He Avas perfectly conscious, yet had marked contraction of the pupils, with accelerated pulse, and a tremulous voice. There Avas considerable ecchymosis about the orbits. The first Avound examined was over the frontal eminence, and penetrated no further than the aponeurosis of the occipito-frontalis 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 likeAvise was a scalp Avound. The fourth Avas on the right parietal eminence; and, upon a close examination, it Avas 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 Avas 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, Avhich 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 Avas uninjured The Avound Avas 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 anaes- thetic, and Avas put to bed and ordered to observe perfect quiet and strict diet. The case proceeded Avithout an unfavorable 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 patholosi- „.„ „.,-,. , ,. . . . v. , ., , r J e > r e> FIG. 24.—External and internal views of a button of cal specimen was presented to the Army Aledical Museum by the operator, and bone removed for a depressed fracture by a blow from is represented in Photograph No. 87 of the Surgical Section of the Army Medical a s one'— pec' "• ..... 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, 1865, 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. Case.—Private James C. Shedd, Co. D, llth NeAV York Cavalry, aged 19 years, Avas throAvn from his horse to the pavement, while riding through the streets of NeAV Orleans, Louisiana, April 10th, 1864. There was a compound comminuted fracture of the cranium, confined principally to the external table, which Avas depressed about an inch and a half in length and half an 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 efforts. Shortly after admission he was placed under the influence of chloroform. Surgeon Samuel Kneeland, U. S. V., then enlarged the Avound of the scalp, Avhich was found much torn and bruised, and trephined the skull at the anterior portion of the right parietal region, removing several pieces of bone and elevating others. Cold water Avas applied to the Avound, rest and quiet enjoined, and light diet ordered. The case progressed favorably, with very little cerebral disturbance, and on the 10th of June, 1864, the patient was discharged from the service, as a long time Avould be necessary for the exfoliation of the bone, extensively denuded of periosteum. His general health and strength Avere excellent. Case.—Jesse Smith, Freedman, aged 18 years, employed as a cattle driver, rolled off, 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 he revived, and Avas carried to the Freedmen's Hospital, at Alexandria, Virginia. Acting Assistant Surgeon Robert N. Atwood, found a wound of the scalp 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 Journal of Medicine and Surgery, New Series, 1866, Vol. I, p. 35. 60 WOUNDS AND INJURIES OF THE HEAD, Fig. 25.—Disk and depressed fragment of bone from right parietal.—Spec. 4817, Sect. I, A. M. M. patient Avas comfortable, sensibility being restored, and the mental faculties being apparently normal, Dr. Atwood decided to aAvait further developments. No decidedly bad cerebral symptoms appeared for tAvelve days after the injury, when the patient complained of increased headache, and a feAV hours subsequently had a severe convulsion. On the folloAving day, the patient was much the same as usual, except that his headache was increased. Dr. Atwood, in consultation with Acting Assistant Surgeon A. AV. K. Andrews, decided to operate, and ether having been administered, enlarged the original wound and applied the trephine, and removed a button of bone to which the greater portion of the depressed fragments Avere united by the inner table. On removing the bone, pus gushed out copiously. At the upper posterior part of the perforation the inner table Avas 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, Avas highly excited, restless, and 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, which he craved earnestly. He also had vinegar and water to drink. In three days after the operation the brain commenced to 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 Avas 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 death, but he gradually rallied, and strange to say, after the subsidence of the convulsions he had no more pain in his head. His bowels had been regular throughout his illness, and he had taken no medicine except the morphia, Avhich 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 A\ithout any impairment of his mental faculties or motor powers. Several months after his recovery he was brought to the Army Aledical 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, (Fig. 25.) Case.—Private W. H. South, Co. H, 168th Pennsylvania Volunteers, while quartered in a house, at Washington, North Carolina, fell down stairs, May 13th, 1863, and struck upon the left side of his head. The medical officer of the garrison, Assistant 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 the left temporal, and a third extending 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 compression of the brain existed. Dr. Hubon applied tbe 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 May, 1863. Case.—Private Charles E. Towns, Co. I, 9th 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 he 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 knoAvn are derived from the report of the Corps Hospital. On the 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, 1st NeAV York Volunteers. The date and other particulars are wanting. The patient died, February 20th, 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 Orleans, Louisiana, January 12th, 1865, with an extensive fracture of the cranium and compression of the brain, caused by a bloAV received in a steamboat collision, January 9th, 1865, between fhe U. S. Transport J. H. Dickey and the Transport John Rain, on the Alississippi River, fifteen miles below Vicksburg. The trephine was applied and a portion of depressed bone was elevated, and another portion was removed. The patient died on January 18th, 1865. 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, 1862, at GeorgetoAvn, 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 fragments of the internal table imvard, penetrating the dura mater and rupturing the middle meningeal artery. He was seen by Acting Assistant Surgeon John S. Billings, Bix hours after the reception of the injury. He was comatose, and presented the usual signs of compression of the brain from depressed fracture. Dr. BillingB applied the trephine and removed the depressed fragments, and also about two ounces of coagulated blood. The patient immediately came to his senses, and did well for four days, when symptoms of cerebro-meningitis set in. The patient was then transferred to the Union Hotel Hospital. Active treatment Avas unavail- ing, and death followed in two days, or on Alarch 2d, 1862. The autopsy showed effusion of lymph over the Avhole of the right hemisphere of the cerebrum. A portion of the cranium, showing the extent of bone removed, was contributed, Avith a memorandum of the case, to the Army Medical Aluseum by Dr. Billings. Fig. 26.—Section of the cranium trephined for It is represented in the adjacent wood cut (Fig 26 ") depressed fracture from the kick of a horse.—Spec. ' v "' 3453, Sect. I, A. M. M. ANALYTICAL REVIEW. 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 Avithout 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 hemorrhage, 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, tAvo 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 men transferred to modified duty in the Veteran Reserve Corps, are included Avith those returned to duty, and the furloughed men, not heard from, and the deserters, with those discharged. 62 WOUNDS AND INJURIES- 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 com- plications ; 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, tAventy-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 casesfthe 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 tAVenty-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. TAventy-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 discharged 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.^ 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 Hennen1 and bchmucker, 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 treatment were sometimes employed. In a few cases, the bad practice ot 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 0f AViggins, on page 50, should have been recorded as fatal. He died on April 14th, 1865. t AI ready referred to among the fifty-two fractures. sureeons^admTtW M* "f ^T' ^^ C,'Dtusions in four degrees, (Lecons Orales, T. IV, p. 267;) but even the French p 3" Par" 1 69 " ***"* " " "» **" "*'**"-W See Folli*, Tral de Pathologic Externe, T. I, ■ Hknxkx. Principles of Military Surgery, 3d ed., London, 1829, p. 283. . c hmi (ker, J. L. Chirurgische Wahrmhmungen. 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 appli- cation of warm water dressings. Though complicated, in a few instances, by erysipelas and sloughing, 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 Avith the occipito-frontalis aponeurosis, producing that remarkable condition in Avhich, 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 circum- ference and soft and depressible in the centre, were more frequently observed over the lateral regions of the skull. Fortunately, there were no symptoms 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,1 of suddenly 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, Avas 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 Avhich 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 cicatrization 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 feAV 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 ha\'e 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 integu- ment, 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 bloAVS 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 Avhich 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 in cold water, and maintained by a 1 Archives Generates de Medecine, Premiere Serie, 1827, T. XV, p. 139. 61 WOUNDS AND INJURIES OF THE HEAD, bandace. In some instances, layers of raw cotton, charpie, or picked oakum, were arranged as graduated compresses upon the flaps. A few surgeons preferred to apply poultices or Avarm Avater dressings, if the scalp was much mangled. In all of the cases of detachment of large flaps, it would appear that the pericranium 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 theemployment 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 considered 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 ordi- nary 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 Avound open, Avas generally 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 commonly 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 haemorrhage Avas controlled by compression, either by the clamp tourni- quet, or the common tourniquet, or by a circular bandage and compress, or by a com- press consisting 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 Avas 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 stimulating 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 solu- tions, appears to have been the ordinary treatment In many of the contused and lacerated * Compound Tincture of Benzoin, or Baume du Commandeur, or Teinture balsamique of the French Codex. ANALYTICAL REVIEW. 65 wounds, there was slight loss of tissue from gangrene, and in two cases, very large portions of the scalp sloughed away, yet the exposed surface was soon covered with florid granu- lations, 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 be 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-tAvo 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 xeturn to modified duty after protracted disability. But concus- sion 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 Avas attended by profound insensibility and collapse and appeared, at first, to be ATery 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 stimu- lating 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 ofnciousness 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, complications 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 (')() WOUNDS AND INJURIES OF THE IIHAD, been 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 tabic: * Table I. Cases of Concussion or Compression of the Brain, generally from Causes other than Gunshot, recorded on the Monthly Reports during the War. 1 Yea u. May and June,! 1*61. ; Year ending Juue 30,1862. Year ending Tune 30.1863. Year ending Tunc 30,1864. 622,058 55,710 Year ending | I tine 30,186)5. Agckk LATE. AA'iini: Tkoops. Mean strength in field and Garrison.. 41,556 279,590 9*548 630,761 45,630 574,022 : 71,484 515, 517 45,593 Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. Cases. 193 Deaths. 60 Cases. Deaths. 873 193 61 17 66,340 3,397 7 ...... 144 19 295 62 234 a Compression of Brain............... 1 60 17 1 Coi.oiiKD Tuoors. 46, 020 1,222 86,660 5,572 ! Cases. Deaths. Cases. Deaths Cases. Deaths. . 18 9 31 49 22 1 i 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, Avhen the concussions from gunshot injury may be supposed to have been generally excluded, there was one case of concussion in a mean strength of 2,292. and a mortality of one in 4.7 cases. In the third complete year there was, among the Avhite 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 H. 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 640 of the medical volume of the First Part of the Medical and Sur_-ical History ofthe Rebellion. The consolidations for the colored troops are furnished me in manuscript by Brevet Lieut. Col. J. J. AVoodward, Assistant Surgeon U. S. A. After 1862, "compression of the brain'' Avas excluded from the nomencla- ture of the montlily ivport of sick and wounded. The deaths are understood to be included among the cases: e. g. of 144 patients with concussion of the brain, during the year ending June 30, 1862, 19 died. ANALYTICAL 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, C. 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 Avriters on military surgery, the compilers of the official manual1 advise, in the early treatment of concussion, the use of external warmth, frictions, and diffu- sible stimuli; Surgeon J. J. Chisolm2, 0. 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,3 with strange confusion, "in order that the pathological difference between con- cussion and compression of the brain may be thoroughly comprehended," ascribes to concussion 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 Avere instances of simple and forty-three of compound 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 cases4; shock and concussion, in two cases; extravasation of blood, in sixteen cases; encephalitis, in ten cases; abscess of the brain, in six cases; epilepsy, 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 from 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; imperfect 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 completely, that twenty-nine recovered partially, and that fifty-seven died. 1 A Manual of Military Surgery, prepared for the Use of the Confederate States Army, by Order of the Surgeon General. Richmond, 1863, p, 7. 2 Chisolm. A Manual of Military Surgery for the Use of Surgeons of the Confederate States Army. Columbia, S. C, 1864, p. 27,'). 3 Warren. An Epitome of Practical Surgery for Field and Hospital. Richmond, 1863, p. 351. 4 In one of the cases of laceration of the brain (AIichael B----, p. 44) there was cerebral hernia, as Avell as in the case of Lowkky (p. 58), cited two lines further on. In the latter, this complication was apparently, 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 exception of the case of Pri- vate 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 reception of the injury, present forty-six deaths, three instances of faArorable progress a few Aveeks after the injury with the ultimate results undetermined, and three examples of complete, and six of partial recovery. In the nineteen remaining cases cerebral compli- cations appeared at a later date:L ten of the nineteen were fatal; eight ended in permanent disabilities, 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. Rkgions. Cases. Died. Disch'd. Duty. Unkn'n. Per cent. of deaths. 22 33 7 2 11 1 1 1 27 105 10 15 6 2 11 6 12 1 5 4 1 2 47.6 48.4 85.7 100. 100. 100. 100. 40.7 55.8 1 1 1 11 57 9 7 4 Total.......................................... 28 17 3 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. 54), 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 frac- 1 At incipere febrem in capitis vulnere, quarta die aut septima aut undecima, valde lethale est. Hippocrates De Prcedict Lib. II, Sect. II. Cap. 10. ANALYTICAL REVIEW. 69 tures has been overestimated by Sir Astley Cooper1 and other eminent surgical writers. In rare instances, bWs upon the mastoid or zygomatic processes, or frontal sinuses, pro- duce such an injury; but, over the vault of the cranium, a depression of the outer table upon the diploe, without lesion of the vitreous lamina, is oftener described in books than demonstrated by pathological preparations.2 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 dis- cussion among surgeons thirty years ago, and which is held to be a positive indication of fissure of the petrous bone.3 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 and 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, lacera- tion, and compression of the brain, of rupture of the meningeal arteries, of cerebral irri- tation, 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 con- clusion of this Chapter. 1 Astley Cooper. Lectures on Surgery, London, 1842, p. 130, 2 Specimen 4853, Section I, A. AI. AI., represents a segment ofthe frontal bone of a young man who received a Woav from 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 Avas revealed. The large collec- tion of specimens of fractures of the skull in the Army Medical Museum fails to afford a single example of fracture of the outer table singly, if the groovings by shell fragments and incisions by cutting weapons are excluded. 3 Berengarius, in bis work on Fractures of the Cranium, published at Bologna, in 1518. first called attention to this phenomenon, and Stalpart Van der Weil, (Obs. rarior. cent, prima, Obs. XV, Leyden, 17:28, 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. ' * Grima, Sur Les Contre-coups dans les Lesions de la Tite. M6moires sur les Sujets proposes pour les Prix de l'Academie Royale de Chirurgie. Paris, 1819, T. IV, p. 207; Saucerotte, in the same Avork, Vol. IV, p. 290. Sabotjraut, 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 ofthe 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.—The 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 III. Results of Seven Thousand Seven Hundred and Thirty-nine Cases of Gunshot Wounds of the Scalp reported during the War of the Rebellion. Patients. U.S. Officers.................. U. S. Enlisted Men (white)...... U. S. Enlisted Men (colored)--- Citizen Employes, U. S........ Confederate Officers........... Confederate Enlisted Men...... 11 167 126 ' 3108 I 7 75 1 4 ....., 1 17 65 'n - - "• 10 10 127 97 ( 35 ...J 542 .... 13 ?. -= \ rz .-e-s 1 _: c a> 7" tc ^ £ c CXj ^ r^ ^ ' £i ' ~ " j 76 261 1427 4 i 26 5 3 118 Total................... 162 3420 L 1561 6 6 108 10 958 11 5 8 114 337 6625 138 10 j 251 604 10 10 97 593 201 275 1609 8 114 10 1103 >i 7739 * The inference from the records is that these ten officers were not dismissed dishonorably, but were stricken from the rolls for failing to comply Avith orders to report their condition Avhile on leave of absence. GUNSHOT WOUNDS OF THE SCALP. 71 The following fifty-four fatal cases of gunshot Avounds of the scalp are reported as uncomplicated. In every instance, the most careful scrutiny has been exercised to determine if any injury of the cranium, or its contents, was suspected by the surgical attendants: Case.—Private Thomas Armstrong, Co. D, 2d Maryland Volunteers, aged 48 years, received a flesh wound of the head, in an engagement before Petersburg, Virginia, July 2, 1864, from a conoidal ball. 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, Ncav York, Avhere he arrived on July 6th. He died on the 14th of July, 1864. Case.—PriA-ate James Barry, Co. 1), 2d NeAV A'ork Alounted Rifles, aged 30 years, received, in an engagement before Petersburg, A'irginia, June 18, 1861, gunshot flesh wounds of the head and arm. He Avas admitted to the hospital ofthe Second Division, Eighteenth Corps, and, on June 19th, was sent to the First Division Hospital at Annapolis, 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 A'ork Arolunteers, was struck, at the battle of Cold Harbor, Virginia, June 3d. 1864, by a fragment of shell, which caused a flesh Avound ofthe bead. He was admitted, on June 8th, to the Columbian Hospital, AA'ashington, D. C, where simple dressings Avere applied. Death occurred on June 12th, 1864. Case.—Private Horace BelloAA'S, Co. G, 98th NeAV A'ork Volunteers, aged 34 years, was wounded, in an engagement at Chapin's Farm, Virginia, September 19th, 1864, by a conoidal ball, Avhich severely injured the scalp over the right side of head. He was admitted to the hospital of the First Division, Eighteenth Corps. On October 2d, he Avas transferred to the hospital at Fort Alonroe, A'irginia, and on October 15th, to the White Hall Hospital, near Bristol, Pennsylvania. He died on October 20th, 1864. Assistant Surgeon AV. H. Forwood, U. 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 ofthe head. He was admitted to the hospital ofthe Second Division, TAventieth Corps, and, on June 2d, was transferred to the hospital at Chattanooga; thence, on June llth, to Hospital No. 1, Nashville, Tennessee, Avhere he died, on June 15th, 1864, from the effects of the wound. Case.—Corporal AA'm. G. Carr, Co. G, 13th NeAV Hampshire Volunteers, aged 40 years, received, in a skirmish, on Alay 13th, 1864, a woupd of the scalp, from a fragment of shell striking over the left eye, and making a ragged wound an inch and a half in length. He Avas sent to the hospital at Point Lookout, Alaryland, and died on June 22d, 1864. Case.—Private Frank Carter, Co. F, 17th NeAV 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 Avas, 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 Avas dressed Avith dry lint, sprinkled Avith opium. The patient died July 7th, 1864. Case.—Lieutenant John R. 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 was admitted to the field hospital of the First Division, Twelfth Corps. He died on Alay 22d, 1863. Surgeon A. Chapel, U. S. V., recorded the case. Case.—Private Jackson Clifton, Co. D, 107th Illinois A'olunteers, aged 22 years, received, at the battle of Franklin, Tennessee, November 29th, 1864, a shell Avound ofthe right side of the scalp. He Avas admitted, on December 1st, to Hospital No. 3, Nashville, Tennessee, where simple dressings were applied. On December 2d, he was transferred to the Jefferson Hospital, Jeffersonville, Indiana, Avhere he died, o.n December 17th, 1864, from the "effects of Avound.'' Case.—Private AA7illiam Coakley,'Co. K, 28th Massachusetts Volunteers, aged 40 years, received, in an engagement before Petersburg, A'irginia, 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 Avound. The patient died on June 28th, 1861. Case.—Private Stephen Colledge, Co. E, 2d Pennsylvania Artillery, aged 33 years, received, in an engagement before Petersburg, Virginia, June 18th, 1864, a gunshot wound of the right side of the scalp. He 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, Avhere he died on July 17th, 1864. Assistant Surgeon E. McClellan, U. S. A., records the case. Case.—Private Martin Cornell, Co. N, 7th Rhode Island Volunteers, aged 33 years, received, at the battle of Spott- sylvania Court House, Alrginia, May 12th, 1864, a gunshot wound of the integuments ofthe 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 Harewood Hospital, Washington, D. C, and, on May 18th, was transferred to the First Division Hospital, Annapolis, Maryland, where he died, on June 1st, 1864 The 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, 1864, by a fragment of shell, which caused a flesh Avound of the head. He was admitted to the hospital of the Third Division, Second Corps, and thence, on the 21st, conveyed to Washington, D. C, to the Lincoln Hospital. On the 27th, he was sent to Cony Hospital, at Augusta, Maine. Death occurred on August 12th, 1864. Surgeon G. Derby, U. S. V., reported the case. Case.—Private Van Buren Danner, Co. H, 87th Pennsylvania Volunteers, aged 26 years, was struck, at the battle of Winchester, Virginia, September 19th, 1864, by a conoidal ball, which produced a lacerated wound of the scalp over the left 72 WOUNDS AND INJURIES OF THE HEAD, frontal eminence. He Avas admitted to the depot field hospital on the same day. On the 25th, he was sent to the hospital at Sandy Hook, Alaryland, and on the 26th, he Avas transferred to the Sixteenth and Filbert Streets Hospital, Philadelphia. He died on November 10th, 1864. Surgeon T. B. Reed, U. S. V., reported the case. Cask.—Private John Duett, Co. E, 8th Maine A'olunteers, aged 26 years, received in an engagement at Drury's Bluff, A'irginia, Alay 16th, 1864, a Avound of the scalp in the occipital region from'a grape shot. He Avas, 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 the case. Cask.—Eben L. Farrar, Musician, Co. I, 96th NeAV York Volunteers, aged 19 years, was wounded in an engagement before Petersburg, A'irginia, June 23d, 1864, by a conoidal ball, which tore the scalp over the parietal bone. He was at once admitted to the field hospital ofthe Eighteenth 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 AVilliam 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 tore the scalp. He was admitted to the hospital of the First Division, Tenth Corps; on May 21st, he Avas sent to the hospital at Fort Monroe, and on June 1st, 1864, transferred to the AVard Hospital, Newark, New Jersey, Avhere 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, Avhere he entered the Emory Hospital on October 30th. Simple dressings Avere applied to the Avound. Death occurred on November 12th, 1864, "from hectic fever." Surgeon N. R. Mosely, U. S. V., reported the case. Case.—Private L. Garrett, Co. C, 56th Alabama Regiment, Avas admitted to the prison hospital at Nashville, Tennessee, Avith a gunshot Avound of the scalp. He died on November 5th, 1863. Acting Assistant Surgeon T. G. Hickman reported the case. Case.—Private AV. A. Giles, Co. C, 98th Ohio Volunteers, received near Atlanta, Georgia, August 6th, 1864, a gunshot Avound of the scalp, and Avas sent to the hospital of the Second Division of the Fourteenth Corps. He Avas transferred, on August 24th, to Chattanooga, Tennessee, and died, at Hospital No. 1, on August 29th, 1864. Cask.—Private George Graff, Co. E, 32d Indiana Volunteers, was struck by a conoidal musket ball, near Dallas, Georgia, May 26th, 1861, and Avas received at Chattanooga, Tennessee, on June 3d, Avith a severe lacerated wound of the scalp. He died June 5th, 1864. Surgeon E. B. Collins, 51st Indiana A7olunteers, records the case. Case.—Private George Hall, Co. D, 30th United States Colored Troops, aged 20 years, received, in an engagement before Petersburg, A'irginia, July 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 September 5th, 1864. Surgeon J. H. Taylor, U. S. V., reported the case. Cask.—Private O. J. Hardin, Co. K, 68th Georgia Regiment, aged 23 years, received at the battle of Gettysburg, Penn- sylvania, July 1st, 1863, a gunshot Avound of the scalp. He Avas probably treated in a field hospital until July 20th, when he Avas admitted to the Chimhorazo Hospital, Richmond, A'irginia, 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 gunshot Avound of the scalp. He was admitted to the field hospital of the Second Division, Thirteenth Corps, and, on April llth, was ordered to be transferred to the St. Louis Hospital, NeAV Orleans, but died on April 14th, 1865, on the journey. Surgeon O. Peabody, 23d IoAva 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 Avas 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 AIcDougall Hospital, New York, where he died, on October 5th, 1864, from "exhaustion following gunshot Avound." 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 scalp at the battle of Cold Harbor, A'irginia, June 3d, 1864. He was, on June 6th, admitted to the Mount Pleasant Hospital, Washington, D. C, and, on June 12th, transferred to the McClellan Hospital, Philadelphia, where the injury is diagnosed as gunshot flesh Avound of right cheek. He died on June 16th, 1864. The late Surgeon Lewis Taylor, U. S. A., reported the case. Cask.—Pi ivate Andrew Jackson, Co. G, 5th Texas Regiment, Avas Avounded, at the battle of Gettysburg, Pennsylvania, July 3d, 1^63, on the right side of the scalp, by a gunshot projectile. He was admitted to the Seminary Hospital, where he died, on July 23d, 1868. Surgeon Henry Janes, U. S. Ar., recorded the case. Case.—Private Jabez Johnson, Co. A, 29th A'irginia 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 Kocks. Avith what appeared to be a lacerated gunshot wound limited to the scalp. He died on April 24th, 1865. FATAL GUNSHOT WOUNDS OF THE SCALP. 73 Case.—Private Wm. A. Johnson, Co. C, 24th Kentucky Volunteers, Avas wounded in the scalp, by gunshot, at Resaca, Georgia, Mny llth. 1864. He was sent to Chattanooga, Tennessee, and died on the day of his admission to Hospital No. 1, Alay 20th, 1864. Surgeon Francis Salter. U. S. V., reported the case. Case.—Sergeant Francis AI. Jones, Co. F, 36th Indiana A'olunteers, aged 28 years, received, in an engagement at Marietta, Georgia, June 23d. 1864, a severe gunshot Avound of the scalp. He Avas admitted to the hospital ofthe First Division, Fourth Corps, and, on June 27th, Avas sent nortliAvard. On July 1st, 1861, he entered Hospital No. 1, Nashville, Tennessee, and died, on July Pith, 1864, "from Avound." Surgeon B. B. Breed, U. S. V., reported the case. Case.—Private Gideon M. Jones, Co. B, 25th Ohio A'olunteers, aged 43 years, was AVounded in an engagement at Honey Hill, South Carolina, November 30tb, 1861, by a musket ball, Aviuch caused a ocalp wound of the occipital region. He was, on the folloAving day. admitted to the hospital at Hilton Head. Simple dressings Avere applied; but death took place on January llth, 1835, " from Avound." Assistant Surgeon C. T. Relier, U. S. V., reported the case. Case.—PriA-ate Lewis Knmpf, Co. D, 12th Alissouri A'olunteers, aged 40 years, received, at the battle of Resaca, Georgia, Alay 14th, 1861, a gunshot scalp Avound of the left side of the head. He was, on the same day, admitted to the hospital ofthe First Division. Fifteenth Corps; on May 23d, Avas sent to the Field Hospital, Chattanooga, Tennessee, and, on May 25th, transferred to Hospital No. 1, Nashville, Tennessee, Avhere he died on June 5th, 1861. Case.—Private Chauncey C. Moore, Co. D, 42d Illinois Volunteers, received, at the battle of Chattanooga, Tennessee, November 24th and 25th. 1863, a gunshot Avound of the scalp ofthe right side of the head. He was treated, for a feAV days, in a field hospital, and, on December 1st, Avas admitted to the (Jeneral Hospital at Chattanooga. He died on December 18th, 1863. Case.—Corporal -S. B. Mortes, Co. K, 1st South Carolina Regiment, Avas admitted to the Jackson Hospital, Richmond, A'irginia, Alay 15th, 1864, with a gunshot Avound of the scalp. He died on Alay 24th, 1864. Dr. AVellford, C. S. A., recorded the case. Case.—Private John Nicholson, Co. D, 56th Alassachusetts Volunteers, aged IS years, received, at the battle of the AVilderness, Alay 6th, 1881, a gunshot Avound of the scalp, over the frontal bone. He was, on May 14th, admitted to the Columbian Hospital, Washington, D. C, Avhere simple dressings Avere applied. He died on May 30th, 1864. Reported by 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, 1804, a gunshot flesh Avound of the head. He was sent from the hospital of the Third Division, Twentieth Corps, for trausfer to the rear, and died on his way to Chattanooga, July 25th, 1864. Case.—Corporal LaAvrence C. Pepoon, (10th Sharpshooters,) 60th Ohio Regiment, aged 21 years, received in an engage- ment before Petersburg, A'irginia, July 6th, 1864, a gunshot wound of the head, obliquely across the occipital protuberance. The bone was apparently uninjured. He Avas admitted to the hospital of the Third Division, Ninth Corps, where simple dress- ings were applied to the Avound. On July 15th, he was sent to the Filbert Street Hospital, Philadelphia, when death occurred on July 24th, 1864, from "the effects ofthe Avound." Assistant Surgeon S. A. StorroAV, U. S. A., reported the case. Case.—Private Alichael Raher, Co. D, 44th Ohio Volunteers, Avas struck by a gunshot projectile at LeAvisburg, Virginia, May 23d, 1862, receiving a Avound of the integuments over the os frontis without any injury to the bone. He Avas 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 Alichigan Volunteers, at Resaca, Georgia, May 14th, Idol, was struck by a musket ball, Avhich produced a lacerated Avound of the left side of the scalp. He was treated at the hospital of the Third DiAdsion, Twentieth Corps. He died on Alay 16th, 1864. Recorded by Surgeon W. C. Bennett, U. S. V. Case.—Private Albert A. Roaks, Co. H, 21st Kentucky Volunteers, aged 3!5 years, Avas wounded in an engagement near Marietta, Georgia, June 26th, 1864, by a conoidal musket ball, which caused a flesh Avound of the head. He was admitted to the hospital of the First Division, Fourth Corps, and, on the 1st of July, was 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 NeAV York Cavalry, aged 17 years, received in an engagement near Charles- town, Virginia, August 29th, 1864, a gunshot Avound 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 September 1st, 1864, from " effects of wound." Case.—Private Wm. Sebring, Co. I, 14th Ohio Volunteers, at Chickamauga, September 19th, 1863, received a lacerated gunshot Avound of the left side ofthe scalp. He was taken to the hospital ofthe Third Division, Fourteenth Corps, and thence to the Chattanooga Hospital, where he died on October 9th, 1863. Surgeon Israel Moses, U. S. Ar., repoited the case. Case.—Sergeant Nelson P. Steinhour, Co. H, 4th New Hampshire Volunteers, aged 23 years, received in an engagement before Petersburg, Virginia, June 30th, 1864, a gunshot Avound of the scalp. He was admitted, on July 3d, to the hospital at Fort Monroe. Irritative fever folloAved, and the patient died from exhaustion, on July 10th, 1864. Case.—Corporal William A. SteAvart, Co. B, 15th Ohio Volunteers, aged 21 years, received at the battle of Nashville, Tennessee, December 15th, 1864, a simple flesh Avound of the scalp. He Avas admitted to the hospital of the Third Division, Fourth Corps, was thence transferred to Hospital No. 1, Nashville, Tennessee, and, on December 20th, sent to the hospital at Jeffersonville, Indiana, Avhere he died on January 24th, 1865, from the "effects of the wound." 10 74 WOUNDS AND INJURIES OF THE HEAD, Case.—Private John Stringer, Co. G, 6th U. S. Colored Troops, received, at Wilmington, North Carolina, February 19th, H'i."). 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 26th, 1865. Recorded by Surgeon D. AV. Hand, U. S. V. Case.—PriA-ate AA'illiam Tait. Co. F, 100th Pennsylvania A'olunteers, aged 40 years, received, at the battle of Spott- sylvania. A'irginia, Alay 12th, 1861. a gunshot wound of the scalp. He Avas admitted to the hospital ofthe First Division, Ninth Corps. On Alay 15th, he Avas sent to the Alount Pleasant Hospital, Washington, D. C, and, on Alay 19th, to the McClellan Hospital, Philadelphia, where he died on Alay 28th, 1864. Surgeon LeAvis Taylor, U. S. A., reported the case. Cask.—Private David Titus, Co. AI. 1st New Jersey Cavalry, aged 19 years, received, at the battle of the AA'ilderness, A'irginia, May 5th, 186 4, a gunshot Avound of the scalp, over the left temporal region. On Alay 12th, he was admitted to Alount Pleasant Hospital, AVashington, D. C, and on June 10th, transferred to DeCamp Hospital, Ncav York Harbor, where he died on June 21st, 1831. Assistant Surgeon Warren AVebster, U. S. A., reported the case. Case.—Lieutenant John A'an De Sande, Co. B, 115th Ncav A'ork A'olunteers, aged 31 years, received, in an engagement near Malvern Hill, Virginia, August 16th, 1864, a severe gunshot wound ofthe scalp. He Avas, on August 17th, admitted to the hospital at Fort Monroe, A'irginia, where he died on September 3d, 1831. Assistant Surgeon E. McClellan, IT. S. A., reported the case. Case.—Private Jackson AV. Vorhees, Co. I, 27th Michigan Volunteers, aged 38 years, received, at the battle of Cold Harbor, A'irginia, June 3d, 1864, a gunshot flesh wound of the left temple. He Avas, on June 8th, admitted to the hospital of the Third Division, Ninth Corps, and on June 14th, to the Second Division Hospital at Alexandria. Simple dressings were applied. Death occurred on June 28th, 1861. Surgeon T. Rush Spencer, U. S. A'., reported the case. Cask.—Private James Walker, Co. B, 1st North Carolina Regiment, received a very slight gunshot wound of the scalp, at the battle of Gaines's Alills, A'irginia, June 27th, 1862. He Avas admitted to HoAvard Grove Hospital, near Richmond, Virginia, and -died July 15th, 1862. Surgeon C. D. Rice, P. A. C. S., recorded the case. Case.—PriA-ate Ezekiel AVimmer, Co. C, 36th Illinois A'olunteers, aged 22 years, received, at the battle of Franklin, Tennessee, November 30th, 1861, a gunshot Avound of the scalp. He was, on the following day, admitted to Hospital No. 15, NasliA-ille, and, on December 3d, sent to the Jefferson Hospital, Jeffersonville, Indiana, Avhere he died, on December 17th, 1864, from " effects ol Avound." Surgeon AI. Goldsmith, U. S. V., recorded the case. Case.—Private AVm. G. Young, Co. G, 44th Illinois A'oluntcers, aged24 years, received, at Marietta, Georgia, June 26th, 1*64, a gunshot wound of the scalp. He Avas admitted to the hospital of the Second DiA-ision, Fourth Corps, on the following day, and transferred to Chattanooga, on July 2d, and died on July 3d, 1831. Assistant Surgeon C. C. Byrne, U. S. A., reported the case. Case.—Sergeant AA'. H. Zimmerman, Co. E, llth Pennsylvania Volunteers, aged 25 years, at the battle of the AVilderness. Virginia, Alay 6th, 1864, received a scalp Avound over the right parietal region, from a musket ball, Avhich lodged beneath the integument. The missile Avas extracted on the field, and the patient was sent to the rear, and conveyed finally to Washington, D. C, entering Armory Square Hospital on May 26th. He died on June 29th, 1864. Nine patients, with gunshot Avounds of the scalp, died Avhile on furlough, and it has been impossible to obtain particulars of the complications Avhich led to the fatal results: Case.—Corporal Selah B. Alden, Co. D, 13th Massachusetts Volunteers, aged 32 years, received at the battle of the AVilderness, Virginia, Alay 8th, 1864, a gunshot wound of the scalp. He was admitted to the regimental hospital, and thence sent to the Campbell Hospital, AVashington, D. C, on Alay 12th. On Alay 17th he was furloughed, and, according to the regis- ters of the Pension Bureau, and the records of the Adjutant General of Massachusetts, he died at Natick, May 25th, 1864. Case.—Private Thomas Bowles, Co. I. 28th Kentucky Volunteers, aged 28 years, received, in an action at Spring Hill, Tennessee, November 29th, 1864, a wound ofthe scalp by a conoidal musket ball. He was admitted into the field hospital ofthe Second Division, Fourth Army Corps, and, on the following day, Avas sent to Nashville and admitted into the No. 8 Hospital. Simple dressings were used. On December 3d, he was tranferred to Jeffersonville, Indiana, and admitted into the general hospital at that place. The report of the Adjutant General of Kentucky states that he died, while on furlough, February 6th, ISIm. "from wounds received in action." ™ , Cask ~Private Tllomas Brrant> Co- C> 11Sth Pennsylvania-Volunteers, aged 29 years, received, at the battle of the AVilderness. A .rginia Alay 7th, 1864, a slight wound of the scalp from a fragment of shell. He was admitted to the hospital of the 1-irst Division, Fifth Corps, and, on May 12th, he was sent to the Campbell Hospital, Washington, D. C On Alay 27th he was furloughed. and died while on furlough. July 16th, 1864. Surgeon A. F. Sheldon, U. S. V., reports the case. „. C-vsi:--Pri™te J- H- C'liase, Co. I, 103th New York Volunteers, aged 42 years, was admitted to the Lincoln Hospital, AA ash.ngton, D. C, on August 19th. 1864, with a contused gunshot wound ofthe scalp. He was furloughed on November 4th, and died Avhile on furlough, December 12th, 1864. CASE.-Private H. F. Higby. Co. H, 121st New York Volunteers, aged 25 years, was wounded, at the battle of Spott- sylvania, A ngmia, May llth, 1HJ4. by a conoidal ball, which cut the scalp at the superior frontal region. He was admitted to the hospital of the First Division, Sixth Corps, and, on May 16th, was sent to the Alount Pleasant Hospital, AVashington, D C The Avound did well, and the patient was furloughed on Alay 21st. He died, while on leave, May 27th 1*6-1. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 75 Case.—Private M. F. Hosmer, Co. A, 9th New A'ork Heavy Artillery, aged 18 years, received, at the battle of Cedar Creek, A'irginia, October. 19th, 1864. a severe gunshct Avound of the scalp. He Avas, on the same day, admitted to the hospital ofthe Third Division, Sixth Corps, and thence was sent to the Cuyler Hospital at (JermantoAvn, Pennsylvania, Avhere he entered on October 24th. He was furloughed on November 6th; and died, Avhile on furlough, December 9th, 1H34. Case.—Lieutenant John Jungericb, Adjutant 121st Pennsylvania Volunteers, received, at the battle of North Anna RiA'er, A'irginia, May 23d, 1864, a slight gunshot flesh Avound over the right side of the frontal bone. He was taken to the hospital of the Fourth Division, Fifth Corps, and thence Avas sent to AVashington. On May 31st, he Avas granted leaA'e, and died on June 23d, 1864, Avhile on leave of absence. Cask.—Private Robert F. Parkhill, Co. B, 9th NeAV York Artillery, aged 27 years, received, at the battle of Cedar Creek, A'irginia, October 19th, 1864, a severe shell Avound of the scalp. He was admitted to the hospital of the Third Division, Sixth Corps. On October 24th, he Avas sent to the Sheridan Hospital, Winchester, A'irginia, and thence to the hospital at York, Pennsylvania, which he entered on October 26th. Under simple dressings the wound Avas doing Avell, and on November 7th, the patient Avas furloughed. He died, while on furlough, November 12th, 1864. Case.—Private AVilliam F. Small, Co. B, 7th NeAV Hampshire Volunteers, received, in an engagement in front of Peters- burg, A'irginia, on Alay 10th, 1864, a gunshot Avound of the scalp, inflicted by a conoidal musket ball. He was admitted into the hospital at Hampton, A'irginia, on Alay llth, and, on June 8th, Avas transferred to De Camp Hospital, David's Island, New York. On November 1st, 1861, he Avas considered convalescent, and received a furlough, and died, while at home, on June 29th, 1865. The records are silent regarding the causes of death in the sixty-three examples of gun- shot wounds of the scalp here enumerated. The average interA'al between the reception of the injury and the fatal termination was twenty-seven days. It may be suspected that in most, if not all. of these cases, there was some undiscovered primary or secondary lesion of the skull or its contents, but precise evidence on the subject is wanting. The seat of injury is specified in twenty-seven cases; as in the frontal region in seven, the temporal in two, the parietal in twelve, the occipital in six. Gunshot Scalp Wounds followed by Encephalitis.—In the following cases of gunshot wounds of the scalp, which terminated fatally from inflammation of the brain or its mem- branes, the reports indicate that the injuries were carefully examined, and that the observers were conA'inced that there were no primary lesions of the skull: Case.—Private AVilliam H. Allington, Co. C. 141st New York Volunteers, aged 21 years, received, at the engagement before Dallas, Georgia, Alay 25th, 1864, a gunshot flesh Avound of the forehead, from a musket ball. He was admitted into the field hospital of the TAveutieth Corps. Simple dressings Avere used The patient was transferred to the Cumberland Hospital, Nashville, Tennessee, on June 2d. Meningitis set in soon afterwards, and resulted fatally, on June llth, 1864. The case is reported by Surgeon C. McDermott, U. S. V. Case.—Private Albert E. Ammon, Co. H, 27th Indiana Volunteers, aged 21 years, Avas wounded, in the engagement near Dallas, Georgia, May 25th, 1864, by a conoidal musket ball, Avhich caused a slight wound of the scalp. He Avas admitted to the hospital ofthe First Division, Twentieth Corps, and, on June 1st, Avas sent to the field hospital at Chattanooga, Tennessee. Meningitis supervened, and death took place on June 10th, 1864. Assistant Surgon C. C. Byrne, U. S. A., reports the case. Case.—Private Simon Birdsell, Co. I, 32d Illinois Volunteers, received a severe gunshot Avound of the integuments of the forehead, at the battle of Shiloh, April 6th, 1862. He Avas treated by Brigade Surgeon William Dickinson, U. S. V., and was conveyed on an hospital steamer to the hospital at Benton Barracks, St. Louis. The wound progressed very favorably, and, on May 5th, the patient was considered convalescent, and was furloughed to go to his home at Iatan, Morgan County, Illinois. Inflammation of the brain supervened, and the case terminated fatally on June 2d, 1862. The attending physician, George M. Smith, AI. D., of Iatan, reports the case. Case.—Private Charles Brown, Co. D, 23d United States Colored Troops, received, in an engagement before Peters- burg, Virginia, July 13th, 1864, a severe gunshot wound of the scalp. He was admitted to the hospital of the Fourth Division, Ninth Corps. On July 31st, he was sent to the hospital for colored troops at City Point, and, on August 17th, he Avas placed on the steamer Baltic for transportation to the Satterlee Hospital at Philadelphia. Surgeon I. I. Hayes, U. S. V., reports that convulsive fits supervened, and that death took place aboard the steamer on August 18th, 1864. Case.—Private Thomas Casey, Co. F, llth Illinois Volunteers, was wounded, at Fort Donelson, Tennessee, February 16th, 1862, by a musket ball, which grazed the left side of the head, producing a slight scalp wound, which was considered of trivial importance. The man was sent to the Academy Hospital at Nashville, Tennessee, and remained in a comfortable condition until February 26th, Avhen he complained of violent headache, and soon afterAvards became wildly delirious. He was freely purged, and a blister was applied to the nape of the neck, and there Avas great apparent improvement, until March 10th, Avhen a relapse took place, and symptoms of compression of the brain supervened, terminating eventually in coma. He died on March 21st, 1862. Acting Assistant Surgeon W. P. Jones recorded the case. 7 1863. Surgeon AV. H. Thorn, C. S. A., reports the case. Cask.—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 Avound of the vertex, from a conoidal musket ball. He was admitted, on September 15th, into the field hospital of the Third Division, Second Corps. On September 19th, the patient Avas sent to field hospital of the Second Corps, and, on the same day, he Avas transferred to Washington, where, on September 21st, he Avas admitted into Emory Hospital. Inflammation of the brain set in, and death folloAved, October 3d, 1864. Surgeon N. R. Moseley, U. S. A'., reported the case. Cask.—Sergeant Thomas H. LaAv, Co. K, 5th NeAV Hampshire Volunteers, received, at the battle of Antietam, Maryland September 17th, 1862. a gunshot Avound of the integuments of the forehead. He was admitted to the hospital of the Second Corps, and, on October 5th, was 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 llth, 1862. Surgeon A. B. Mott, U. S. V., reports the case. Cask.—Private .9. Lawson, Co.E, 22d Georgia Regiment, received, at the battle of Gettysburg, Pennsylvania, July 3d, 1863. a gunshot wound of the scalp, and was taken to the Seminary Hospital. On July 25th, he was transferred to the AA'est's Building Hospital, Baltimore, Alaryland, Avhere 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, Pennsylvania, July 3d, 1863, a gunshot wound of the right side ofthe scalp. He was, on July 6th, admitted to Hospital No. 1, Frederick, Alaryland, on July 7th, transferred to Annapolis, probably for exchange, and on August 1st, 1863, he was admitted to a Confederate hospital, at Petersburg, A'irginia, Avhere he died, on August 18th, 1863, of meningitis. Cask.—Private Hugh O'Donnell, Co. C, 29th Pennsylvania Volunteers, aged 24 years, received, at the battle of Atlanta, Georgia, July 20th, 1864, a severe gunshot Avound of the scalp. He Avas admitted into the hospital of the Second Division, TAventieth Corps, and thence sent to Hospital No. 2, at Chattanooga, Tennessee, on July 25th. He Avas transferred, about the 1st of August, to Nashville, and thence, within a feAV weeks, sent to the Satterlee Hospital in Philadelphia. Death supervened on August 3lst, 1864. Case.—Private Duncan Stone, Co. C, 1st North Carolina Battery, received a wound of the right side of the scalp by a conoidal musket ball. He Avas admitted into the PettigreAv Hospital, Raleigh, North Carolina, on Alarch 23d, 1865. Simple dressings were used. Meningitis supervened, and the case terminated fatally on Alarch 29th, 1865. Surgeon E. Burke Hay- wood, C. S. A., records the case. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 77 Case.—Private Nicholas St raver, Co. C, 205th Pennsylvania Volunteers, aged 30 years, received, in an engagement before Petersburg, Virginia, April 2d, 1S65, 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, Avas sent to the Lincoln Hospital, Washington, D. C, where he died on May 12th, 1865, from inflammation of brain. Assistant Surgeon J. C. McKee, U. S. A., records the case. Case.—Private Henry Warner, Co. B, 1st Alichigan Volunteers, aped 29 years, was AVounded near Petersburg, Virginia July 24th, 1864, by a fragment of shell, Avhich caused a severe wound of the scalp. He was admitted to the hospital of the First Division. Fifth Corps, and thence sent to City Point, Avhere 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 A'ork Harbor, where death resulted on August 20th, 1834. Case.—Private John AVarner, Co. D, 4th New Jersey Volunteers, aged 26 years, received, at the battle of the Wilder- ness, Alay 6th, 1861, a gunshot wound 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 Alay llth; from thence he was sent to Philadelphia, and admitted to the Satterlee Hospital on May 18th. On May 28th, he Avas attacked by a chill, attended by a violent pain in the head, and symptoms of cerebral inflammation. The case terminated fatally on May 29th, 1864. Case.—Corporal James E. AVhite, Co. A, 3d New Hampshire Volunteers, aged 33 years, received, in an engagement near James's Plantation, A'irginia, May 20th, 1864, a gunshot Avound of the scalp from a conoidal musket ball. He was admitted into the field hospital of the Tenth Corps on the same day, and a day later was transferred to the Hampton Hospital at Fort Monroe. On June 1st, the patient Avas sent to the Ward Hospital, at Newark, New Jersey. Congestion ofthe 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, from 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, September 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 Carolina, April 20th, 1864, a gunshot wound of the scalp. He died on May 9th, 1864. Surgeon D. G. Rush, 101st Pennsylvania A'olunteers, 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, TAventieth Army Corps, on the same day, and, on May 30th, he Avas sent to Chattanooga. He died on June 16th, 1864. Case.—Private J. H. Hatley, Co. D, 27th North Carolina Infantry, received, in action, a gunshot Avound of the scalp. He was admitted into the Moore Hospital at Richmond, A'irginia, December 20th, 1863, and died on December 22d. Surgeon Otis F. Alanson, 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 Chatta- nooga, and Avas admitted, on November 23d, 1863, to Hospital No. 4, Chattanooga, Tennessee, with a gunshot scalp Avound 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, Washington, 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 Avound of the right side of the scalp. He was admitted to the hospital of the Third Division, Twentieth Corps, and, on Alay 20th, was sent to the general field hospital at Resaca, Avhere he died, on May 24th, 1864. Assistant Surgeon M. C. Woodworth, U. S. V., recorded the case. Case.—Private Madison Wilman, Co. D, 15th Iowa Volunteers, aged 26 years, received, at the battle of Shiloh, Ten- nessee, April 6th, 1862, a slight gunshot wound of the scalp. He died on June 1st, 1862. Surgeon Samuel B. Dawes, 15th 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, Cask.__J. B. Bristoe, Co. C, 26th Virginia Regiment, aged 30 years, receiA-ed, on July 17th, 1864, a gunshot wound of the scalp, just above the right eye. During the progress of the case erysipelas supervened, but it was checked, and, on July 30th, the patient Avas reported as convalescing. Surgeon P. F. Brown, C. S. A., records the case. Cask.—Private Charles Ferry, Co. B, 72d New York Volunteers, aged 37 years, received, in the Peninsular cam- paign, at Alalvern Hill, July 1st, 1862, a shell wound of the occipital region of the scalp. He Avas admitted to Division No. 1 Hospital, at Annapolis, Maryland, from the Steamer Kennebec, July 5th, 1862. A severe attack of erysipelas supervened, from Avhich the patient recovered, and Avas returned to duty on October llth, 1862. Acting Assistant Surgeon Arthur Rich recorded the case. Case.—Private Henry T. Frazell, Co. B, 6th Missouri Volunteers, received in front of Vicksburg, Mississippi, Alay 22d, 1863, a gunshot Avound of the scalp in the right temporal region. He was received on board the hospital steamer R. C. Wood, from ChickasaAV Bayou, on the 8th of June, and transferred to Memphis, Tennessee, where, on the same day, he Avas admitted to Union Hospital. On the morning of the 29th, the wound Avas attacked by erysipelas, Avhich soon extended over the entire scalp and face. The disease yielded readily to treatment, and, on July 7th, the patient Avas reported as very nearly free of the disease. On the 22d of July, he had so completely recovered as to be able to return to duty. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—PriA-ate T. A. Gallagher, Co. C, 10th Louisiana, was Avounded at the battle of Gettysburg, Pennsylvania, July 3d, 1863, by a musket ball, which entered the scalp to the left of the median line, near the superior ridge of the occiput. The mis- sile passed forward, and downward behind the ear, and lodged about the middle of the loAver jaw. He also received a gunshot Avound of the ankle. The wounds Avere dressed in a field hospital, and thence he was sent to Camp Letterman Hospital at Gettysburg, where he was admitted on July 27th. Erysipelas supervened, which, by appropriate treatment, was subdued, and, at the date of his transfer to Baltimore, the patient was doing Avell. He was admitted, on October 6th, to West's Building Hos- pital, at Baltimore, Alaryland, Avhere he remained until November 12th, 1863, on which date he was paroled. Case.—First Sergeant Samuel B. Gray, Co. I, 123d Illinois Volunteers, in an engagement near Milton, Tennessee, March 20th, 1863, received a gunshot scalp Avound. 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 until August 1st, Avhen he Avas sent to Louisville, and admitted into Hospital No. 7. On September 3d, he Avas sent to Hospital No. 19, where erysipelas supervened. Simple dressings Avere used. He was discharged from service October 13th, 1863, on account of a scrofulous abscess. The case is reported by Assistant Surgeon E. O. BroAvn, 26th Kentucky Volunteers. Case.—Sergeant R. AI. Harris, Co. F, 3d Tennessee Infantry, aged 24 years, received at the battle of Kenesaw Mountain, Georgia, June 30th, 1864, by a conoidal ball, a Avound of the scalp over the right temple. He Avas admitted, on July llth, to Holston Hospital, at Knoxville, Tennessee. The Avound became affected with erysipelas, which was subdued, and the patient Avas furloughed on the 26th of October. On November 18th, he Avas 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. Case.—Sergeant John McPeake, Co. B, 82d NeAV York Volunteers, received, at the battle of Antietam, Maryland, Sep- tember 17th, 1862, a gunshot Avound of the integuments of the forehead. He was admitted to the regimental hospital, and, on November 21st, was sent to hospital at Camp Parole, Annapolis, Maryland. Erysipelas of a severe character supervened, but the patient recovered, and Avas discharged from the service on February 23d, 1863. Surgeon James Norval, 79th New York State Militia, recorded the case. Case.—Private J. L. Means, Texas Regiment, received, in the assault on Fort Donelson, Tennessee, February 15th, 1862, a slight wound of the scalp, over left parietal region, by a musket ball. He was conveyed to a Confederate hospital in Nashville. Erysipelas set in, on the tenth day after the reception of the injury,, and extended over the entire head and face. Tincture of iodine was applied locally, and general supporting treatment was employed. He rapidly recovered, and was discharged from the hospital about March 26th, 1862, for duty. Case.—Private J. L. Smiley, Co. E, 12th Alabama Infantry, aged 19 years, received, in the assault on Fort Steadman, Virginia, Alarch 25th, 1865, a gunshot Avound of the occipital region, by a conoidal musket ball. He was admitted into the AVashington Street Hospital, at Petersburg, Virginia, on the same day. Erysipelas supervened. The patient was made a prisoner and transferred to the Hampton 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 AVilliam H. Smith, Co. I, 99th Pennsylvania Volunteers, aged 18 years, received, in an action on the Southside Railroad, Virginia, about April 7th, 1865, a gunshot wound of the right parietal region. He was admitted into the field hospital of the Third Division, Second Corps. Simple dressings were applied. On April 12th, he was admitted into the Second Corps field hospital, at City Point, whence he was transferred, on April 18th, to Finley Hospital, 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 Hospital, Philadelphia, May 19th, and on July 19th, 1865, he was discharged from service. Case.— Private F. M. Streeter, Co. G, 42d Mississippi Infantry, received a gunshot wound ofthe scalp. He was admitted, on July 23d, 1863, into the Howard Grove Hospital, Richmond, Virginia. Erysipelas supervened. On September 16th, 1863, he Avas furloughed. The case is reported by Surgeon C. D. Rice, P. A. C. S. Cask.—Private L. H. Taylor, Co. A, 46th A7irginia Regiment, Avas admitted, on July 2d, 1864, to the HoAvard Grove Hospital, Richmond, Virginia, with a gunshot wound of the scalp. Erysipelas supervened; but otherwise the case progressed favorably, 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 by haemorrhage, will be recorded further on among the abstracts of scalp Avounds with haemorrhage. Still another affords an instance of the application of sutures in gunshot lacerations of the scalp: Case.—Private James Buchanan, Co. C, 6th IoAva Volunteers, aged 35 years, received at the battle of Resaca, Georgia, May 14th, 1864. a lacerated wound of the vertex of the scalp, from a fragment of shell. The cranium was laid bare for a distance of tAvo and a half inches. He Avas admitted to the field hospital of the Fifteenth Army Corps, in charge of M. C. WoodAVorth, Assistant Surgeon U. S. V., on the same day, and the Avound Avas cleaned, the scalp shaved, and its edges approxi- mated by sutures. The Avound was then covered with water dressings. The next report is dated Alay 20th, when it is stated that the wound Avas tumefied, highly inflamed, suppurating, and gaping, the sutures having broken out. The wound was cleaned of purulent matter, and Avas dressed Avith strips of isinglass plaster, and covered by a compress. On the 21st, there Avas erysipelatous inflammation extending from the vertex over the forehead nearly down to the eyelid. The wound was dressed with plasters, as before, and strong tincture of iodine Avas painted over the entire inflamed surface and a border of the sound skin adjacent. On the 22d, the erysipelas extended slightly doAviwards to the face. On the 25th, the inflammation had, in a great measure, subsided. The patient was transferred to the Cumberland Hospital, at Nashville, Tennessee, under the care of Surgeon C. McDermont, U. S. A'., and was treated by simple dressings to the scalp and Avith purgatives. On June 4th, he Avas transferred to the Holt Hospital, at Jeffersonville, Indiana, in charge of Surgeon II. P. Stearns, U. S. V. It is stated on the register of this hospital, that the Avound Avas inflicted by a conical musket ball. The patient recovered without further complication, and Avas returned to duty August 19th, 1864. Eight cases were reported which terminated fatally in consequence of the meningeal inflammation following the invasion of erysipelas: Case.—PriA-ate LeAvis Alfrey, Co. K, 22d Indiana Volunteers, received, in an engagement at Kenesaw Mountain, Georgia, June 27th, 1864, a gunshot wound of the scalp. He was admitted to the hospital of the Second Division, Fourteenth Corps, and, on July 1st. Avas transferred to the Cumberland Hospital at Nashville, Tennessee. He died, on July 26th, 1864, "of erysipelas, folloAving gunshot wound of scalp." Assistant Surgeon W. B. Trull, U. S. V., records the case. Case.—Corporal AA'illiam Cammire, Co. H, 73d Illinois Volunteers, aged 22 years, was admitted to hospital No. 19, Nashville, Tennessee, on December 1st, 1864, with a gunshot Avound 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 B. Fant, Co. B, 17th Alississippi Regiment, Avas, on May 9th, 1864, admitted to the Howard Grove Hospital, Richmond, Virginia, with a lacerated wound of thescalp in the left temporal region, caused by a grape shot. On July 8th, erysipelas attacked the wound, and death resulted on July 29th, 1834. Surgeon T. M. Palmer, C. S. A., records the case. Case.—Private William Jackson, Co. F, 16th Ohio Volunteers, received, at the siege of Vicksburg, Mississippi, Decem- ber 28th, 1862, a gunshot Avound of the left side of the scalp. He Avas conveyed, on the steam transport City of Memphis, to Paducah, Kentucky, and was admitted, on January 8th, 1863, into Hospital No. 2. Erysipelas of the scalp supervened, and death resulted from exhaustion, on February 23d, 1863. At the post mortem examination the liver, spleen, and mesenteric glands Avere found enlarged. The case is reported by Surgeon H. P. Stearns, U. S. V. Case.—Corporal Francis X. Lewis, Co. E, 18th North Carolina Regiment, received, in an engagement before Petersburg, April 1st, 1865 a gunshot wound of the scalp. He was, on April 4th, admitted to the hospital at Fort Monroe, where he died, on April 13th, 1865, of erysipelas. Assistant Surgeon AV. D. AVolverton, U. S. A., records the case. Case.—Private Reinhold MayAvold, Co. G, 6th Wisconsin Volunteers, aged 27 years, Avas AA-ounded, in an engagement at the Soufhside Railroad, April 1st, 1865, by a conoidal ball, Avhich struck over the squamous portion ofthe left temporal bone. He was, on the folloAving day, admitted to the field hospital ofthe Fifth Corps, and, on April 4th, was sent to the Lincoln Hos- pital, AA'ashington, D. C, where he died, on April 24th, 1865, from erysipelas folloAving gunshot wound of scalp. Case.—Private Fountain AlcClarry, Co. E, 100th U. S. Colored Troops, aged 24 years, receiA-ed, at the battle of Nashville, December 16th, 1864, a gunshot wound of the scalp, on the back of the head. He Avas admitted, on the folloAving day, to Hospital No. 16. Simple dressings were applied. Erysipelas supervened, and death folloAved, on January 14th, 1865. Case.—Private John.Williams, Co. B, 12th NeAV 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 scalp. He Avas admitted, on June 19th, to the hospital of the Second Corps at City Point, and, on June 25th, Avas sent to the Lovell Hospital, Portsmouth Grove, Rhode Island. Erysipelas supervened, and death occurred on July 7th, 1864. Gangrene —The contused wounds of the scalp made by balls, always followed by the death of a thin layer of tissue, sometimes lead to spreading gangrene, a complication more common in head wounds with fracture of the skull than in those limited to the scalp. 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 Joseph H. Clouse, Co. H, 20th Indiana Volunteers, was wounded at the battle of Gettysburg, Pennsyl- vania. Julv 3d, 1863, by a conoidal ball, Avhich entered just above the frontal eminence of the left side, and made a large; flesh Avound. He Avas sent to Philadelphia, and, on July 5th, admitted to the Satterlee Hospital. Cold water dressings were applied until the llth. Avhen flax-seed poultices Avere used. The wound did comparatively well until the 20th, Avhen gangrene appeared. Tincture of the sesquichloride of iron was given, and applications of nitric acid, folloAved by,emollient dressings, were made for a feAV days, when the sloughs came aAvay, and the Avound commenced to heal. On the 24th, the edges were approximating. About a square inch of the bone was visible, one-half of Avhich Avas denuded of its periosteum. The patient Avas furloughed on August 2d, 1863; returned to his regiment, and was, on December 22d, 1863, transferred to Co. F, 20th Indiana Regiment, reorganized. Case.—Private William Padget, Co. B, 1st Florida Battery, was admitted, on June 4th, 1864, to HoAvard Grove Hospital, Richmond, A'irginia, with a gunshot Avound of the scalp over the left temporal bone. Gangrene attacked the wound, but was readily checked, and on July 23d the patient was furloughed for sixty days. Case.—Private Horace Garrquis, Co. E, 8th Connecticut Volunteers, aged 20 years, received, in an engagement before Petersburg, Virginia, Alay 7th, 1861, a gunshot Avound of the scalp. He was, on May 9th, admitted to the Hampton Hospital near Fort Alonroe, and, on May 18th, transferred to the Mower Hospital, Philadelphia. On May 30th, the wound commenced to slough. Bromine Avas applied, and afterwards flax-seed poultices, and on June 15th, healthy granulation set in. On July llth, the patient Avas sent to the Knight Hospital, NeAV Haven, Connecticut, and on October llth, 1864, he was returned to duty. Case.—Private John R. Kittredge, Co. I, 93d NeAV York Volunteers, aged 20 years, was AVounded at the battle of the Wilderness, A'irginia, Alay 5th, 1864, by a conoidal ball, which passed across the vertex of the cranium from left to right, causing a scalp Avound two inches in length. He was admitted to the hospital of the Third Division, Second Corps; on May 10th, sent to the Carver Hospital, Washington, D. C, and, on May 15th, transferred to MoAver Hospital, Philadelphia. On June 14th, the wound began to slough; poultices were applied, and on June 18th the sloughing had ceased. Kittredge Avas returned to duty on October 4th, 1864. Case.—Private W. I. Watson, Co. D, 20th Georgia Cavalry, received, on October 27th, 1864, a gunshot Avound of the' scalp. He Avas admitted into the second division of the Jackson Hospital, Richmond, on the same day. Gangrene supervened. He recovered, and Avas furloughed March 24th, 1865. The following cases of sloughing after gunshot wounds of the scalp, terminated fatally: Cask.—Private Daniel L. Dougherty, Co. H, 55th Pennsylvania Volunteers, aged 27 years, was Avounded before Peters- burg, A'irginia, June 16th, 1864, by a conoidal ball, Avhich injured the scalp and the left shoulder. He was, on the folloAving day, admitted to the hospital ofthe Eighteenth Corps, at Point of Rocks, Virginia, and, on June 19th, was sent to the Hampton Hospital, Fort Alonroe, where simple dressings Avere applied to the Avound. Death occurred on July 15th, 1864, from gangrene and exhaustion. Assistant Surgeon E. McClellan, U. S. A., recorded the case. Cask.—Private Patrick Doyle, Co. D, 117th New York Volunteers, aged 36 years, was wounded before Petersburg, A'irginia, June 15th, 1864, by a fragment of shell, which caused a Avound of the scalp. He was treated, for some days, in a field 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 Avound, and the patient died on July 30th, 1864. Cask.—Private Irvine Hawkins, Co. I, 2d, New York Artillery, aged 19 years, received, in an engagement at Petersburg, A'irginia, June 16th, 1864, a gunshot Avound of the occipital region, by a round ball. He Avas admitted, on the same day, into the field hospital ofthe First Division, Second Army Corps, and, on the 21st, was sent to the base hospital at City Point. Simple dressings Avere used. The patient Avas subsequently transferred to Washington, and was received into the Mount Pleasant Hospital on June 27th. He was, a feAV 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, 1834. Surgeon Thomas H. Bache, U. S. V., reports the case. Case.—Corporal William Roth, Co. E, 119th NeAV York Volunteers, aged 28 years, received, at the battle of Gettysburg, Pennsylvania, July 3d, 1863, a scalp Avound in the left parietal region, and also a Avound 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. Hemorrhage.—In gunshot wounds of the scalp, primary haemorrhage was very infrequent, but secondary haemorrhage 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, Avas admitted to hospital at Annapolis, Maryland, on January llth, 1863. He had been wounded by a musket ball, which entered the scalp to the right ot the occipital protuberance, and, passing fonvard and slightly upward, emerged at a distance of two inches above the ear. The missile, in its course, cut the occipital artery, from Avhich there Avas profuse haemorrhage. Sight and hearing were some- COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 81 what affected; but, on the date of his leaving the hospital, the patient was doing Avell. He was transferred, on January 21st; 1863, to Pittsburg, Pennsylvania, after Avhich there is no account of him. Surgeon T. A. McParlin, U. S. A., records the case. Case.—Private Burton Fuller, Co. H, 7th Iowa Volunteers, was wounded, at the battle of Corinth, Mississippi, October 3d, 1862, 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 Avas, on October 13th, 1862, admitted to the Hospital at Mound City, Illinois, Avhere the temporal artery Avas ligated. Fuller Avas discharged from the service on January 13th, 1863. Case.—Private John Hearne, Co. E, 164th NeAV A'ork Volunteers, was wounded, in an engagement near Suffolk, A'irginia, April 24th, 1863, in the right temporal region, the missile dividing the temporal artery, Avhich bled freely. The haemorrhage Avas checked by compression, and the patient Avas sent, on the following day, to the hospital at Hampton, Virginia. On June 22d, 1863, he Avas returned to duty. Case.—Lieutenant A. St. Clair Smith, Co. E, 12th New Hampshire Volunteers, Avas wounded at the battle of Cold Harbor, A'irginia, June 3d, 1861, by a conoidal musket ball, which cut the scalp over the left ear and severed the temporal artery, Avhich Avas secured with some difficulty. He Avas admitted, on June 5th, to the field hospital of the Eighteenth Corps, and thence sent to Washington, D. C, and AA-as treated, at his quarters, at the Avenue House. He Avas furloughed, on June llth, 1864, and Avas 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 NeAV Jersey A'olunteers, aged 44 years, received, at the battle of Fair Oaks, June 1st, 1862, a gunshot wound of the scalj). He Avas sent to the Seminary Hospital at Georgetown, D. C, and admitted on June 4th. Profuse haemorrhage occurred, on the same day, from one of the branches ofthe temporal artery. The main trunk Avas ligated, just above the zygomatic process. The patient was returned to duty on August 19th, 1862. The case is reported by Acting Assistant Surgeon Josiab F. Kennedy. In six cases of secondary haemorrhage 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 AA'ilder- ness, A'irginia, Alay 5th, 1861, by a conoidal musket ball, which caused a wound of the scalp in the right parietal region. He Avas admitted to the HareAvood Hospital, Washington, D. C, and, on May 15th, sent to MoAver Hospital, Philadelphia. On the folloAving day haemorrhage occurred from the parietal branch ofthe temporal artery, which was controlled by compression. On May 31st, the Avound 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 NeAV Jersey A'olunteers, aged 25 years, was AVounded at the battle of the Seven Pines, A'irginia, 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 AVashington, and admitted, on June 4th, into the Seminary Hospital, Georgetown. A haemorrhage took place from the temporal 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. Assistant Surgeon Joseph R. Smith, U. S. A., reports the case. Case.—Private Zachariah Hancock, Co. I, 19th Indiana Volunteers, Avas wounded, at the battle of Gettysburg, Penn- sylvania, 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 llth, sent to the AlcClellan Hospital, Philadelphia. Haemorrhage, 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 December 3d, 1863. Surgeon LeAvis Taylor, U. S. A., records the case. Case.—Private John LoAvrey, Co. I, 2d United States Infantry, aged 29 years, was wounded, at the battle of Antietam, Maryland, September 17th, 1862, in the right temporal region. He was, on September 22d, admitted to Hospital No. 5, Frederick, Maryland, and, on October 10th, sent to McDougall Hospital, Fort Schuyler, New York Harbor. On October 16th, haemorrhage occurred from the temporal artery, but was easily controlled by compresses and styptic preparations. The patient Avas 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 Gettys- burg, Pennsylvania, July 2d, 1863, a wound of the scalp near the vertex, by a fragment of shell. He was admitted into a field hospital, and, a feAV days later, was sent to Philadelphia, and admitted, on July 7th, into the MoAver Hospital. On July llth, a considerable haemorrhage took place, Avhich 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 Schurringhausen, Co. I, 1st Ohio Light Artillery, aged 25 years, was wounded in the forehead, by a buckshot, in the engagement at Chantilly, Virginia, September 1st, 1862. He Avas admitted to the Master Street Hospital, Philadelphia, on September 3d, 1862. The injury Avas regarded as slight, but subsequent sloughing caused haemorrhage from the frontal artery 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 AVounded vessel: Case.—Lieutenant Henry Gilmore, Co. A, 17th Vermont Volunteers, aged 32 years, received, at the battle of Spott- sylvania, Virginia, May 12th, 1864, a gunshot flesh wound of the head. He was treated in a field hospital until May 19th, 11 8^ WOUNDS AND INJURIES OF THE HEAD, when he Avas sent to the Campbell Hospital, Washington, D. C. On admission, the wound was in a bad condition ; the temporal bone was exposed to A-iew, and the tissues were sloughing and inclined to gangrene. On May 21st. haemorrhage occurred from the temporal artery. Acting Assistant Surgeon F. AV. Kelly, ligated the artery in its continuity. No untoward symptoms occurred. On August 15th, Lieutenant Gilmore was transferred to the Officers' Hospital, at Annapolis, Alaryland, and, on September 6th, 1854. he was returned to duty. Surgeon A. F. Sheldon, U. S. V., records the case. Cask.—Private F. C. Hartly, Co, G, 49th Virginia Regiment, aged 21 years, Avas admitted on June 1st, 1864, to Chimborazo Hospital, Richmond, Virginia, with a gunshot wound of the scalp, received on Alay 31st, 1861. (In June 5th haemorrhage occurred from the anterior branch of the temporal artery, Avhich Avas ligated near the expansion of the temporal muscle. On June 30th, the patient Avas doing Avell, and, on July 1st, he Avas furloughed for sixty days. Case.—Private Josiah Mullen, Co. A. 100th Pennsylvania A'olunteers, was wounded during the siege of Knoxville, Tennessee. November 30th, 1833, by a conoidal ball, Avhich struck the left side of the head and severed the temporal artery. He Avas at once admitted to Hospital No. 5, Knoxville, Avhere Surgeon George B. CoggsAvell, 29th Alassachusetts A'olunteers, ligated the temporal artery near its origin. The ball Avas not discovered until December 5th, when it Avas extracted from beneath the sterno-cleido-mastoid muscle, near the sternal extremity. The patient recovered, Avas furloughed on February 17th, 1834, and finally returned to duty. The case is reported by Surgeon A. M. AVilder, U. S. A'. Case.—Private Henry Reese, Co. I, 53d Pennsylvania Volunteers, aged 18 years, was wounded at the battle of Gettys- burg, Pennsylvania, July 2d, 1863, by a shell, Avhich caused a flesh wound over the right temple. He was, on July 5th, admitted to the Satterlee Hospital, Philadelphia. On July 13th, haemorrhage, amounting to four ounces, occurred from the temporal artery, Avhich was ligated in the wound. Haemorrhage did not recur, and the patient Avas returned to duty on Decem- ber 7th, 1833. The case is reported by Surgeon I. I. Hayes, U. S. V. Case.—Corporal A. Talmadge, Co. E, llth NeAV Jersey A'olunteers, aged 32 years, was Avounded at the battle of Gettys- burg, Pennsylvania, July 3d, 1863, by a conoidal musket ball, Avhich tore the scalp over the left temple for a distance of one by tAvo and a half inches. He was admitted, on July 5th, to Satterlee Hospital, Philadelphia. The Avound became gangrenous, and Avas treated with flaxseed meal and porter poultices. The pain was intense, and the patient was unable to rest; the Avound began to slough, and there was such free bleeding, that on July 14th the anterior temporal artery Avas ligated. The slough Avas gradually throAvn off, and, on July 23d, healthy granulation commenced. A slight haemorrhage occurred on July 27th, but Avas speedily arrested by compression. The patient Avas furloughed on August 1st, 1863, and returned to duty on Alarch 24th, 1864. 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 : Cask.—Corporal Henry Kullman, Co. I, 27th AVisconsin Volunteers, aged 25 years, was Avounded in an engagement before Petersburg, A'irginia, July 30th, 1864, by a conoidal musket ball, which entered anteriorly to the right ear, passed through the pavilion, and emerged just behind the concha. He was at once admitted to the hospital ofthe First Division, Ninth Corps, and, on August 1st, Avas sent to the Harewood Hospital, Washington, D. C. On August 14th, hemorrhage, amounting to four ounces, occurred from the temporal artery, Avhich was ligated in its continuity by Surgeon R. B. Bontecou, U. S. V., a ligature being placed above and below the Avound. Haemorrhage did not recur. On September 3d, 1864, the patient Avas sent to the Mower Hospital, Philadelphia, and, on Alay 30th, 1865, was mustered out of service. The case is reported by the opera- tor, Surgeon R. B. Bontecou, U. S. V. Case.—Private Richard Norris, Co. C, 1st United States Cavalry, aged 32 years, was wounded at theTiattle of the AVil- derness, A'irginia, May 8th, 1864, by a conoidal musket ball, which entered in front of the right ear and emerged two inches back ofthe right mastoid process. He was admitted into Finley Hospital, Washington, D. C, on May llth, 1834. On May 25th, haemorrhage occurred from the occipital artery, Avhich 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 term of service. Surgeon G. L. Pan- coast, U. S. \., reported the case. Iii the following case, recovery ensued after ligation for secondary haemorrhage, and the patient deserted from hospital: Case.—Private David Jones, Co. B, 1st Alassachusetts Volunteers, aged 26 years, was wounded at the battle of Spott- sylvania, Virginia, Alay 9th, 1864, by a conoidal musket ball, which 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 con\-eyeu to the Second Division Hospital at Alexandria, and, on May 21st, Avas transferred to Alower Hospital, Philadelphia. 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. Marshall. 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, NeAV Jersey, Avhence he deserted on July 23d, 1864. Tavo cases of gunshot wound of the scalp, complicated by haemorrhage, had a fatal termination: Case.—Private Alexander Brown, Co. B, llth New York State Alilitia, aged 33 years, was wounded at the battle of the \\ llderness. A'irginia, Alay 8th, 1861, by a conoidal musket ball, which entered in front of the left ear, passed doAvmvard and backwards, and emerged about one inch below the occiput. He was admitted into the field hospital of the Fourth Division, COMPLICATED GUNSHOT WOUNDS OF THK SCALP. 83 Fifth Army Corps, on the same day, and a feAV days later sent to Alexandria, and Avas admitted, on May 12th, to the Second Division Hospital. Simple dressings were used. On May 19th, haemorrhage took place from the occipital artery, and, though temporarily checked, the arterial bleeding recurred on the 20th, and, on the 21st, about thirty-eight ounces of blood Avere believed to have been lost altogether. Compression and astringents Avere the measures unavailingly employed. The patient died on Alay 21st. 1864. The case is reported by Surgeon T. Hush Spencer, U. S. V. Case.—Private LeAvis Jones, Co. C, 115th NeAV A'ork Volunteers, aged 23 years, received, in an engagement at Olustee, Florida, February 20th, 1864, a gunshot Avound of the scalp. He Avas 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 bgated, and haemorrhage did not recur. On April 20th, he was sent to the hospital at Fort Monroe; on April 26th, to the DeCanip Hospital, New York Harbor; and, on September 27th, 1864, to Albany, New A'ork, Avhere he died on October 15th, 1864, from the effects of the Avound. Assistant Surgeon M. F. Cogswell, U. 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 complication was ascribed to exposure to dampness, with sudden depression of the temperature of the atmosphere: Case.—Corporal Charles G. Carpenter, Co. F, 19th Iowa A'olunteers, aged about 32 years, received a Avound of the scalp, in the engagement at Morganzia, Louisiana, September 2i)th, 1863, by a conoidal ball. He Avas admitted, from the field, to St. Louis General Hospital, at -Ncav Orleans, on October 4th, 1863, where he Avas treated by application of simple dressings, and the administration of saline cathartics, and the free use of morphiae. On the night of October 7th, the Aveather became cold and damp, and, on the folloAving morning, the patient manifested symptoms of trismus. The phenomena of acute tetanus rapidly ensued, and the case terminated fatally, on October llth, 1863. At the autopsy, an extravasation of blood Avas 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. Cask.—Private A. J. Cook, Co. B, 92d Ohio Volunteers, by the accidental discharge of a pistol in his oavh hands, received, on November 2d, 1862, a slight bullet wound of the integuments of the forehead, over the right superciliary ridge. He Avas admitted to hospital at CharlestoAvn, A'irginia. The Avound at first granulated kindly; but, on November 10th, the patient 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 Avithin twenty-four hours. Acting Assistant Surgeon 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 tAvo inches above the left ear. He Avas taken to the hospital of the Second Division, Twenty-fifth Corps, where the ball Avas removed. On April 5th, 1865, he was admitted to the hospital at Fort Alonroe. He Avas placed in a hospital tent, and unavoidably exposed to dampness owing to inclement Aveather. On April 14th, trismus commenced, and spasms gradually extended to the muscles of the chest, abdomen, and extremities. Active purgatives were given until the boAvels Avere thoroughly evacuated, after Avhich opium Avas prescribed without effect. Subsequently, ether and chloroform Avere administered, with but temporary benefit; assafcetida also,Avas 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. AI, 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 Avas admitted to the hospital of the Fifth Corps. On July ?th, tetanus, in the form of trismus, made its appearance. Chloroform Avas 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 Avith increased severity, and death took place, on July llth, 1863. Case.—Private Thomas J. Severance, Co. F,-2d NeAV Hampshire Volunteers, aged 25 years, was Avounded, at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a fragment of shell, which caused a wound of the right side of the scalp, posterior aspect. He was, at first, admitted to the Seminary Hospital, and, on July 8th, Avas transferred to Turner's Lane Hospital, Philadelphia. The general health of the patient was good. The edges of the wound were inflamed, and cold Avater dressings were therefore applied, and continued until July 16th, Avhen the patient complained of stiffness of the jaws The throat was rubbed Avith strong ammoniacal liniment. On the following day, there Avas confirmed trismus, and, in addition to this, emprosthotonos occurred during the night. AVarm cataplasms Avere applied to the Avound, and anodynes were administered internally. On July 18th, the anodynes Avere continued, and, as the Avound was found to be suppurating freely, a supporting course, consisting of milk punch, and injections of beef tea, Avas resorted to. On July 19th, the 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 application of powerful rubefacients along the spine. Death resulted on the morning of the 20th of July. The apparent cause of the invasion was damp Aveather, as it occurred during a very damp, rainy period. The case is recorded by Assistant Surgeon C. H. Alden, U. S. A. The following case was regarded as an instance of recovery from traumatic tetanus, but the evidence is anything but satisfactory: 84 AVOUNDS AND INJURIES OF THE HEAD, C\se.__Private Conrad Wentzell, Co. E, 75th Pennsylvania A'olunteers, aged 34 years, received, at the battle of Gettys- burg Jul v 1st. 1833, uninshot wounds of the left side ofthe head and of the upper third of the left arm. He Avas at once adndtted into Seminary Hospital, Gettysburg, and thence, on July 13th, sent to Satterlee Hospital, Philadelphia. There Avere indications of trismus or tetanus; but upon chloroform being hihaled, no spasms or pain recurred. On the 16th. the patient complained of burning pain in the wound, but on the 25th, he Avas doing well. The wound looked healthy, and no further complication ensued. He was furloughed on September 23th, 1883, and transferred to Veteran Reserve Corps on February 29th, 1861. Fyai/iia,—The reports specify five cases of gunshot Avounds of the scalp in which pyaemia supervened: Case.—Private T. D Biggs, Co. I, Anthorn's Regiment, was, on July 5th, 1863, admitted to the hospital steamer R. C. AA'ood, with a gunshot Avound of the left side of the scalp. On July 7th, he Avas transferred to the Overton Hospital, Memphis, Tennessee, and, on July 31st, he Avas sent to the Church Hospital of the same city, Avhere he died, on September 3d, 1863, of septicaemia, accompanied by embolic obstructions in some ofthe smaller arteries. Cask.—Private George Gold, Co. I, 155th Pennsylvania A'olunteers, aged 23 years, Avas admitted to HareAvood Hospital on October 7th, 1864. He had been Avounded at Poplar Grove Church, on September 30th, by a musket ball, Avhich struck the scalp, passing from before backAvards, 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 Avatched for symp- toms indicative of cerebral or meningeal inflammation; but none Avere manifested up to the moment of his death, unless a slight drowsiness, which, at the time, Avas attributed to the administration of eight grains of Dover's powder, might be so regarded. He Avas up aud about the Avard, 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 loAver lobe of the lung. There Avas some dullness on percussion over the part complained of. but no marked physical signs of inflam- matory mischief. On October 19th, the patient Avas worse. The pain in the left chest was more severe, resembling that of pleurisy; the pulse Avas full and frequent; the tongue broAvn and rather dry; there was very little cough, and no expectoration. On percussion, the right side was very dull over the loAver lobe, less so over the upper lobe. The respiratory murmurs Avere 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 appeared more comfortable in the early part of the day, the respiration less labored, and pulse more quiet, and tongue more moist; toAvaids the latter part ofthe day, hoAvever, the symptoms increased in severity. Great dullness over Avhole of left side of chest was noticed, and greatly diminished resonance on the right side. The vesicular murmur Avas 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 Avas rather faint, and greatly obscured by bronchial respiration. On October 21st, there Avas less pain and dyspnoea, \-ery little cough, Avith a soft infrequent pulse, pale countenance, and increasing dullness on percussion over the riglft side. ToAvards the latter part of the day there was less droAVsiness. The patient died at half-past eight o'clock, on October 22d. 1861. lie Avas perfectly sensible and rational Avitbin ten minutes of his death. A post mortem examination was made three hours afterAvards. Cadaveric rigidity Avas strongly marked; the skin ofthe chest and face Avas of a deeply jaundiced hue On making an opening into the chest, about twenty ounces of yelloAv serum Avas found in the left pleura, none in the right. The pleural cavities of both sides, but particularly the left, were covered to a considerable extent with coagulable lymph of considerable firmness. The left costal and pulmonary pleural Avere bound strongly together by broad, thick bands, the result of some former disease. There Avere also a feAV much less firm attachments on the right side. The lower lobe of the left lung Avas 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 loAver lobe were found tAvo or three purulent deposits, which appeared to form centres of inflammation, or metastatic foci. The wound along the scalp appeared as during life. Pus Avas found along the coronal and sagittal sutures, throughout the Avhole extent, dissecting the scalp from the bone, to the breadth of one inch. The skull Avas roughened, and deprived of pericranium 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 was found betAveen the bone and dura mater, extending along the sagittal and coronal sutures to the same extent as on the external surface, the amount of pus within the skull being less than one drachm. There Avas a narrow strip cf the dura mater each side of these sutures which Avas inflamed; at other parts this membrane Avas healthy. The arachnoid and pia mater Avere perfectly normal. The brain and its ventricles, the cerebellum, medulla oblongata, and roots of all the cerebral nerves, Avere carefully examined, and no lesions Avere 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, Avere in a normal condition. The liver was apparently healthy. Acting Assistant Surgeon Cobb recorded the case. Case.—Private Rufus Hedges, Co. G, 10th Alichigan A'olunteers, 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 folloAA-ing day, he Avas 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. A'., reports the case. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 85 Case.—Private Gilmer P. Rook, Co. B, 9th Maine Volunteers, aged 18 years, received, at the seige of Petersburg, Virginia, July 8th, 1864. a gunshot Avound of the scalp. He Avas admitted to the hospital ofthe Second Division, Tenth Corps, and was thence sent to the AIcDougall Hospital, at Fort Schuyler, Avhere 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 Pegiment, received, at the battle of Gettysburg, Pennsylvania, Julv 3d, 1863, a gunshot wound of the scalp. He Avas admitted to the Seminary Hospital, and, on July 17th, was transferred to the De Camp Hospital, at David's Island, NeAV York. Pyaemia supervened, and death occurred on September 20th, 1863. Surgeon Charles Cray, llth NeAV A'ork 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 AA'. Beisel, Co. K, 55th Pennsylvania Volunteers, aged 29 years, was Avounded, Avhile on picket, Alay 20th, 1834, by a musket ball, Avhich tore the scalp on the left side. Ho was admitted, on May 23d, to the hospital at Pcint Lookout, Alaryland, furloughed June 24th, and readmitted on August 17th, 1864. Typhoid fever then set in, and death occurred on October 27th, 1864. Case.—Private Charles AA'. Hapenstall, Co. G, 36th Illinois A'olunteers, aged 18 years, was Avounded, at the battle of Franklin. Tennessee, November 30th, 1834, by a conoidal ball, which injured the scalp. He Avas treated in a regimental hospital at first, and transferred, on December 2d, to Hospital No. 19, at Nashville; but, on the same day, he Avas returned to modified duty, at the Convalescent Camp. On December 4th, he was admitted to the Clay Hospital, Louisville, Kentucky, on account of the same injury. On December 25th, he Avas transferred to Hospital No. 5, at Quincy, Illinois, Avhere he died, on December 26th, 1864, of "typhoid fever." Case.—Private LeAvis Hicks, Co. K, 6th NeAV York Heavy Artillery, was Avounded, in an engagement before Petersburg Virginia, June 18th, 1864, by a conoidal ball, which struck the left temporal region, inflicting a laceration of the integument. He also received a shell wound of the second finger of the left hand. He Avas admitted to the hospital of the Second Division, Fifth Corps, where the terminal phalanx was removed. On July 2d, he Avas sent to the Slough Hospital, Alexandria, A'irginia, where cold Avater dressings Avere applied to the scalp wound. Death occurred, from enteric fever, on July 10th, 1864. The autopsy revealed the pathognomonic ulceration of Peyer's gland*, and extensive inflammation of the intestinal canal. Case.—Private Thomas Jorman, Co. A, 35th North Carolina Regiment, was admitted to the hospital transport De Molay, Avith a gunshot Avound of the scalp. Typhoid fever supervened, and the patient died, on August 28th, 1864. Case.—Private John Leach, Co. I, llth IoAva Volunteers, aged 26 years, received, at the battle of Shiloh, Tennessee, April 6th, 1862, a gunshot Avound of the scalp. He subsequently contracted typhoid fever, from which he died, on Alay 22d, 1862, at Monterey, Tennessee. Assistant Surgeon A. R. Derby, 20th Missouri A'olunteers, reports the case. Case.—Private Otis Packard, Co. I, 3d Alaine Volunteers, aged 1.8 years, received, at the battle of Spottsylvania, -Virginia, Alay 12th, 1864, a gunshot Avound of the scalp, over the left eye. He was admitted to the hospital of the Third Division, Second Corps, and, on May 14th, sent to the Harewood Hospital, Washington, D. C, Avhere he died, on July 9th, 1864, of "typhoid fever." Case.—Private John O'Ragan, Co. C, 1st Alaine Infantry, aged 41 years, received, at the battle of Cedar Creek, Virginia, October 19th, 1864, a gunshot Avound of the scalp. He was admitted, on the same day, to the hospital of the Second Division, Sixth Corps, and, on October 23d, Avas sent to the Haddington Hospital, Philadelphia, where he died, "of typhoid fever," December llth, 1864. Case.—Private George A. Raush, Co. B, 103th Illinois A'olunteers, received, in the engagement at Arkansas Post, January llth, 1863, a slight gunshot wound over the eye. He was treated in a field hospital, and, on March 8th, was discharged from the service, on account of chronic diarrhoea and hernia. He died "of typhoid fever," on board of the steamer Nashville, on Alarch 12th, 1863, Avhile in transit for his home. Case.—Private Barney Riley, Co. F, 1st NeAV York Dragoons, aged 26 years, was Avounded in the engagement at Tre- vilian Station, Virginia, on June llth, 1864, by a conoidal musket ball, Avhich caused a Avound ofthe left side ofthe scalp. He was immediately admitted to the field hospital of the Cavalry Corps, and, on June 21st, he Avas transferred to Alount Pleasant Hospital, Washington, D. C. Typhoid fever supervened, and the patient died on August llth, 1864. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case.—PriA'ate Alfred B. Smith, Co. F, 1st Massachusetts Heavy Artillery, aged 26 years, Avas Avounded, in an engage- ment before Petersburg, Virginia, June 15th, 1864, by a conoidal ball, Avhich lacerated the scalp severely. He Avas admitted to the hospital of the Third Division, Second Corps, and thence, on July 17th, Avas sent to the Finley Hospital, AVashington, D. C. He died, on July 27th, 1864, "of typhoid fever." Casi:.-Private George F. Stetson, Co. E, 23d Massachusetts Volunteers, aged 23 years, was Avounded, at the battle ot Cold Harbor, Virginia, June 3d, 1364, by a fragment of shell, Avhich caused a scalp wound of the left side of the head. He was admitted to the field hospital of the Eighteenth Corps, and, on June 9th, sent to the First Division Hospital, at Alexandria. Typhoid fever supervened, and death occurred on July 8th, 1864. s6 WOUNDS AND INJURIES OF THE HEAD, ('aSK.—Private Charles Tennis, Co. K, 7th Pennsylvania Cavalry, aged 25 years, received, in a skirmish, near Dallas, Georgia. Alay 27th, 1864, a severe gunshot wound of the left side of the head. He was sent to Kingston, Georgia, and in May sent north. On June 3d, he was admitted to Hospital No. 8, Nashville, Tennessee, and, on June 27th, transferred to the Third Division Hospital, at Alurfreesboro, Tennessee, Avhere he died, on September 16th, 1864, of typhoid fever. In four cases of gunshot wounds of the scalp, the fatal terminations Avere attributed to incidental malarial attacks. But, as the symptoms were not minutely described, and the necroscopic appearances were not observed, suspicion arises that, in some of the cases at least, the chills may have been symptomatic of internal suppuration, or a part of the characteristic phenomena of pyaemia. Case.—Private John A. Boyle, Co. A, 105th Ohio Volunteers, received, in an engagement, near Chattanooga, Tennessee, September 23d, 1863, a gunshot wound of the head. He Avas admitted to Hospital No. 15, Nashville, where he died, on October 19th, 1863, of typho-malarial fever. Case.—Private Daniel Aleyers, Co. C, 110th Pennsylvania Volunteers, aged 40 years, received, at the battle of the Wilderness, A'irginia, Alay 5th, 1864, a gunshot Avound of the scalp, caused by a fragment of shell. He was, on May 26th, admitted to the Carver Hospital, AVashington, D. C, and, on June 2d, transferred to the Hospital at Brattleboro', Vermont. Fever of a malarial character supervened, and death occurred on June 13th, 1864. Cask.—Private LeAvis Price, Co. A, 73d Illinois A'olunteers, received, at the battle of Chickamauga, Georgia, September 19th, 1863, a slight gunshot wound ofthe scalp, over the left eyebroAv. He was admitted to the hospital of the Third Division, TAventieth Corps, on September 24th ; was sent to an hospital at Nashville, and on February 7th, 1864, Avas returned to the hospital at Chattanooga, Tennessee, where he died, on March 14th, 1864, of congestive fever. Case.—Private Jeremiah R. Putnam, Co. B, 1st Alassachusetts Heavy Artillery, aged 42 years, received, in an engage- ment before Petersburg, Virginia, June 16th, 1864, a gunshot Avound of the scalp. A conoidal ball struck over the parietal bones in the line ofthe sagittal suture. He Avas admitted to the hospital of the Third Division, Second Corps, and thence sent, by City Point, to the Broad and Cherry Streets Hospital, Philadelphia, which he entered on June 30th. He was, on July 2d, transferred to the Haddington Hospital. When admitted the patient suffered from intermittent fever and chronic diarrhoea, and Avas extremely anaemic and emaciated. He died, on July 7»th, 1864, "undoubtedly in consequence of serous effusion in brain, causing general paralysis." In thirteen cases of gunshot wounds of the scalp, pneumonia is reported as the cause of death; but, in several of them, it is questionable if the pulmonary complications were not embolic phenomena, indicating the formation of metastatic foci, and whetherxthese cases would not have been more properly classified under the head of pysemia: Cask.—Private Benjamin D. Cargill, 2d Vermont Volunteers, aged 19 years, received, at the battle of Spottsylvania Court House, A'irginia, Alay 8th, 1864, a gunshot wound of the anterior portion of the scalp. He was admitted to the hospital of the Second Division, Sixth Corps, and, on May 26th, sent to the Lincoln Hospital, Washington, D. C. Furloughed on Alay 24th, he was readmitted on June 23d, and died on August 8th, 1864, of acute bronchitis. Case.—Private James R. Coulter, Co. E, 95th Ohio Volunteers, aged 38 years, received, during the siege of Vicksburg, Mississippi, June 20th, 1863, a gunshot wound of the scalp, right side, and also a flesh wound of the right forearm. He was admitted to the hospital of the Third Division, Fifteenth Corps, Avhere he is reported as recovered for duty. On November 5th, 1864. he Avas admitted to the Adams Hospital, Memphis, Tennessee, with pneumonia, and died on November 9th, 1864. Case.—Sergeant Richard Decker, Co. K, 1st New Jersey Cavalry, aged 22 years, received, at the affair at Salem Church, A'irginia, Alay 28th, 1864, a wound from a conoidal musket ball, which tore up the scalp over the vertex for the length of an inch. No injury to the bone could be detected. The patient was sent to Washington, and admitted to Alount Pleasant Hospital on June 4th, 1364. Pneumonic complications supervened, and the patient sank into a typhoid condition, which terminated fatally on June llth, 1861. Assistant Surgeon H. Allen, U. S. A., recorded the case. Case.—Private Samuel Healey, Co. C, 25th Massachusetts Volunteers, aged 28 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864. by a fragment of shell, Avhich caused a wound of the scalp. He was at once admitted to the hospital ofthe Eighteenth Corps, on June 7th transferred to the Second Division Hospital at Alexandria, and, on June 12th, sent to the hospital at Chester, Pennsylvania. Warm applications were made to the wound to promote discharge, but on the 19th pleuro-pneumonia set in, and death occurred on June 23d, 1864. Surgeon E. Bentley, U. S. V., records the case. Cask.—Private John A. Huff, Co. E, 5th Michigan Cavalry, aged 48 years, received, in an engagement near Cold Har- bor, A'irginia, Alay 28th, 1864, a severe gunshot wound of the scalp from a conoidal ball. He Avas admitted to the Cavalry Corps Hospital, and, on June 3d, sent to the Campbell Hospital, Washington, D. C, Avhence he was furloughed on June 17tli, 1^64. He died while on furlough, June 23d, 1864, from Avound and pneumonia. Surgeon A. F. Sheldon, U. S. V., records the case. COMPLICATED GUNSHOT WOUNDS OF THE SCALP. 87 Case.—Private C. W. Johnson, Co. I, 31st Maine Volunteers, aged 25 years, received, at Spottsylvania Court House, Virginia, May 12th, 1864, a shell Avound of the scalp. He was admitted to Harewood Hospital, Washington, on Alay 16th, transferred to Patterson Park, Baltimore, Alay 18th, thence to David's Island, New York Harbor, May 24th, and, finally, to Cony Hospital at Augusta, Alaine, on June 3d, Avhere pneumonia supervened, and the patient died, on June llth, 1864. Case—Private Allen H. Aloore, Co. E, 1st Ohio A'olunteers, aged 26 years, received, in an engagement near Dallas, Georgia, Alay 27th, 1864, a gunshot scalp Avound of the left side of the head. He was admitted to the hospital of the Third Division, Fourth Corps, and, on June 1st, Avas sent to the Cumberland Hospital, Nashville, Tennessee, where he died, on June 15th, 1864, of typhoid pneumonia. Assistant Surgeon W. B. Trull, U. S. V., records the case. Case.—Private John Porter, Co. D, 35th Indiana A'olunteers, aged 32 years, received, in an engagement at Marietta, Georgia, June 18th, 1864, a gunshot Avound ofthe scalp. He Avas admitted to the hospital ofthe First Division, Fourth Corps, and, on June 23d, he Avas transferred to Hospital No. 2, Chattanooga, and, on June 30th, thence sent to the Cumberland Hospital, NasliA-ille, Tennessee. Simple dressings Avere applied to the wound, but the patient Avas attacked by pleuro- pneumonia, and died on July 13th, 1864. Assistant Surgeon W. B. Trull, U. S. V., records the case. Case.—Private James Reardon, Co. B, 6th Missouri Volunteers, received, before Vicksburg, Mississippi, in the latter part of December, 1862, a scalp wound. He Avas taken on board the Steamer City of Alemphis, and, on January 13th, 1863, was admitted to the hospital at Paducah, Kentucky, where he died of wound of scalp, with pneumonia, on January 18th, 1863. Case.—Captain F. AA'. Sabine, Co. G, llth Alaine A'olunteers, aged 25 years, received, in an engagement at Deep Bottom, A'irginia, August 14th, 1864, a gunshot Avound ofthe scalp. He Avas, on the following day, admitted to the Chesapeake Hospital, at Fort Monroe, Virginia. Pneumonia of the right lung existed at time of admission, and terminated fatally on September 15th, 1864. Assistant Surgeon E. McClellan, U. S. A., records the case. Case.—Private James Shields, Co. I, 69th NeAV York Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot wound of the scalp. He Avas admitted to the hospital of the Third Division, Ninth Corps, on December 14th, Avas sent to the Armory Square Hospital, AVashington, D. C, and. on December 19th, transferred to the De Camp Hospital, NeAV A'ork Harbor, Avhere he died, on January 9th, 1863, of pneumonia. Surgeon T. Simons, U. S. A., recorded the case. Case.—Private George AI. Snow, Co. D, 25th Wisconsin Volunteers, aged 23 years, received, at the battle of Resaca, Georgia, May 14th, 1864, a shell Avound of the scalp. He Avas, at once, admitted to the hospital of the Sixteenth Corps. On May 19th, he was sent ro the field hospital at Chattanooga, on May 21st, Avas transferred to Hospital No. 1, Nashville, and thence, on Alay 24th, Avas sent to the BroAvn Hospital, Louisville, Kentucky. He died, on June 9th, 1864, of pleuro-pneumonia Case.—Private AVilliam Spencer, Co. F, 51st Ohio Volunteers, received, at the battle of Kenesaw Mountain, June 22d, 1864, a shell Avound 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 Michigan Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1832, a gunshot Avound 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 Mansion House Hospital, Alexandria, and, on April 10th, 1863, symptoms of small-pox being manifested, he Avas transferred to hospital for eruptive diseases, at Kalorama, Washington, D. C, Avhere he died, on May 27th, 1863, of varioloid with cerebral symptoms. Case.—Private John Crandall, Co. K, 64th New York Volunteers, aged 33 years, received, at the engagement at North Anna, Virginia, Alay 18th, 1864, a scalp wound of the occipital region, from a musket ball. He was sent to AA'ashington, 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 Avas removed, July 14th, to Turner's Lane Hospital; again, on October 10th, to Filbert Street Hospital, and again, on February 16th, 1865, to Islington Lane Hospital. Here he died, on February 24th, from the effects of the Avound, and of the sequelae of small pox. Case.—Sergeant Charles Harbstrutt, Co. D, 74th Pennsylvania Volunteers, received, at the battle of Gettysburg, July 2d, 1863, a shell Avound of the integuments on the back of the head. He 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 the wound and fever. In one case of gunshot scalp wound hepatitis is adduced as the cause of death: Case.—Private Edward McDole, Co. G, 7th New York Heavy Artillery, received, in an engagement before Petersburg, Virginia, June 16th, 1864, a scalp wound, caused by a fragment of shell. He was admitted to the hospital ofthe First Division, Second Army Corps; on June 21st, he Avas sent to the Lincoln Hospital, Washington, D. C, and, on June 28th, to the Satterlee Hospital, Philadelphia, where he died, on July 9th, 1864, "of hepatitis." Diarrhoea is reported as a fatal complication in four cases: Case.—Private Joseph Coad, Co. F, 3d Maine Volunteers, aged 35 years, was wounded, at the battle of the Wilderness, Virginia, May 8th, 1864, by a conoidal ball, which lacerated the right side of the scalp. He was sent to Washington, and admitted, on May 27th, to Carver Hospital, where simple dressings were applied to the wound. Death occurred on June 18th, 1864, from "chronic diarrhoea." Surgeon O. A. Judson, U. S. V., recorded the case. 88 WOUNDS AND INJURIES OF THE HEAD, Cask.—Private A. F. Dana, Co. E, United States Marine Corps, aged 22 years, Avas wounded, at the assault on Fort Fisher, January 15th, 1865, by a fragment of shell, Avhich lacerated the right side ofthe scalp and caused a transitory concussion of the brain. He Avas made a prisoner, but was shortly afterAvards exchanged, and, on February 3d, 1865, 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. Cask.—Private Alvah B. Small, Co. C, 20th Alaine Volunteers, received, at Gettysburg, Pennsylvania, July 3d, 1863, a gunshot Avound of the scalp. He Avas, at once, admitted to a field hospital, and, on July 8th, was transferred to the Satterlee Hospital, at Philadelphia. Simple dressings were applied to the wound, and tonics and astringents were administered internally. Chronic diarrhoea, from which he was suffering, persisted, and death ensued August 28th, 1863. Case.—Corporal Richard H. A'an Devine, Co. K, 1st New Jersey Infantry, aged 28 years, received, at the battle of Spottsylvania, A'irginia. Alay 12th, 1864. a gunshot wound of the scalp He Avas admitted, on June llth, to the Mount Pleasant Hospital, AVashington, D. C, and, on June 20th, transferred to the Summit House Hospital, Philadelphia. At the period of his admission he was very much reduced, aud 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. BroAvn, Co. B, 73d Illinois A'olunteers, Avas Avounded, at the battle of Chickamauga, September 19th, 1863, by a musket ball, which produced a lacerated Avound of the scalp. He Avas made a prisoner, and was sent to Andersonville, Georgia, Avhere he died, on August 17th, 1864. The following case terminated fatally in consequence of the supervention of diphtheritis: Case.—Private Julius AIcKnight, Co. D. 27th U. S. Colored Troops, aged 23 years, received, on July 30th, 1864, at the Biege of Petersburg, A'irginia, a gunshot wound of the scalp. He was sent to the hospital for Colored Troops, a feAV miles in the rear, at City Point. Here little importance Avas attached to the Avound of the head, and the patient Avas entered on the register as suffering from remittent fever. On August 14th, he Avas sent to Philadelphia, to the Summit House Hospital, where the scalp Avound Avas regarded as serious. As it was progressing favorably, light, simple dressings A\-#e applied. In Septem- ber, symptoms of diphtheria were manifested, and the disease making very rapid progress, the patient died, on September 20th, 1864. At the autopsy, the mucous coat of the fauces and trachea appeared to be ulcerated and disorganized. A tough tubular membrane lined the larynx, trachea, and bronchi, even to the smaller ramifications; and in the larger air passages, this pseudo-membrane Avas detached. It Avas of a yelloAvish gray or ash colored hue. The lungs Avere much engorged. An abscess containing half an ounce of pus Avas found in the right lung. Entangled among the columnae carneae of the right ventricle of the heart was a concretion, half an ounce in Aveight, very similar in appearance to the membranous exudation in the lung. It Avas very unlike the ordinary fibrinous coagula or heart clots so frequently observed in autopsies, and, under the microscope, presented the same histological elements as the exudations in the air passages. Surgeon J. 11. Taylor, U. S. V., records the case. In another of the one hundred and sixty-tAVO fatal gunshot scalp wounds, the fatal result was probably due to delirium tremens: Case.—Corporal AVilliam Quinn, Cc A, 95th New York Arolunteers, aged 29 years, received, at the battle of Gettysburg, July 2d, 1863, a gunshot scalp wound ofthe frontal region. After a feAV days treatment in field hospital, he was sent to Phila- delphia, and admitted into Satterlee Hospital on July llth. He died "from mania apotu" 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 most careful exploration. There was cirrhosis of the liver; but the other viscera showed no organic alteration. Surgeon I. I. Hayes, U. S. A'., 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 York Volunteers, aged 23 years, received, at the battle of Cold Harbor, A'irginia, 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. A'., records the case Cask.—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 May 25th, 1863. Surgeon C. Powers, 160th N. Y. A'ols., reports the case. ,,. . .Cas: '~Private W- IL Griffith, Co. II, 20th Virginia Regiment, was brought to the Chimborazo Hospital, Richmond, A irginia, on December 10th, 1864, with a gunshot wound of the head. He died on December 25th, 1864. Assistant Surgeon J. B. \\ ilv. C. S. A., records the case. GUNSHOT WOUNDS OF THE SCALP. 89 Case.—Private Charles Russell, Co. B, 37th Massachusetts Volunteers, Avas wounded at the battle of Winchester, Sep- tember 19th, 1864, and is reported by Assistant Surgeon Elisha AI. White, 37th Massachusetts Volunteers, as "killed in battle.'' He Avas not killed, hoAvever, but Avas conveyed to the general field hospital of the Sixth Corps, Avhence the case is reported by Sursreon S. A. Holman, U. S. A'., as a flesh wound of the scalp, produced by a fragment of shell. On October 4th, the patient was transferred to Sheridan Hospital, Avhere 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 AV. 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 AVilmore, 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 Spring- field, 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 haemorrhage, 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 compli- cations. 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 imperfec- tion 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 ascer- tained. 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, haA'e 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 hoAV 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 gunshot wounds of the scalp, Avhen the evidence indicated the probability that the injury was limited to the integument. The 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 Avounds 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. Matthew * 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,f presents a tabular statement of 1,633 gun- shot wounds of the head distinguished from fractures of the cranium and wounds of an undetermined 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 Report on the Italian War 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 haemorrhage. 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. Regions. Cases. Died. Disch'd. Duty. Unkn'n. Per cent. of death. 573 1,234 416 270 18 37 9 11 117 237 80 46 239 586 192 133 199 374 135 80 4.8 4.3 3.2 5.7 Parietal............................................................... Temporal............................................................. Total.......................................... 2,493 75 480 1,150 788 4.4 were mere The gunshot wounds of the scalp presented many varieties. There 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 lodgement 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 l-~>4-'55-'56, London, 1858, Vol. II, p. 286. t Rapport au Conseil de Sante des Armies sur les Resultats du Service Medico-Chirurgical pendant la Campagne d'Orient en 1854-'55-'56. Par J. C. Ciiexu, Paris, 1865, p. 134. t Statistique Medico-Chirurgicale de la Campagne d'ltalie en 1859 et 1860. Par J. C. Chenu, Paris, 1869, Tome II, p. 424. GUNSHOT WOUNDS OF THE SCALP. 91 The abrasions and superficial cuts require no other comment than the ITippocratic aphorism, that no injury of the head is too slight to be 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 cylindro-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 lodgement 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.........'.___ Round Alusket Ball................. Explosive Musket Ball............. Buck Shot........................ Pistol Ball......................... Solid Cannon Ball.................. Shell Fragments................... Grape Shot........................ Case and Canister Shot and Shrapnel Torpedo Fragments................. Piece of Iron...................... Total...... 2,612 384 2 94 25 3 861 9 6 4 2 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 wounded 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 projectiles causing flesh wounds of this region are not well marked, and suggest few considerations of interest. The varieties in gunshot scalp wounds depends 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 INJURIES OF THE HEAD, FIG. 27.—Projec- tiles extracted from a patient with a wound of the scalp. —Spec. 4526 and Spec. 4527, Sect. I, A. M. M. 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. They Avere 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 Diedrich Dasenbuck, Co. C, 151st Pennsylvania Volunteers, was wounded, at the battle of Gettysburg, July 1st, 1863, 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 check. He received another wound, the entrance being on the right side of the neck, at the border of the trapezius, tAvo inches Avithin 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 3d. He was treated for a feAV days in the Seminary field hospital, at Gettysburg, Penn- sylvania, and Avas then sent to Philadelpbia, and admitted, on July llth, to the hospital in Turner's Lane. On July 17th, the position of the larger foreign body Avas ascertained, and it was removed from the cheek, by an incision through the inner or buccal surface, from its lodgement immediately below the orifice of the duct of Steno. Both wounds 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 Avas 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 hard surface before inflicting the wound in the scalp. The two projectiles were con- tributed to the Army Medical Aluseum 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 lodgement 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. Nelaton: Case.—A soldier of the First Brigade, First Division, Fifth Corps, was wounded, on May 20th, 1864, in the advance from Spottsylvania toAvards the North Anna river, by a musket ball, which entered the left cheek over the canine fossa of the left superior maxillary, and passed outward and backAvard eight inches, without apparent injury to the bone, and lodged under the scalp above the nucha. The discoloration of the porcelain tip of a Nelaton probe passed through the long fistulous track, revealed the exact location of the ball, which was immediately extracted, on the field, by Surgeon T. M. Flandrau, 146th New York Volunteers. The notes ofthe case, together with the specimen, repre- sented in the Avood-cut (Fig. 28), were fonvarded by Assistant Surgeon J. Sim Smith, U. S Army. In a letter from Dr. Flandrau, dated Rome, 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 St John's Island, South Carolina, February llth, 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 irregularly triangular frag- ment of a shell was found beneath the integument, and was speedily extracted. Under appropriate treatment the wound healed perfectly in six weeks, the patient recovering without any impairment of vision. The specimen, contributed by Surgeon Brillantowski to the Aluseum, with the foregoing notes, is represented in the adjacent wood-cut. (Fig. 29.) Brevet Lieutenant Colonel C. H. Laub, Surgeon U. S. Army, lately informed the writer that, during the hostilities with the Seminoles in Florida, the lodgement 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 balls healed within two weeks, and there were no unpleasant consequences. Fig. 28.—Elongated ball extracted from be- neath the occipital re- gion of the scalp.—Spec. 3153, Sect. 1, A. M. M. Fig. 29.—Small cast-iron fragment, apparently from the base of a cvlindrical shell.—Spec. 2345) Sect. I, A. M. M. GUNSHOT WOUNDS OF THE SCALP. 93 Gunshot contusions of the head without breach of surface, of sufficient severity to cause ecchymosis, were invariably attended by commotion, concussion, or intracranial extravasation, and are classified, and will be 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 enlisted men were transferred to the Veteran Reserve Corps, after receiA'ing gunshot Avounds of the scalp. The reports to this Office afford no informa- tion 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 conse- quences, and the degree of disability, without specifying its nature. A critical examination of the returns constrains me to disagree with Neudorfer,1 Denonvilliers,2 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. 1 Neudorfer. "Im Kriege kommen derlei Verletzungen der Schiidelbedeckungen viel seltener vor, als man glauben sollte, weil die meisten Schussverletzungen des Kopfes sich nur ausserst selten auf die Weichtheile beschranken," u. s. w., in Handbuch der Kriegschirurgie, Leipzig, 1867. Zweite Halfte, Erstes Heft, S. 6. . 2 Denonvilliers et Gosselin. "Rarement les coups de feu bornent leur-action aux parties molles." Compendium de Chirurgie Pratique, Art. Lisions Traumatiques du Crane, T. II, p. 570, Paris, 1851. 91 WOUNDS AND INJURIES OF THE HEAD, 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 Avith 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 com- plications as erysipelas, gangrene, haemorrhage, tetanus, and pyaemia, in twenty-four cases. The remaining forty fatal cases include twenty-nine deaths, attributed to typhoid and malarial fevers, and pneumonia, 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 haemorrhage, erysipelas, sloughing, and abscess, will be offered in the next sub- section, 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. Remarks upon the cases of tetanus and pyaemia will more appro- priately find a place in the chapters specially devoted to the discussion of those important affections. The Army Medical Museum has but a single anatomical preparation1 illustrating gunshot wounds of the scalp; but possesses a large collection of photographs of patients with such injuries.2 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 photographs are faithfully copied in Plate III. The ordinary primary treatment of gunshot wounds limited to the scalp, consisted in washing the parts with a warm sponge, shaving the scalp in the vicinity of the wound, removing foreign bodies, and suppressing haemorrhage, 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 adhesive 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 dressings, a strip of muslin or lint spread with simple cerate, and kept in place by adhesive plaster, and thus avoided the 1 Sjiccimen 131 2, 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 sloughing ofthe contused edges. Sergeant J. F----, Co. K, 14th Maine A'olunteers, aged 31 years, wounded at Port Hudson, Louisiana, Alay 27th, admitted into hospital at NeAV Orleans, 29th Alay; died, June 7th, 1863. The specimen was contributed by Assistant Surgeon P. S. Conner, U. S. Army. See Catalogue of the Surgical Section ofthe Army Medical Museum, p. 38. - See Card Photographs, A. AI. M., A'ol. Ill, p. 1., (Case of Sergeant Coletrap;) Vol. Ill, p. 3, (Case of Private Folsom)—for illustrations of lacerations of the integuments of frontal and parietal regions, Avithout injury to the skull. See Phot Mulligan Vol' 4 Private Dem* Itullivtm. :> Virginia Cavalry .) liu-ll hi ■ i 1'nvnl. lVnitH-oKv >> oil < '.. 1) i;»a P.-mi" \..I" GUNSHOT SCALP WOUNDS AND CONTUSIONS OF THE SKULL GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 105 Scott, Pembroke, Private, Co. D, 198th Pennsylvania Volunteers, aged 25, was wounded, in an engagement at Gravelly Run, Virginia, March 29th, 1865, by a conoidal ball, which inflicted a avouih! 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 Avas transferred to City Point, A'irginia, Avhere he remained in the depot field hospital of the Ninth Corps until the 2d of April, when he Avas transferred to the Harewood Hospital, AVashington, D. C. ]>y April 29th, the Avound Avas doing Avell and healing kindly, and there were no indications of depression nor compression. On Alay 15th, he was transferred to the Satterlee Hospital, Philadelphia, Pennsylvania. On June 16th, several small pieces of the outer table of the skull Avere removed. The patient improved gradually, and was, on the 6th of July, 1865, discharged from service. The appearance of the Avound, Avhile the man was at HareAvood Hospital, is exhibited in the third figure of Plate III. Scott Avas pensioned to date from July 5th, 1865. In April, 1866, 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. JeAvell regarded the disability as permanent. Tree, Franklin, Private, Co. A, 20th Alaine Volunteers. Contusion and denudation of the vault of the skull for one inch by a musket ball. Gettysburg, July 3d, 1863. Treated at Seminary and Satterlee Hospitals. A scale of bone exfoliated. The Avound then healed, and the man Avas returned to duty October 23d, 1863. His name is not on the Pension Roll. Whitmcr, B. M., Captain, Co. G, 3d South Carolina Battalion, received, at the battle of Gettysburg, Pennsyh'ania, July 2d, 1863, a gunshot scalp Avound, Avith contusion of the cranium. He Avas admitted to the Confederate Hospital No. 10, Richmond, Virginia. Exfoliation of the external table of the bone took place. Captain Whitmer Avas furloughed on July 20th, 1863. Wilson, J. P., Lieutenant, Co. B, 9th A'irginia Regiment, received, at the battle of Spottsylvania Court-house, Virginia' May 10th, 18(31, a gunshot injury of the left parietal bone. The Avound of the scalp Avas about tAvo inches in length. He was, on Alay 24th, admitted to the Confederate hospital at Farmville, Virginia. An exfoliation of the bone took place, otherwise the case progressed favorably, and the patient Avas furloughed on July 1st, 1864. 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. A\tilson, Jarvis C, Sergeant, Co. I, 10th VT;sconsin Volunteers, aged 21 vears. Contusion of the occipital by a conoidal musket ball, Avhich lodged beneath the scalp below the semi-circular ridge, in enesaAV Mountain, Georgia, June 29th, 1864. The missile Avas extracted on the field by Assistant Surgeon R. G. James, 10th Wisconsin A'olunteers. Treated at Totten Hospital, Louisville, till August 26th, at Harvey Hospital, Madison, Wisconsin, till October 25th, and then sent to Mihvaukie to be mustered out. Pension Examiner C. F. Falley reports, May 24th, 1869, that there had been exfoliation of the external plate ofthe occipital, and that the muscles inserted into the curved lines ofthe occipital were indurated and contracted. The head Avas drown backward someAvhat, and the pensioner alleged that bending it forward caused dizziness and pain. He was totally disabled for manual labor; but Doctor Falley thought that he would ultimately improve. Gilkey. Francis AV., Private, Co. K, 10th Pennsylvania Reserves, Avas 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. The skull Avas necrosed, and probably there had been denudation, with contusion of the bone. Erysipelas supervened, folloAved by gangrene. When this was arrested, exfoliation trok 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 Fig. 30.—Exfoliation from without any further complications. He Avas discharged from service the parietals following gunshot 0n January 29th, 1863. His name does not appear on the Pension contusion. Spec. 5587, Sect. I, J ' A. M. M. Rolls. ^% FIG. 31.—Interior foregoing specimen. Hay, John AV., Private, Co. D, 61st Pennsylvania Volunteers, aged 29 years, was wounded, at the battle of Spott- sylvania, Virginia, May llth, 1864, by a conoidal ball, which struck obliquely about the middle of the forehead. He Avas 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 Mount Pleasant Hospital, on account of a gunshot scalp wound near the occipital protuberance, subsequently received in General Early's demonstration against the defences of AVash- ington, the day of the patient's admission. Gangrene attacked this later wound. Bromine, nitric acid, yeast, and charcoa} poultices were successively applied to the gangrenous wound. The sloughing was checked, and the Avound soon assumed a healthy appearance. The wound on the forehead was not affected by gangrene, and was supposed to be trifling, and was treated with simple dressings. 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, 1864, at the post mortem 14 106 WOUNDS AND INJURIES OF THE HEAD, examination, the brain Avas found to be slightly congested, but no pus was observed between the skull and dura mater; yei latter was detached from notes of the case were furnished by Acting Assistant Surgeon F. J. Kern. Caries.—Gunshot contusions of the cranial bones were succeeded, in three instances, by caries. This complication, common enough in tertiary syphilis, mercurio-syphilis, and scrofula, rarely occurs as a result of injury, unless there is some constitutional taint. There is no evidence, however, that any such vice of system existed in the cases of which abstracts are subjoined. The energetic treatment advised by authors,* such as applications of the rugine or trepan, the actual cautery, or chloride of zinc, red oxide of mercury, and other potent escharotics, Avere not employed in any of these cases. Price, Wii.li.vji, Private, Co. H, 8th Tennessee Infantry, aged 39 years, received, in the engagement near Atlanta Georgia, August 8th. 1864, a slight injury of the left parietal bone, and also a flesh Avound of the leg. He was taken to the field hospital ofthe 23d Corps, and, on August 15th, was admitted to the Asylum Hospital, Knoxville, Tennessee. No account of the treatment is recorded. He was discharged from the service on June 20th, 1865, and pensioned from that date. On Alarch 1st, 1869, Pension Examining Surgeon R. P. Mitchell reports that this man was living at Rogersville, Hawkins County, Tennessee; that he had caries of the skull, bits of bone passing out in the purulent discharge. The wound was still open and suppurating five years subsequent to the injury, and the man was utterly unable to perform manual labor, or to bear exposure to the sun's rays. Rubinson, J. A., Private, Co. B, 7th South Carolina Battalion, received, on June 18th, 1864, a gunshot contusion of the right parietal and right side of the frontal bone. He was admitted, on June 20th, to the hospital at Farmville, Virginia. The Avound resulted in extensive ulceration of bone. The patient was furloughed July 19th, 1864, by Surgeon H D. Taliaferro,C. S. A. Vaughan, George W., Assistant Surgeon, Tennant's Battery, received, at the siege of Atlanta, Georgia, August 19th, 1864, a wound of the head from a fragment of shell. The scalp Avas lacerated and the cranium contused, and caries of the occipital resulted. He Avas recommended for furlough, October llth, 1864, by a medical examining board. Persistent Pain in the Head.—Ten instances are found in the reports of cases of gunshot contusions of the skull, in which persistence of pain, either in the cicatrices or in distinct spots of the cranium, constituted the prominent symptom. Some of them belong to the class of cases described by Quesnay.f All of these patients were spared incisions of the scalp, or the application of the rugine or trephine; and five recovered and went to duty, while five were discharged for disability, two of whom were subsequently pensioned. * BOVEB, Dictionairc des Sciences Medicates, T. vii, p. 283, Paris. 1813; PlRME, The Principles and Practice of Surgery, London, 1860, p. 381; SEpili.ot. Traite de Medecine Operatoire, Paris, 1865, T. ii, p. 3: Fano, Traiti filementaire de Chirurgie, Paris, 1809, T. i, p. (184. The latter author even advises the ablation of the entire bone, citing Lapeyronie's case of removal of the whole frontal, and suggests the gouge and chisel and mallet as suitable instruments. t (jiesn ay. Memoires de VAcadimie Royale de Chirurgie. Nouv. ed., Paris, 1819, T. I, p. 169. GUNSHOT CONTUSIONS OF THK CRANIAL BONES. 107 Brunnello, Pietro, Private, Co. F, 55th NeAV York Volunteers. Gunshot contusion ofthe vertex ofthe cranium by a fragment of shell, with much laceration of the scalp. Malvern Hill, Virginia, July 1st, 1862. 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 AV. S. Forbes. He was suffering from severe local pain at the seat of injury. He was discharged from the service on February 25th, 1863. His name does not appear on the Pension Roll. Epesetkr, Charles J., Captain, 7th United States Colored Artillery, received, at the capture of Fort PilloAV, Tennessee, April 12th, 1864, a gunshot Avound 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 Avas always more or less pain extending backAvards from the seat of injury, nearly parallel Avith the median line. With every change to bad Aveather the pain would become intolerable, and exposure invariably aggravated it. Captain Epeneter resigned on March 16th, 1865. Hants, Enoch XV., Private, Co. C, 9th New Jersey Volunteers, aged 23 years, was wounded, at the battle of Kinston, North Carolina, December 14th, 1862, by a conoidal musket ball, Avhich apparently only involved the scalp. He Avas admitted to the Stanley Hospital at Newbeme on the 20th, whence he Avas furloughed and sent north in February, 1864. On the 8th of April, 1861, he Avas admitted into the Balfour Hospital, Portsmouth, Virginia, still suffering from the wound in the head. In the latter part of April he Avas transferred by steamer to the De Camp Hospital, in Ncav York Harbor, where the case is reported as a contusion of the skull. He Avas returned to duty on May 27th, 1834, but Avas again admitted to the Hampton Hospital, Fort Monroe, on June llth, 1864, suffering from cephalalgia. On June 21st, he was transferred to the Mower Hospital at Philadelphia, and finally sent to Trenton, NeAV Jersey, on September 22d, 1864, to be mustered out of service. His name does not appear on the Pension List. Hayes, AAtii.liam A., Private, Co. A, 28th Massachusetts 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 Alay 13th, 1867, was reported by the pension examiner to be very sensitive on pressure. It was particularly painful in warm weather and after exposure to the sun. King, Samuel, Private, Co. H, 49th Pennsylvania A'olunteers, 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 Philadelphia, 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 Avound healed gradually. On September 29th, he Avas 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. Laroste, S. D. M., Sergeant, Co. K, 23d South Carolina Regiment, was admitted to the South Carolina Hospital, Charlottesville, Virginia, September 6th, 1862, with a gunshot injury a little to the left of the median line and midAvay betAveen the eye and the root of the hair. There was an indentation of the bone, but no perceptible fracture. The periosteum was 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 operated upon. The case is reported by Assistant Surgeon B. W. Allen, P. A. C. S. AIarshall, James, Private, Co. H, 28th 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 Hospital, Washington, D. C, and, on January 8th, 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, Avhen he Avas returned to duty. Rate, Edward, 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, Avhere his Avounds were dressed. After the troops recrossed the river, he Avas sent to Point Lookout, Alaryland, Avhere 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 sIoav manner in which the Avound 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. Russell, W. P., Private, Co. L, 6th Alabama Regiment. Gunshot contusion of the left parietal, received at the battle of Fair Oaks, Alay 31st, 1862. Neuralgia supervened, and constant pain in the cicatrix for a long period after the injury. The patient was examined by Surgeons Welford, Thom, and Cabell, of the Confederate service, and for a long time he Avas unfit for duty. He finally recovered, and returned to duty March 5th, 1863. 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, 1866, Pension Examining Surgeon F. P. Fitch, of Milford, NeAV Hampshire, reported that he 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 have recovered from contusions of the skull. The cases of Hastings (p. 100), of Kinne (p. 103), of Marsh, Scanlan, Sheffler (p. 104), and of Wilson (p. 105), 108 WOUNDS AND INJUIES OF THE HEAD, haAre been 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, 27th Alissouri A'olunteers, received a contusion ofthe right frontal eminence by a conoidal musket ball, at the siege of Vicksburg, June 17th, 1863. He was discharged from service July 9th, 1865, and pensioned. On January 19th, 1866, he Avas reported by Doctor J. T. White, at Edina, Alissouri, as suffering greatly from vertigo, being entirely unfit to labor at his trade of brick-laying. G.vLMisn, George, Private, Co. H, 150th Pennsylvania A'olunteers. Gunshot contusion of the right parietal, at (iettysburg, July 2d, 1863. Treated at Gettysburg and Philadelphia, and discharged from serA'ice 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, Avith much cerebral disturbance, and Avas then troubled Avith 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 Alilitia, 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 Avas admitted into the field hospital on the same day, and subsequently transferred to Ncav York, and admitted, on July 27th, into the Central Park Hospital. He suffered from headache and vertigo. Simple dressings were used. He gradually recoA'ered, and was returned to duty, November 29th, 1863. Leighton, Charles W., Corporal, Co. E, llth New Hampshire Volunteers, aged 23 years, was wounded at the battle of Petersburg, Virginia, June 16, 1864, by a conoidal musket ball, Avhich contused the occipital bone. He was admitted to the hospital of the 2d division, Ninth Corps, and thence conveyed to Annapolis, Alaryland, and admitted, on the 20th, into the First Division Hospital. After several transfers, he Avas admitted into the AVebster Hospital, in NeAV Hampshire, on December 2d. On Alay 27th, 1865, he Avas discharged from service. In March, 1868, the Commissioner of Pensions reported that this man's disability Avas rated at one-half and permanent, and that he had been greatly troubled with vertigo since the reception of the Avound. Magnesk, W. A., Alusician, Co. B., 5th Maryland A'olunteers, aged 29 years, was wounded in front of Petersburg, July 6th, 1864, by a conoidal musket ball, Avhich tore up the pericranium over the right parietal protuberance. Treated at field hospital of the Eighteenth Corps, Balfour Hospital, Lovell Hospital, Patterson Park 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 Avere 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 Avas furloughed. AYooDUoiiNE, George AA'., 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, ATirginia, August 16th, 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 Avas regarded as permanent. Pension Examining Surgeon W. E. 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 be added the cases of McCarty (p. 100), and Crinyan (p. 103): England, Sam uel, Sergeant, Co. C, 9th Pennsylvania Reserves, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a buckshot, Avhich 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 bxfipital 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. During 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 Alassachusetts 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 llth, sent to the Turners Lane Hospital, Philadelphia. His general health was good, but he suffered considerable pain in the head. The wound, Avhich gaped very much, healed gradually, the headache ceased, and, on September llth, 1863, the jwtient was returned to duty. The case is reported by Actiug Assistant Surgeon David Burpee. Helmreich, Peter, Private, Co. A, 44th Illinois Volunteers, aged 29 years, received, at the battle of Peach Tree Creek, Georgia, July 2Uth, 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 Avas sent to Nashville, and admitted into the Cumberland Hospital. On August 6th, he was transferred to Louisville' and admitted into the BroAvn 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 Ouincy. He was discharged from service, June 10, 1865. The case is reported by Suryeon Horace Wardner, U. Su V. The name of this patient does not appear on tlie Pension List. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 109 Lake, Joshua, Sergeant, Co. B, 2d DelaAvare Volunteers, aged 19 years, received, at the battle of Antietam, Maryland, September, 17th, 1862, a gunshot contusion of the right parietal. He Avas admitted, on September 24th, to Walnut street hospital, 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, 1863, when he was transfsrred to Mower Hospital. During the progress of the case, the patient complained of headache, the cause being attributed to the Avound. On February 2d, a part of the ball, still remaining lodged, was removed, after which he did Avell, and, on the 25th of the same month, was able to do light duty, in the performance of Avhich he was engaged at the latest report. Laeghlin, Josiah D., Private, Co. G, 91st Ohio \7olunteers, aged 16 years, Avas wounded in an engagement at Winchester, A'irginia, July 20, 1861, by a revolver ball, which contused the skull at the junction of the sagittal and lambdoidal sutures. He Avas admitted into the hospital at Cumberland, Maryland, July 23d. There Avas cephalalgia and slight impairment of audition. The wound healed rapidly under the application of simple dressings, and the patient was returned to duty, August 18, 1861. McClung, George W., Private, Co. G, 12th A'irginia Volunteers, aged 22 years, was Avounded, March 6th, 1864, by a pistol ball, Avhich 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, tAvo inches from point of entrance, and contused the skull. Admitted to Cumberland hospital, Alaryland. He had headache and ringing in the ear, which continued for some days. He Avas returned to duty. Alay 26th, 1864. Moakly, E.. Private, Co. A, 14th Ncav York State Militia, aged 26 years, received, at the battle of Gettysburg, Penn- sylvania, July lst-3d, 1863, a gunshot contusion of the skull. He was, on July 6th, admitted to the Cuyler Hospital, GermantOAvn, Pennsyhrania. The injury Avas painful and caused much headache, and at times the patient was delirious. In a few Aveeks the Avound began to heal, and in September it had closed. The patient Avas returned to duty on February 10th, 1864, but he still complained of much headache after exertion. The case is reported by Acting Assistant Surgeon C. R. Prall. Xason, Alexander, Corporal, Co. C, 1st Alabama Artillery, aged 28 years, Avas wounded, at the capture of Fort Pillow, Tennessee, April 12th. 1861, by a conoidal musket ball, which struck the right side of the head, immediately above the ear, contusing but not fracturing the bone. He was, on April 14th, admitted to the hospital at Alound City, Illinois, and for weeks he suffered from headache, restlessness, and fever. On Alay 18th, he had entirely recovered, and, June 22d, 1864, he Avas returned to duty. Spurr, AVilllvm E., Sergeant, Co. A, 56th Massachusetts Volunteers, aged 23 years, received, in an engagement before Petersburg, Virginia, June 17th, 1864, a gunshot contusion of the skull. He was taken to the hospital of the 1st division, Ninth Corps, and, on June 30th, sent to the Alount Pleasant Hospital, A\rashiugton, Avhere he was treated for concussion of the brain. On July 22d, he was transferred to the Mower Hospital, Philadelphia, Pennsylvania. He Avas then suffering from headache. He Avas 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, A'irginia, 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 Avas first dressed, on June 7th, by Assistant Surgeon Reuben Hunter, 54th Pennsylvania Volunteers, Avho extracted five or six fragments of the ball, which Avere imbedded beneath the integument, and applied cold Avater dressings. He Avas admitted into hospital at Cumberland, Alaryland, on June 2Uth, and on June 23d the Avound Avas nearly cicatrized; suppuration had ceased, and the general symptoms were good, Avith the exception of an occasional headache. The patient's appetite and digestive poAvers were unimpaired. On July 20th, he left the hospital on furlough, but, not returning, Avas reported as a deserter, August 3d, 1864. His name does not appear on the Pension Rolls. Chronic Irritability 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 by grave structural lesions: Farnham, Noah L., Colonel, llth 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 Avound over the left parietal. He was much stunned, and fell from his horse. He was conveyed to the E Street Infirmary, AA'ashington, and placed under the care of Assistant Surgeon W. J. H. White, U. S. A. The wound healed promptly, and his condition was hopeful until August 10th, Avhen grave cerebral symptoms appeared, terminating in hemiplegia, followed by coma and death on August 14th, 1861. At the autopsy, 110 WOUNDS AND INJURIES OF THE HEAD, made by Assistant Surgeon J. XV. S. Gouley, U. S. A., an abscess, the size of an English walnut, was found at the seat of injurv, with extravasation of blood in the neighboring sulci of the brain. The folloAving description of this case Avas prepared by Surgeon John A. Lidell, U. S X. :* * * * "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 pia mater (connective tissue), denotes a genuine 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 superadded to the concussion. These cases of concussion, complicated Avith contusion of the nerve tissue, Avhen the cerebrum happens to be the part involved, exhibit a marked tendency to the occurrence of meningo-cerebral inflammation and cerebral abscess. The following case strongly corroborates this statement: * * Colonel Farnham, of the NeAV York City Fire Zouaves, was Avounded, at the battle of Manassas, July 21st, 1861, by a spent ball, which hit his head and knocked him off his horse. He was picked up insensible. The Avound Avas small in size, superficial in character, and situated on the left side of the head, three inches above the meatus 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 subsequent to the infliction of the injury. It Avas thought that he Avould recover, until about four days before death. He was partially paralyzed on the right side (hemiplegia) toAvard 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 Avas an unusual quantity of yelloAV-colored serum in the ventricles, and that there was an abscess of the cerebrum, situated directly beneath the Avound of the scalp. This abscess was about the size of an English Avalnut, 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 Avhile making the autopsy, though it was carefully done, the abscess Avas torn open. There Avere also traces of an extravasation of blood, three or four weeks old, in the sulci of the brain, beneath the visceral arachnoid membrane over the seat of the abscess, and likeAvise 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, Avas someAvhat thickened, roughened, and opacified." Medical Inspector F. H. Hamilton, U. S. A., has described this case as follows: t "First, I Avould remark, that you may ha\re 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 situation may be so injured as to lead to necrosis, or a sufficient shock may be given to the brain and its envelopes to bring on inflammation. 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 ofthe character referred to, and which I examined myself. It Avas a very slight and superficial wound, which seemed to have taken off very little more than the hair. He was transferred from the field to the Washington Infirmary, Avhere he was reported as doing very well, the wound being considered as a very slight and insignificant one; but, notAvithstanding 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 tAvo 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 Avas 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 Avas determined to lead his regiment to the charge. But his previous condition I do not think had much, if anything, to do with his death, which, in my opinion, and in the opinions of many other surgeons who saw him, Avas due directly to the apparently slight wound which he received during the fight." * * " Next, I called your attention to those injuries of the scalp produced 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 EllsAvorth Zouaves after the death of Colonel EllsAvorth. He received an injury of such a character, Avhich was exceedingly slight and superficial. I saw him myself, and examined him particularly, and all that Avas visible Avas a very trivial scalp Avound. He was taken into a hospital in Washington, and there I saAv 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 Avas certain. Three or four days after this, if I remember correctly, the symptoms 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 death after gunshot contusion of the cranium: CUTTING, A. H., Private, Co. K, 13th Alassachusetts A'olunteers, was wounded, at the battle of Gettysburg, July 2d, 1863, by a conoidal musket ball, Avhich caused a contusion of the frontal bone, just above and external to the right parietal eminence. He was admitted to Camp Letterman, and thence Avas sent to the McDougall Hospital, NeAV York, on July 12th. Meningitis supervened, and death ensued on July 30th, 1863, tAventy-seven days from the reception of the injury. The specimen * American Journal of the Medical Sciences, vol. xlviii, p. 323. t American Medical Times, vol. viii, pp. 73-8j. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. Ill is copied in the adjacent wood-cut (Fig. 34). The injured portion of the external table is porous and spongy, and a small scale of bone Avas 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 Avere contributed by Acting Assistant Surgeon A. E. M. Purdy. Johnson, C. R., Captain, Co. F, 16th Massachusetts Volunteers, received, at Gettysburg, July 2d, 1863, a scalp wound from a m'mi6 ball, which produced a con- tusion of the cranium. He was taken to the field hospital of the 2d division of the Third Corps, Avhen meningitis supervened, and he died on July 17th, 1863. Larkins, Daniel, Private, Co. H, 188th Pennsylvania Volunteers, aged 19 years, received, at the battle of Cold Harbor, Virginia, June 3d, 1864, a gunshot scalp Fig. 34.—Results ot coutusion ot the frontal J ' ' . . ' TT ° , bone by a conoidal ball, twenty-seven days Avound, with contusion of the left parietal. He was carried to the hospital of the after the injury. Spec. 1660, Sect. I, A. M. M. EigLteenth Col.pSi and, on June 6th, was transferred to the Harewood Hospital at Washington, and thence, on June llth, to the convalescent hospital, Philadelphia, Avhere he died, on June 26th, 1864, from meningitis, folloAving the Avound of head. Morris, James, Pri\rate, Co. I, 150tb Pennsylvania Volunteers, was admitted, on July 12th, 1863, to the McDougal! Hospital, Fort Schuyler, NeAV York, with compression of the brain, following a gunshot Avound of the scalp, with contusion of the skull. He died on July 18th, 1863. Thurm.an, C, Private, Co. E, 42d Pennsylvania Arolunteers, was, on May 30th, 1863, admitted to a hospital in Richmond, Virginia, with a gunshot Avound of the scalp, involving the cranium. He died on January 7th, 1864, of pneumonia and meningitis. Waterman, AA'illiam A., First Sergeant, Co. H, Michigan Cavalry, aged 27 years, Avas 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 Alt. Pleasant hospital, AA'ashington, 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, A'irginia, and, on August 17th, was transferred to the Satterlee Hospital, Philadelphia, where meningitis supervened, from which he died on August 26th, 1864. 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 AV., Co. K, 1st Ohio Volunteer , received, at the battle of Stone river, Tennessee, December 29th, 1862, a gunshot Avound, 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. Kennedy, Thomas, Private, Co. M, 1st Massachusetts Heavy Artillery, aged 30, was Avounded, at the battle of Petersburg, Virginia, June 16th, 1854, 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 Avas 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, Avith one-fourth of a grain of opium, were ordered evrery three hours, until the third dose had been taken; meantime, tonics and stimulants Avere given, and afterwards continued 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 ofthe 31st, remaining fully sensible and able to ansAver questions intelligently until within two or three hours of his death. At the autopsy, the seat of injury was found to be near the middle of the posterior edge of the right parietal bone: The missile had glanced doAvnward and forAvard, and Avas found lying against the skull, two inches from the point of injury. The pericranium was separated 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 point of 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 vessels 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 sixteen days after a gunshot contusion. Spec. 2920, Sect. I, A. M. M. 112 WOUNDS AND INJURIES OF THE HEAD, Reimer, 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 was taken on board an hospital steamer, and conveyed, on January 24th, to the McDougall Hospital, New York Harbor, Avhere he died, on February 9th, 1865, from inflammation of the brain. Sherron, Thomas, Private, Co. A, 15th Virginia Volunteers, aged 20 years, received, at the battle of Hatcher's Itun, A'irginia, Alarch 31st, 1865, a gunshot contusion of the cranium. He Avas admitted to the hospital of the 2d division of the Ninth Corps, and, on April 3d, Avas sent to the hospital at Fort Monroe, Virginia. Death occurred on April 16th, 1865, from meningitis and encephalitis. Sunday, Jacob C, Corporal, Co. C, 34th Illinois Volunteers, was, on May 9th, 1854, admitted to hospital No. 1, Chattanooga, Tennessee, Avith a gunshot contusion of the skull. He died on June 18th, 1864, from cerebritis. Welch, Charles, 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 AVashington, and admitted, on the 10th, into Harewood Hospital. The case seemed to be progressing favorably. The patient was sent, on June 16th, to NeAV 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 be found among the cases of trephining: Crane, Ethan, A., Alusician, Co. K, 44th NeAV York Volunteers, was wounded, at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, which struck the frontal bone on the right si e, near the median line, and glanced, apparently causing only a flesh Avound; the bone Avas barely bruised. He Avas 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 became 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 was found of a dark yellowish gray color, as in cases of osteo- myelitis in long bones. The pathological specimen was sent to the Army Medical Museum, and is numbered 1393 in Section I. The specimen and history were contributed by Assistant Surgeon H. Allen, U. S. Army. Smith, William, Private, Co. G, 4th New York Heavy Artillery, aged 18 years, was Avounded, at the battle of Hatcher's Run, Virginia, March 31st, 1865, by a conoidal ball, which caused a contusion of the left parietal bone. He was, on the folloAving 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 Cuyler Hospital, Philadelphia, Pennsylvania. On admittance no osseous lesion could be detected. The case progressed favorably until April 16th, when the patient had two or three slight convulsive paroxysms, lying in a somewhat soporose condition during the intervals. He afterwards became delirious, and finally almost completely comatose. The muscles of the left side of the body Avere observed to be in a state of spasmodic contraction, and a large collection of pus formed beneath the left side of the scalp, anterior to the wound, and was opened on April 29th. The path- ological condition Avas supposed to be, that an abscess, resulting from the original shock to the brain substance, was exciting irritation, and Avould probably eventually burst into one of the lateral ventricles. Mercurials, tartarized antimony, and the fluid extract of veratrum viride were exhibited internally, Avhile the head Avas kept somewhat elevated. Death ensued on the night of April 30th, 1865, 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 be detected when the scalp Avas 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 beloAV the original Avound. On remoA'ing the skull cap it was found that a plate of bone, about one inch long and three- quarters of an inch broad, had been separated by exfoliation from the inner table, and Avas adherent to the dura 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 OATer the middle lobe of the cerebrum Avas found to be acutely inflamed, 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 Avas healthy; on the left side, it Avas softened beneath the position of the wound, and, at the depth of about three-quarters of an inch, Avas a small abscess, not larger than a small hickory-nut. All other parts of the body examined appeared normal. The muscular contraction on the same side of the body as the wound was hoav accounted for by the existence of intracranial disease upon the opposite side. The case 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 in this class: Adams, J. E., Corporal, Co. F, 15th Alassachusetts Volunteers, received, at the battle of Ball's Bluff, Virginia, October 21st, 1861, a gunshot Avound of the scalp, Avith 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, Avith partial paralysis of the sensory nerves and diminution ofthe temperature. He was discharged from the service, Alarch 8th, 1862. His name is not upon the Pension Rolls. Arend, John, Private, Co. F, 46th NeAV A'ork A'olunteers, received, at the battle of South Mountain, Maryland, September 14th, 1862, a gunshot wound of the scalp, with contusion of the frontal bone. He was admitted to No. 1 Hospital at Frederick, on the 17th, and from there, on the 20th, was transferred to SteAvart's Alansion Hospital at Baltimore. He was discharged from the service, March 17th, 1863. on Avhich date Assistant Surgeon De Witt C. Peters, U. S. A., reports him as being greatly debilitated, and suffering from spinal irritation, with partial paralysis ofthe lower extremities, for which, treatment had afforded very little benefit. His name does not appear on the Pension List. Booth, John, Private, Co. E, 55th Pennsylvania Volunteers, aged 29 years, received, at the battle of Drury's Bluff, Virginia, Alay 16th, 1864, a gunshot Avound 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 Divison Hospital at Annapolis, Maryland. The patient was aftenvards sent to Camp Parole, and, on November 5th, transferred to the general hospital at Pittsburg. Paralysis of the left leg resulted, and he Avas discharged from service, May 20th, 1865, and pensioned. The case is reported by Assistant Surgeon H. R. Silliman, U. S. A. In August, 1867, Pension Examining Surgeon G. AlcCook reported that this pensioner was totally incapable of earning a living by manual labor, on account of partial hemiplegia, and that his disabilities Avere permanent. Brown, Presley I., Corporal, Co. B, 102d Pennsylvania Volunteers, aged 24 years, received, at the battle of the Wilderness. A'irginia, Alay 6th, 1864, a gunshot Avound of scalp, a conoidal ball entering at middle of left parietal bone, passing backwards, making a flesh wound two inches in length, denuding the bone. He was admitted to Lincoln Hospital, Washington, D. C, on May llth, and, on Alay 16th, was transferred to Patterson Park Hospital, Baltimore, Maryland; thence, on May 21st, to hospital at York, Pennsylvania. Acting Assistant Surgeon H. S. Smyser, under whose care the patient came at the latter hospital, reports that the patient stated that there Avas 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, Pennsylvania, whence he Avas returned to duty on May 9th, 1865. Bush, Aaron C, Lieutenant, 4th AVisconsin Cavalrj', 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 regimental 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 Avas discharged on August 30th, 1864, 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 loth, 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 Alonroe, and, on January 30th, was transferred to military prison, after which all trace of him is lost. The case Avas reported by Assistant Surgeon Ely McClellan, U. S. A. Cooke, R. H, 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. Curuy, John, Private, Co. A, 142d Pennsylvania Volunteers, was Avounded, at the battle of Fredericksburg, Virginia, December 13th, 1862, 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 seiwice 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 ofthe AVilderness, A'irginia, Alay 6th, 1864, a wound of the right side of the scalp, by a conoidal musket ball, -with contusion of the parietal. He Avas admitted into the Finley Hospital at Washington, May llth. Partial paralysis of the loAver extremities resulted. On August llth, the patient was sent to the Smith Hospital at Brattleboro', Vermont, and, on September llth, Avas transferred to the Baxter Hospital at Burlington. He was returned to duty, November 21st, 1864. The case is reported by Assistant Surgeon S. W. Thompson. U. S. V. Garland, James W., Corporal, Co. G, 5th Wisconsin Volunteers, aged 23 years, Avas wounded at the battle of Cold Harbor, Virginia, June 1st, 1864, 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 scalp, about tAvo inches in length by one inch in width, and contusing the cranium. He Avas unconscious for about ten minutes, the control of the lower extremities Avas lost, and sensation was impaired. Spasms and temporary partial paralysis of the upper extremities supervened. On June 6th, he was admitted to First Division Hospital at Alexandria, Virginia. On June 28th, he Avas transferred to McClellan Hospital, Philadelphia, and thence, on July 6th, to Turner's Lane Hospital. At the latter date, the patient suffered from severe headache, and the power of motion of the left leg was still impaired, though his general health Avas good On July 20th, a 15 114 WOUNDS AND INJURIES OF THE HEAD, small piece of bone exfoliated, and was removed. Patient Avas gradually regaining the use of left leg. On November l.'th, the wound was reported as being healed. During the treatment, he had three paroxysms of intermittent fever. The patient was transferred to the Areteran Reserve Corps on Alarch 17th, 1865. The case is reported by Surgeon Robert A. Christian, U. S. V. He Avas discharged from service. September 26th, 1865. In 1866, Pension Examining Surgeon J. H. Gallagher reported that he had slight paralysis of the left leg, and headache and faintness on exposure to the sun. Any excitement or study aggravated these symptoms. The examiner regarded these symptoms as likely to increase in severity. Henslcy, H. S., Sergeant, Co. C. 16th North Carolina Regiment, aged 24 years, was Avounded, on Alay 22d, 1864, by a conoidal ball, Avhich inflicted a severe Avound of the scalp, and probably, a contusion of the skull. Paralysis of the loAver extremities ensued. He was admitted to the field hospital of the 1st division, Fifth Corps, and, on Alay 29th, Avas transferred to Alount Pleasant Hospital, Washington; thence, on July 14th, to Lincoln Hospital, whence he Avas transferred to Old Capitol Prison on August 30th, 1864, and finally exchanged. Inoersoll, Frank D., Private, Co. E, 26th New York Arolunteers, was, on September 24th, 1862, admitted to the Carver Hospital, Washington, D. C, with a shell Avound of the head, lacerating the scalp and contusing the outer table of the skull. He Avas discharged on January 12th 1863, on account of debility and deranged innervation. His name does not appear on the Pension List. Keser, AVallace, Private, Co. F, 126th NeAV York A'olunteers, aged 25 years, received, in the engagement at Harper's Ferry, Virginia, September 13th, 1862, 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 Avas discharged from service on January 7th, 1863. He is not reported as being an applicant for a pension. McFoley, James, Private, Co. A., llth Pennsylvania Reserve, aged 35 years, was Avounded at the battle of Spott- sylvania, Virginia, Alay 10th, 1864, by a conoidal ball, Avhich passed through the scalp, grazing the left parietal bone near the sagittal suture. He Avas conveyed to the Mount Pleasant Hospital, AVashington, and, on Alay 19th, Avas sent to the Camden Street Hospital at Baltimore. Hemiplegia of the right side had supervened. He Avas transferred to Annapolis, June 22d, and, on August 10th, to Pittsburg, where he Avas 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 NeAV Hampshire Volunteers, received, at the battle of Chancellorsville, Virginia, May 3d, 1863, 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 Avas admitted, on June 14th, to Alansion House Hospital, Avhence he Avas transferred, on the 16th, to hospital at Concord, New Hampshire. Paralysis of both lower extremities ensued, and the patient suffered from constaut uneasiness and pain in the head. He Avas examined by Surgeon J. W. Buchanan* U. S. V., and discharged from the service on the 12th of August, 1863. His name does not appear on the Pension List. Miles, Levi. Private, Co. C, 52d Indiana Volunteers, aged 50 years, was Avounded at Fort De Russy, Louisiana, March 14th, 1864, by a conoidal ball, Avhich entered through the lobule of the left ear, and emerged at the nape of the neck, beloAV the occipital bone, contusing in its course, but not fracturing, the temporal bone. He was sent, on March 16th, to the hospital steamer AVoodford, and, on April 30th, Avas transferred to the hospital steamer R. C. AVood. On Alay 8th, he was sent to NeAV Orleans, and thence to the Overton Hospital at Memphis, Tennessee. He Avas returned to duty on September 5th, 1864. On February 13th, 1865, he Avas admitted to the Washington Hospital at Memphis, suffering from frequent attacks of trembling, and other symptoms of paralysis. The Avound had not yet healed. He was discharged from service on April 20th, 1865. Pore, Theodore, Private, Co. C, 9th Ohio Volunteers, received, at the battle of Chickamauga, Georgia, September 19th, 1863, 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 the left parietal bone. On December 30th, 1863, he entered Washington Park Hospital, Cincinnati, and, on January 8th, 1864, was sent to Camp Dennison, Avhere 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 Ararian, U. S. V. Remick. Martin, Private, Co. I, 79th Illinois Volunteers, aged 19 years, was wounded, at the battle of Murfreesboro', Tennessee, December 31st, 1862, 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 fracturing, the bone. He Avas, on January 25th, 1863, admitted to Hospital No. 5, Alurfreesboro'; on February 16th, he Avas sent to Hospital No. 8, Nashville; on Alarch 1st, to Hospital No. 13, Louisville, Kentucky; and, on March 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 Avas subject to many nervous symptoms. He was discharged from the service on MaA* 18th, 1865. He is not an applicant for a pension. Snyder, Joskpii, Colonel, 7th AA'est Virginia Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862. a severe gunshot contusion of the skull. The bone was denuded of periosteum, and slight paralysis of the left arm supervened. The patient aa as treated in private quarters, was? furloughed on December 18th, 1862, and finally discharged from the service on September 7th, 1863. 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, Avith contusion of the cranium, received on September 24th, 1863. Hemiplegia resulted from the njury, and the patient was furloughed for sixty days on November 24th, 1863. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 115 Sterling, William, Private, Co. B, 44th Illinois Volunteers, aged 32 years, was wounded, at the battle of Kenesaw Mountain, Georgia, June 27th, 1864, by a fragment of shell, Avhich struck the right supraorbital ridge, injuring the frontal bone and destroying the right eye. He had previously received, at the battle of Chickamauga, Tennessee, September 19th, 1863, a flesh Avound of the right arm. He was, on November 29th, 1864, admitted to the hospital steamer R. C. Wood, and, on December 1st, transferred to the hospital at Mound City, Illinois. Chronic neuralgia of the right supraorbital nerve followed. The patient Avas discharged from the service on February 16th, 1865. The strength and usefulness of the right arm Avere impaired. His name does not appear on the Pension Rolls. Siiekiran, Thomas, Private, Co. B, 3d United States Cavalry, aged 27 years, was Avounded, near Little Rock, Arkansas, October 16th, 1804, in the head by a conoidal ball, which lodged beneath the scalp, near the right ear. He Avas admitted, on October 23d, to the hospital at Little Rock. Convulsions supervened, and death occurred on December 23d, 1864. Thompson, Kund, Private, Co. I, 82d Illinois Volunteers, aged 30 years, received, at the battle of Chancellorsville, Virginia, Alay 3d, 1863, a Avound by a pistol ball, Avhich 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, 1803, and transferred to Douglas Hospital at Washington on July 21st, During the progress of the case, paraplegia ensued. The patient also suffered from a general aud constant pain in the head. He Avas transferred to Christian Street Hospital at Philadelphia on September 15th, 1863. Assistant Surgeon XV. XV. Keeu, U. S. Army, reports that, on the date of his discharge, although suffering from an evident disease of the brain, he had so far improved as to be able to walk. Discharged February 17th, 18o4. His name does not appear on the Pension Rolls. Wagoner, Jeremiah, Private, Co. G, 85th Illinois Volunteers, aged 25 years, was Avounded, in an engagement at Peach Tree Creek, Georgia, July 19th, 1804, by a musket ball, Avhich 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 Avas admitted to the hospital at the latter place ou September 4th, 1864, at which time the Avound Avas 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 Avas transferred on September 23d, and, on the following day, admitted to hospital at Quincy, Illinois, Avhere he remained until returned to duty, April 12th, 1865. Loss 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 Avere the consec- utive 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, Avhich 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 feAV days, later sent to the Chesapeake Hospital at Fort Alonroe. On July 4th, the patient Avas transferred to Philadelphia, and admitted into the AlcClellan Hospital. On August 8th, he Avas sent to Turner's Lane Hospital. There Avas ptosis of the eyelids of both eyes, and loss of vision for some days. On May 10th, he Avas again received into the AlcClellan Hospital, and on July 13th, 1865, Avas mustered out of service. The case is reported by Surgeon LeAvis Taylor, U. S. A. The name of this patient does not appear on the Pension List, Bczzell, Hiram H., Private, Co. G, 40th Alassachusetts Volunteers, aged 38 years, received, in an engagement before Petersburg, A'irginia, in June, 1864, a contusion of the skull, by a fragment of shell. He Avas admitted into the hospital of the Eighteenth Army Corps on July 1st. On July 2d, he Avas transferred to the general hospital at Fort Monroe, Virginia. Conjunctivitis supervened. He Avas 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 Avound of the scalp, Avith contusion of the bone. He was admitted, on the folloAving day, to hospital No. 1, Nashville, and, on Alay 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, A'irginia, May 3d, 1863, a contusion of the right parietal bone, by a fragment of shell. He Avas admitted into the Held hospital of the 1st division of the Second Corps on the folloAving day, and, about June 13th, was sent to the hospital at Point Lookout, Maryland On September 20th, be was transferred to the MoAver Hospital at Philadelphia. Vision was much impaired. On December 22d, 1863, he Avas returned to duty. Graham, 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. He Avas admitted on the same day to hospital No. 3, Knoxville; on Alarch 8th, 1864, he was sent to the hospital at Cleveland, Ohio, and, on April 7th, 1864, transferred to the Veteran Reserve Corps. On July 6th, he was admitted to the Satterlee Hospital, Philadelphia, suffering from granular conjunctivitis. He Avas discharged from the service on July 6th, 1865, on account of impaired vision, the result of gunshot wound of the head. His name is not upon the Pension Roll. Hays, E. B., Private, Co. H, 21st Mississippi Regiment, was admitted into Jackson Hospital, Richmond, Virginia, Avith a gunshot Avound of left temporal region, received Alarch 25th, 1865. A'ision was impaired. 116 WOUNDS AND INJURIES OF THE HEAD, Hagan. Thomas, Captain, Co. G, 71st Pennsylvania A'olunteers, received, at the battle of Antietam, September 17th, 1863, a gunshot wound over left parietal bone, causing amaurosis of both eyes. He was unable to do duty until November 16th, when he joined his regiment, but was compelled to apply for sick leave again on December 19th, 1862. He resigned on February 7th, 1863. The loss of vision Avas almost complete in the left eye. and the right eye was only impaired. In April, 1H55, Pension Examiner T. F. Smith, of New A'ork, reports that the left iris Avas very much dilated; that he could not read other than the very largest type. James, AV. J., Sergeant, Co. F, 83d Ohio A'olunteers, was wounded at the battle of Arkansas Post. Arkansas, January llth, 1863, by a conoidal musket ball, Avhich 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 Avas, for a short time, nearly lost. He was taken to the hospital steamer D. A. January, on January 13th, and conveyed to Memphis, Tennessee, Avhere he was admitted, on the 23d of the month, into Hospital No. 3. In the course of tAvo or three days, he Avas seized with convulsions, Avhich recurred at intervals of three or four Aveeks. The vision ofthe right eye Avas more affected than that of the left, and seemed to vary Avith the condition of the Avound. He Avas 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 patieut Avalked with a feeling of giddiness and insecurity, the cerebral symptoms not being in any degree alleviated, though his general health Avas good. In July, 1868, James was a pensioner at six dollars per month, his disability being rated at three-fourths. Lanigan, James, Private, Co. E, 25th Alassachusetts Volunteers, received, in an engagement before Petersburg, Virginia, June 23d, 1861, a gunshot contusion of the skull. He was admitted to hospital at Hampton, Virginia, on June 25th, and, on July 4th, sent to Filbert Street Hospital, Philadelphia. On July 24th, he Avas transferred to Summit House Hospital; thence, on August 24th, to Satterlee Hospital, Avhere, on May 20th, 1865, he Avas 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, Alay 5th, 1864, a wound of the frontal region by a conoidal musket ball, Avhich scraped the bone. He Avas admitted into the field hospital of the 3d division, Second Army Corps, and, afeAV days later, sent to AA'ashington, and admitted, on Alay llth, into the Finley Hospital. Simple dressings. The patient Avas transferred to Philadelphia on May 18th, and was admitted into the South Street Hospital. On Alay 16th, 1865, he Avas sent to the Summit House Hospital, and, on July 5th, 1865, he Avas discharged from the serA'ice. The case is reported by Surgeon S. J. Y. Mintzer, U. S. V. He Avas pensioned July 6th, 1865, and, in May, 1867, Pension Examiner T. B. Read reported that his eyesight Avas much impaired, and that he suffered from giddiness and headache, and he thought the pensioner's disabilities permanent, though some amelioration might be anticipated. Neil, AA'm. H., Captain, Co. D., 26th NeAV York Volunteers, was Avounded at Fredericksburg, Virginia, December 13th, 1862, by a conical ball, which passed across his forehead about an inch above his eyebrows, making a very slight Avound, hardly sufficient to draAV blood, but probably contusing the os frontis. He was instantly rendered totally blind; at the same time, the motor nerves near the eye Avere paralyzed, so that the lids drooped, notAvithstanding every effort he made to raise them. The eye-balls were entirely devoid of expression. He Avas admitted to regimental hospital, and thence sent to general hospital. Surgeon W. B. Coventry, avIio reports the case, states that he incidentally learned afterwards that the patient commenced to recover the sight of one eye. This officer's name does not appear on the rolls of the Pension Bureau. Newson, John G., Sergeant, Co. B, 30th North Carolina Regiment, aged 18 years, was Avounded, in an engagement at Kelly's Ford, Virginia, November 7th, 1863, 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 Avas 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 Avas free from pain and able to walk about. His appetite had improved, and the discharge from the Avound looked healthy. He Avas transferred to the Lincoln Hospital, and, on December 7th, 1863, sent to the Old Capitol Prison. The case is reported by Acting Assistant Surgeon Carlos Carvallo. Plott, Lewis, Sergeant, Co. A, 71st Ohio Volunteers, aged 25 years, Avas Avounded in an engagement in front of Nashville, Tennessee, December 15th, 1864, by a conoidal musket ball, Avhich contused the frontal bone, aud destroyed the vision of the right eye. He was admitted, on the 17th, into Hospital No. 1, Nashville, and, on the 22d, transferred to Hospital No. 15, ofthe same city. On the 4th of January, 1865, he was sent to the Brown Hospital at Louisville, Kentucky, and, in Alarch, transferred to (.'amp Dennison, Ohio. Simple dressings constituted the main treatment. He recovered, and was discharged from service on the 13th of June, 1865. The Commissioner of Pensions reports, December llth, 1869, that Plott is a pensioner at four dollars per month. The sight of the right eye is destroyed, and the hearing impaired as Avell. SorDER. Andrew, PriA-ate, Co. C, 3d Alichigan Volunteers, aged 30 years, in the action at Groveton, A'irginia, August 27th, 1862, receiA-ed a gunshot contusion of the left temporal region. He was admitted into the GeorgetoAvn College Hospital, I). C, on December 13th, aud, on January 2d, Avas transferred to Philadelphia, and admitted into the MoAver Hospital. Loss of vision of the left eye resulted. He Avas discharged from service, February 21st, 1863, 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 AA'ilson Jewell, the patient Avas unable to open his mouth more than half an inch. Deafness—The cases of King (p. 101), and of Chamberlain (p. 119), and those detailed in the fourteen following abstracts are examples of deafness following gunshot contusions of the skull: AlilVS, Ciiari l>, Private, Co. I, 15th New York Artillery, aged 30 years. Contusion of the left temporal by a piece of shell. Weldon Railroad, August 20th, 1864. Treated at field ho>pital of Fifth Corps, and Mount Pleasant, Washington* GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 117 Discharged from service, June 20th, 1865, on account of deafness of the left ear and facial neuralgia, by Assistant Surgeon H. Allen, U. S. A. His name does not appear on the Pension List. Benson, Stephen D., Sergeant, Co. A, 31st Alaine Volunteers, aged 20 years, was wounded at the battle of Spottsyl- vania Court House, A'irginia, May 12th, 1864, by a conoidal ball, which entered the left side of the head, one inch behind the meatus auditorius externus, on a line Avith its opening, and emerged close to the acromion process of the right scapula. He was entirely unconscious for several hours, but bad some realization of pain in the evening, when he made an ineffectual effort to get on his feet. He was admitted to the hospital of the 2d division of the Ninth Corps, and, on May 24th, Avas sent to the Harewood Hospital, Washington. For about three Aveeks there Avas much mental aberration, especially at night. Assistant Surgeon Sumner A. Patten, aa'Iio reports the case, examined the patient on June 20th, 1864. The wounds of entrance and of exit discharged freely. There Avas numbness of the left side of the head, and deafness of the left ear. The scalp in the vicinity ofthe wound was much sAvollen. On rising to his feet, he was so dizzy that he was compelled to lay hold of something to avoid falling. Occasionally small pieces of necrosed bone Avere 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, 1866, Doctor Patten wrote that this officer had not been able to labor since the reception of the injury; that there Avas a constant feeling of 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 Avas deteriorated, and he Aveighed but 144 pounds, having weighed 163 Avhen he enlisted. In September, 1868, Examining Surgeon E. F. Sanger reported that this pensioner, residing in Bangor, Maine, had total deafness of the left ear, and that his general health Avas 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, 1862. The missile entered over the inferior curved line ofthe occipital bone, two inches to the left ofthe median line; it then passed forward, immediately below the auditory foramen, and produced a large lacerated exit wound in front of the ear. He was admitted on September 6th to Judiciarv Square Hospital, at Washington, D. C. At the end of the third Aveek, although his Avounds had nearly closed, there was an entire loss of hearing on that side, the recovery of which the probabilities Avere very unfavorable. He Avas discharged from the service, December 16th, 1862. His name does not appear on the Pension List. This case is reported in the Boston Medical and Surgical Journal, volume 67, page 493. Dcngan, T. J., Private, Co. F, 46th Pennsylvania Volunteers, received, in an engagement at Cedar Mountain, Virginia, August 9th, 1862, a gunshot wound ofthe right temple. The bone near the auditory foramen Avas 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 heAvas discharged from the service on November 12th, 1862. The sense of hearing Avas impaired, and the right side of the face paralyzed. In March, 1863, Pension Examiner G. McCook, of Pittsburg, Pennsylvania, reported this man's disabilities permanent and incurable. In November, 1867, Pension Examiner E. SAvift reported that the sense of hearing ou the right side Avas almost entirely lost, and that facial paralysis existed, together Avith 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, Alay 9th, 1864, a contusion of the left parietal by a conoidal musket ball. He Avas treated in a field hospital until May 16th, Avhen he Avas transferred to Nashville, Tennessee, and remained in Hospital No. 19, until May 19th, when he Avas sent to Clay Hospital, Louisville, Kentucky, and thence, on June 29th, to Camp Dennison, Ohio, from whence he Avas discharged from the service, August 27th, 1864, by reason of deafness and impaired mind. His name does not appear on the Pension List. Surgeon A. P. Ararian, U. S. V., reports the case. Gregory, Adam, Corporal, Co. H, 18th Ohio Volunteers. Shell contusion ofthe skull. Chickamauga, September 19th, 1863. Treated at Cumberland Hospital, Nashville. Slight deafness resulted. Returned to duty September 28th, 1863. He does not appear to be a pensioner. Havens, 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, 1864. Treated at regimental, Hilton Head, AIcDougall, and Elmira Hospitals, and discharged from service May 25th, 1865, and pensioned. In September, 1868, Examining Surgeon John S. Pfouts reports that this man had complete deafness of the left ear. Kroesen, Cyrus, Private, Co. A, 77th Illinois Volunteers, was wounded at the battle of Arkansas Post, January llth, 1863, 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 Avas conveyed to Memphis, Tennessee, by the hospital steamer D. A. January, and admitted, on January 22d, to the Adams Hospital. Audition ofthe left ear Avas entirely destroyed; that of the right ear is perfect. The wound healed without any untoward symptom. He was returned to duty July 2d, 1863. His name does not appear on the Pension Rolls. Peppers, Maktin, Private, Co. D, 3d Iowa Arolunteers, Avas, on November 4th, 1862, admitted to the hospital 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, 1802 The injury was folloAved by abscess of the frontal sinus. The patient was discharged from the service on Alarch 30th, 1863. His name does not appear on the Pension List. Pulliam, Elijah C, Private, Co. H, 32d Illinois Volunteers, received, at the battle of Shiloh, Tennessee, April 6th, 1862, a wound of the scalp in the occipital region, with contusion of bone, by a buckshot. His hospital history previous to August 6th, the date on which he was admitted to House of Refuge Hospital at St. Louis, Missouri, is wanting. Erysipelas supervened. The patient suffered several relapses of the disease, Avhich finally terminated in abscesses behind both ears causing temporary deafness on the left side. He avus discharged from the service on October 15th, 1862. His name is not recorded on the Pension Rolls. 118 WOUNDS AND INJURIES OF THE HEAD, Raaadox, James, Corporal, Co. K, 34th Alassachusetts Arolunteers, aged 18 years, was Avounded, at the battle of Ncav Alarket, A'irginia, Alay 15th, 1S04. by a fragment of shell, Avhich lacerated the scalp over the posterior border of the left parietal bone to the extent of two inches, and contused the bone. He Avas conveyed to the hospital at Cumberland, Maryland. The Avound 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 26th, 1864, the man Avas returned to duty. His name does not appear upon the list of pensioners. Risa, A. H., Private, Co. I, llth North Carolina Infantry, received, July 1st, 1863, a gunshot scalp Avound of the temporal region, with contusion of the bone. He Avas admitted into the Moore Hospital No. 21, Richmond, October 28th. Audition impaired. On November 4th, 1863, he was furloughed for sixty days. Thurston, AA'illiam F., Surgeon 1st Rhode Island Artillery, was wounded, at the battle of Fair Oaks, June 28th, 1^62. by a ball from a spherical case shot, which struck his left parietal bone, contusing but not fracturing it. Notwithstanding his injury, be continued to attend the wounded of his regiment till a few days after the battle, Avhen 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 6th, 1863, he was mustered out of service, and pensioned. In April, 1869, Pension Examining Surgeon C. Hoppin reported that he was completely deaf, and a great sufferer from vertigo. AVinsor, AV. H., Captain, Co. F, 18th Alassachusetts Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot Avound 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, 1862, he reported to Surgeon Thomas Antisell, at AVashington, D. C, Avho reported the injury as a scalp wound, with contusion of the left temple, Avith loss of hearing on that "side. He was furloughed on December 19th for twenty days. Resigned March 15th, 1863. 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, H. V., Private, Co. A, 5th Virginia Cavalry, aged 29 years, received a wound, by a pistol ball, on October llth, 1863, above the left superciliary ridge. The Avound Avas contused, and the ball passed out from under the ligaments about the left jaAV, after causing a concussion of the brain, resulting in aphasia. He was admitted to the Chimborazo Hospital, Richmond, October 23d, 1863, and Avas furloughed on the 17th of the following month, his speech being partially regained, though he could not formulate sentences in his mind. Helmes, J. C, Private, Co. F, 48th North Carolina Infantry, received a gunshot Avound of the scalp, contusing the skull. He Avas admitted into the No. 8 Hospital, Richmond, on September 28th, 1862. 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 Alassachusetts Volunteers, was discharged from the service on October 19th, 1862, at Camp Convalescent, Fort McHenry, Maryland. He had been wounded in the head in March, 1882, near NeAvberne, North Carolina, by a fragment of shell, which lacerated the scalp and contused the left parietal. Twice afterwards, he Avas attacked by epileptiform convulsions. He was pensioned and, December 27th, 1862, Pension Examining Surgeon G. S. Jones reported that he suffered from convulsion, that his memory was impaired, and that he was unable to labor. Davis, AA'illiam E., Private, Co. C, 28th Kentucky Volunteers, aged 21 years, Avas wounded in the engagement before Marietta, Georgia, June 27th, 1864. The missile entered just above the left, and escaped above the right superciliary ridge, contusing the frontal. He was admitted to the field hospital of the Fourth Corps, and, on the next . ay, sent to the general field hospital at Big Shanty; on July 18th, to hospital No. 2, Chattanooga, Tennessee; on July 20th, to the Cumberland Hospital, Nashville; on August 3d, to the Foundry Hospital Kentucky; and, on October 12th, to the Brown Hospital, Louisville, Kentucky, whence he Avas returned to duty on Alarch 8th, 1865. In the various hospitals, he is reported as suffering from epilepsy. His name does not appear on the Pension Rolls. Harmon, Gilbert J., Sergeant, Co. F., 1st New York Cavalry, aged 18 years, was admitted into the hospital at Parkersburg, A'irginia, September 26th, 1864, with a gunshot contusion of the skull. He Avas pale, emaciated, and weak, and subject to epileptic convulsions. He had not done duty for sixteen months, and being unfit for the Veteran Reserve Corps, he was discharged from the service on November 18th, 18L.4. His name is not on the Pension List. Miller, Noah, Private, Co. H, 91st, Pennsylvania Volunteers, aged 33 years, received, in the battle of Fredericksburg, A'irginia, December 13th, 1862, a gunshot wound of the scalp, with denudation of the cranium. He was conveyed to AVash- ington, and admitted, on the 17th, into the Mt. Pleasant Hospital. On January 5th, 1863, the patient was transferred to the Mower Hospital, Philadelphia. On May 2d, he was seized Avith an epileptic convulsion, Avhich continued two hours, He also suffered from rheumatism. Discharged from service, September 21st, 1863. Surgeon Joseph Hopkinson, U. S. V., reports the case. The name of the patient is not upon the records of the Pension Office. Preiss. Charles, Sergeant, Co. A, 40th NeAv A'ork Arolunteers, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which caused a gunshot scalp Avound over the occipital, with contusion of the outer table. He was taken to the hospital of the 1st division, Third Corps, and, on September 5th, 1863, Avas admitted to the Ladies' Home Hospital, New York-. He was discharged from the service on December 12th, 1863, Buffering from epilepsy. His name is not on the records of the Pension Office. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 119 Stroud, H M., Private, Co. F, 4th South Carolina Infantry, aged 23 years, received, on May 20th, 1864, a gunshot wound of the left side of the head. He was admitted into the Jackson Hospital, Richmond, Virginia, on the 24th. Frequent attacks of epilepsy fblloAved, and he Avas retired upon a surgeon's certificate of disability, March 25th, 1865. Sullivan, Timothy, Private, Co. D, 2d Massachusetts Cavalry, Avas admitted to the field hospital at Sandy Hook, Marvland, after the battle of Cedar Creek, Alrginia, Optober 19th, 1865, where he Avas treated for epilepsy. From here, he was transferred, successively, to Jarvis Hospital at Baltimore; Cuyler Hospital at Germantown, Pennsylvania; Turners' Lane Hospital at Philadelphia ; and finally, on May 10th. 1865, to McClellan Hospital. Here the cause of the disease was attributed to a gunshot wound of the scalp, Avith contusion of the skull, but as his name does not appear on the list of casualties, and as his wound is not mentioned in the reports of the hospitals in which he had been previously treated, it is not certain that his disease can be traced to this cause. He was discharged from service, June 25th, 1865, and pensioned. Pension Examiner G. S. Jones reports, in July, 1865, that this pensioner had depressed cicatrices on the top of the head, and suffered greatly from epilepsy, and that his disabilities Avere probably permanent. Wallace, AA'illiam, Private, Co. A, 23d Ohio Volunteers, received, at the battle of Antietam, Maryland, September 17th, 1862, a gunshot scalp wound, implicating the pericranium. He Avas admitted, on September 21st, into the Capitol Hospital, Washington, and, on the 25th of the same month, transferred to the Ward Hospital, NeAvark, New Jersey. He is reported as returned to duty on Alarch 26th, 1863; but, on July 23th, he was admitted into the general hospital at Gallipolis, Ohio. Epileptiform commlsions supervened upon long-continued exertion. He was transferred to the Veteran Reserve Corps, October 30th, 1803. The case is reported by Acting Assistant Surgeon James R. Beel. The name of this patient is not upon the Pension Rolls. Wallers, George W., Private, Co. C, 51st A'irginia Infantry, aged 24 years, received, at the affair at Fayetteville, Virginia, September 10th, 1862, a Avound at the anterior and superior portion of the right temporal region by a fragment of shell. Epilepsy resulted, and he was discharged from the service upon a certificate of disability, February 14th, 1865. The case is reported by Surgeon James Thomas Cropp, 51st Virginia Infantry. Mental Aberration.—In the following cases, gunshot contusions of the cranial bones produced such lesions of the brain as led to insanity: Chamberlain, Cornelius AV., Corporal, Co. B, 10th New Hampshire Volunteers, aged 28 years, in an action near Fort Harrison, A'irginia, September 30th, 1864, received contused wounds of the head, trunk, and upper extremities, by fragments of shell. He was admitted into the general hospital of the Eighteenth Corps, at Point of Rocks, Virginia, on October 9th, and, on October 26th, sent to the hospital at Fort Monroe. On November 4th, he was furloughed, and, on the 18th, examined for discharge, at Concord, New Hampshire. Partial paralysis of the right side resulted. There was a purulent discharge from the right ear, and audition was impaired. There was, likewise, constant aberration of the mind. He was discharged from service, January 16th, 1865, Avith a degree of disability rated total. He receives a pension of eight dollars per month. Colvtn, Perry, Private, Co. C, 47th Pennsylvania Volunteers, aged 30 years, received, at the battle of Cedar Creek, Virginia, October 19th, 1864, a contusion of the left parietal by a fragment of shell, about an inch from the median line. He Avas admitted into the AIoAver Hospital, Philadelphia, from the field, on October 23d. About two weeks after the reception of the injury, a haemorrhage of blood, which afterwards became purulent, took place from the right, and, subsequentlv, from the left ear. Tavo months later, a piece of bone, about five-eighths of an inch in diameter, came away from the external table. Simple dressings were used. On January 24th, the patient was transferred to the Satterlee Hospital. The wound Avas healed but deafness remained. He was discharged on June 14th, 1865, by reason of impairment of the mental faculties. He was pensioned on this account. He is quite incapacitated from transacting business, according to the account of Pension Examiner Wm. H. Cornell. Craavford, Quimby H., Private, Co. D, 4th Michigan Volunteers, aged 21 years, was wounded, at the battle of Gettysburg, Pennsylvania, July 3d, 1863, in the scalp, by a conoidal musket ball, which entered the right temple and emerged behind the ear. His mental powers were deranged for two days after the reception of the injury. He was, on July 5th, 1863 admitted to the Satterlee Hospital, Philadelphia, Pennsylvania, and returned to duty on January 22d, 1864. Erwin, Henry, Private, Co. D, 7th Connecticut Volunteers, was wounded, in the action at Pocotaligo, South Carolina October 22d, 1862, and was admitted, on the folloAving day, to the hospital at Hilton Head, with a gunshot lacerated wound over the left parietal bone. He Avas afterwards sent to Fort Wood, New York Harbor, and, on February 6th, 1863, discharged from the service on account of gunshot wound, involving a contusion of the skull. He was pensioned from this date. Lonw subsequently, Pension Examiner E. R. Bardin, of Fairfield county, Connecticut, reported that the pensioner's mind was greatly deranged, that he Avas totally and permanently incapacitated for labor, and required constant supervision. Fullard, Andreav, Private, Co. D, 78th New York Volunteers, aged 31 years, received, at the battle of Gettysburg, Pennsylvania, July 3d, 1863, a gunshot contusion of the frontal bone, from a fragment of shell. He Avas admitted to a field hospital, and, on July llth, was sent to the Satterlee Hospital, Philadelphia. He suffered from violent headache and vertigo, and Avas much debilitated in body and mind. He was discharged from the service on November 27th, 1863. His name does not appear on the Pension Rolls. Palmer, Fraxklin L., Private, Co. C, 146th NeAV York Volunteers, aged 36 years, received, at the battle of the Wilderness, Virginia, May 5th, 1864, a wound of the right side of the scalp, involving the periosteum, by a conoidal musket ball. He was admitted into the field hospital of the 1st division, Fifth Corps, and, about May 24th, sent to Washington and admitted into the Carver Hospital. Simple dressings were used. On the 31st, the patient Avas transferred to the MoAver 120 WOUNDS AND INJURIES OF THE HEAD, Hospital, Philadelphia. On August 5th, a large spicula of necrosed bone Avas remoATed. The wound gradually healed, and he Avas discharged from service, October 29th, 1864, and pensioned. In June, 1866, his pension was doubled. Pension Examiner S. Rhoades reported that there was great impairment of memory, sight, and hearing, and that, though he had no bad habits, this pensioner was very much debilitated and unfit for any mental or bodily labor. Rea, Robert, S., Private, Co., F, 31st Ohio Volunteers, aged 22 years, received, at the battle of Chickamauga, September 19th, 1863, a gunshot contusion of the head. The wound of the scalp Avas slight. After a month's treatment at Hospital No. 1, Nashville, this man was returned to duty. Six months subsequently, he Avas sent to Camp Chase, Ohio, insane. He died on April 30th, 1864. The autopsy revealed a clot, the size of a filbert, and two small abscesses on the surface of the brain. The skull Avas not fractured. SnAND, John L., Corporal, Co. B, 93d Pennsylvania Volunteers, was admitted to the Ladies' Home Hospital, New York, August 2d, 1862, with a gunshot contusion of the skull. His mental faculties Avere impaired, and he Avas discharged from the service on September 17th, 1862, and pensioned. Pension Examiner W. M. Guilford reported, April 23d, 1863, that the wound had healed with a depressed cicatrix, and that there was a constant dull and heavy pain in the head. Sweet, Oscar F., Private, 8th United States Infantry, was examined for a pension on April 15th, 1864. by Pension Examining Surgeon H. B. Day. He had received a gunshot Avound of the cranium near the vertex, tearing the scalp and contusing the cranium. There was much mental aberration. The following cases of gunshot wounds of the head, with contusion of the bones of the cranium, terminated fatally : Caraker, J. V., Corporal, Co. D, 15th Alabama Infantry, received a Avound of the frontal region, with injury of the bone. He was admitted, on October 14th, 1864, into the Howard Grove Hospital, Richmond, Virginia. There was much cerebral disturbance, and death took place, October 29th, 1864. The case is reported by Surgeon S. M. Palmer, P. A. C. S. Carter, Joseph, Private, Co. A, 39th Illinois Volunteers, received, in an engagement on Morris Island, August 25th, 1863, a gunshot wound of the scalp. The missile, a conoidal ball, grazed the right parietal bone, and removed the periosteum. He was, on the following day, admitted on board of the steamer Cosmopolitan, where he died on August 26th, 1863. Elliott, Estes E., Private, Co. G, 36th Massachusetts Volunteers, aged 21 years, received, at the battle of Cold Harbor, Virginia, June 3d, 1864, a wound in the left parietal region, denuding the bone of its periosteum, by a conoidal musket ball. He was admitted into the field hospital of the 3d division, Ninth Corps, and, a feAV days later, sent to Washington, and admitted into the CarA'er Hospital. Simple dressings were used. He died from concussion of the brain, June 23d, 1864. Fink, Ira, Private, Co. C, 6th Maine Volunteers, received, in an engagement at Charlestown, Virginia, August 21st, 1864, a gunshot wound of the scalp, with contusion of the skull. He was sent to the hospital at Sandy Hook, Maryland, but died in transit, August 22d, 1864. George, D., Private, Co. K, 1st Michigan Sharpshooters, aged 26 years, received, at the battle of Spottsylvania Court- house, Virginia, May 12th, 1864, a wound of the head, with contusion of the bone, in the right parietal region, by a conoidal musket ball. He was admitted into the field hospital of the 3d division, Ninth Corps, and transferred thence to Washington, and admitted, on May 25th, into the Emory Hospital. He died comatose on the following day. The case is reported by Surgeon N. R. Mosely, U. S. V. Gibbs, Frank L., Private, Co. I, 21st Connecticut Volunteers, aged 26 years, was wounded, in an engagement before Petersburg, Virginia, August 1st, 1864, by a conoidal musket ball, which severely injured the scalp and contused the bone. He was admitted to the hospital of the 1st division, Eighteenth Corps, and, on August 4th, was sent to the hospital at Fort Monroe. The treatment, so far as recorded, Avas of an expectant nature. Death resulted from the injury on August 12th, 1864. Hodges, W. T, Sergeant, Co. D, 66th Georgia Regiment, was admitted into Pettigrew Hospital, Raleigh, North Carolina, on March llth, 1865. with a gunshot Avound of the scalp, Avith contusion of the right parietal bone. The patient died on March 13th, 1865. Long, C. H., Private, Co. C, 1st Maine Heavy Artillery, aged 19 years, was wounded, in front of Petersburg, Virginia, June 18th, 1864, by a conoidal musket ball, which produced a severe scalp wound, with contusion of bone. He was sent, June 22d, to the hospital of the 3d division, Second Corps, at City Point, and thence conveyed to Washington, and admitted, on June 24th. to Alount Pleasant Hospital. On June 27th, he was sent to the Cony Hospital at Augusta, Maine where he died on July 16th, 1864. Martin. Samuel, Private, Co. I, 15th Veteran Reserve Corps, was brought to the hospital at Camp Douglass, Illinois, on December 27th, 1864, from his regiment, with a gunshot scalp wound over the occiput. He died on December 30th 1864. There was contusion of the bone externally. The encephalon Avas not examined. Palmer, J. H., Corporal, Co. K, 10th Connecticut Volunteers, aged 26 years, Avas wounded, in an assault on the lines before Petersburg, A7irginia, April 2d, 1865, by a conoidal musket ball, in the temporal region, the bone being contused, but not fractured He Avas admitted to the hospital ofthe 1st division, TAventy-fourth Corps, and. on April 5th, Avas sent to the hospital at Fort Alonroe. He died on April llth, 1865, from compression of the brain. Phillips, Albert S., Lieutenant, Co. I, 1st Delaware Volunteers, received, at the battle of Fredericksburg, Alrginia, December 13th. 1862, a contused Avound of the head by a fragment of shell. He was admitted into the field hospital of the 3d division, Second Army Corps, on the same day. Simple dressings Avere used. He subsequently went on leave of absence to his home, where he died, on January 14th, 1863. The case is reported by Surgeon D. W. Maull, 1st Delaware Volunteers. GUNSHOT CONTUSIONS OF THE CRANIAL BONKS. 121 Rose, ArousTi's. Corporal, Co. B, 143d New York Volunteers, received, in the action at Atlanta. Georgia, July ~0tli. 1861, a severe Avound of the scalp, with contuision of the cranium, and concussion of the brain. He Avas admitted, on the same day, to the hospital of the 1st division, Twentieth Corps, and on the 20th, sent to Hospital No. 3, at Lookout Mountain, Tennessee. Death resulted on the 1st of August, 1864. Rufe, LEWIS F., Private, Co. C, 13th Ohio A'olunteers, received, during the campaign around Atlanta, Georgia, a gunshot Avound ofthe scalp, with contusion ofthe skull. He Avas, on September 2d, admitted to the hospital ofthe 3d division, Fourth Corps, and thence sent to the field hospital at Chattanooga, Avhich he entered on September 8th. On September 17th, he Avas transferred to Hospital No. 14, Nashville, Avhere he died, on October 1st, H04, from concussion of the brain. Smitiisox, J. D., PriA-ate, Co. II, 130th Indiana Volunteers, aged 28 years, was, on May 17th, 1861, admitted to Hospital No. 1, Chattanooga, Tennessee, with a gunshot scalp Avound. He died on Alay 18th, 1864, and, at the autopsy, the brain was found contused near the seat of injury. Wr.nr.R, Andreav J., Colonel, llth Missouri A'olunteers, Avounded, opposite Vicksburg, Alississippi, by a fragment of shell, AA-hich took effect on the croAvn of the head, laying bare the periosteum for an inch square. No fracture of the bone Avas perceptible. He never returned to consciousness, and died, on June 30th, 1*03, twenty hours after the receipt of the injury. with symptoms rather of compression than of concussion. Weld, S., Corporal, Co. K, 19th Alaine A'olunteers, aged 31 years, Avas wounded, at the battle ofthe Po River, Virginia, May 13th, 1864, by a conoidal musket ball, which struck at the vertex of the head, producing an open Avound three inches in length and one in breadth and denuding a portion of bone of its periosteum. He was admitted into the Mount Pleasant Hospital, Washington, from the field, Alay 16th, and thence transferred, on the 19th, to the hospital at Annapolis. Death resulted on June 5th, 180 4. The case is reported by Surgeon B. A. Vanderkieft, U. S. X. Yaav, Andrew, J., Private, Co. B. 157th New York Volunteers, received, at the battle of Gettysburg, Pennsylvania, July 1st, 18J3, a gunshot contusion of the head, Avithout fracture. He Avas admitted to the Seminary Hospital, Gettysburg, and, on July 25th, sent to the AIcDougall Hospital, New York Harbor. Death occurred from apoplexy on August 22d, 1863. The eight following cases of gunshot contusions of the skull should probxbly bo referred to the category of cases resulting in chronic irritability of the brain; but the details given in the reports are insufficient to determine their nature precisely: Baker, Charles C, Alajor, 39th NeAV York Volunteers, Avas Avounded, at the battle of North Anna river, Virginia, May 18th, 1^64, by a fragment of shell, Avhich caused a contusion of the right side of the head. He had bleeding from the nose and ears, and subsequently great vascular excitement, headache, aud other cerebral derangements. He was treated at the hospital cf the 1st division ofthe Second Corps, aud thence, on May 21st, was sent to AVashington, where he was examined by Acting Assistant Surgeon J. C. Nelson, who thought that the disabilities Avere likely to continue. On Alay 30th, this officer Avas mustered out of service. His name does not appear on the Pension List. Beam, An sell IL, Corporal, Co. I, 26th Michigan Volunteers, aged 21 years, was Avounded in the engagement at Farmville, A'irginia, April 6th, 1865, by a conoidal ball, Avhich made a ragged scalp Avound to the right of the sagittal suture, Avith contusion of the parietal bone. He was admitted to the hospital of the 1st division, Second Corps, and on April loth. AA-as sent to the Harewood Hospital, Washington, where a photograph was made of his injury. On Alay 18th, he Avas transferred to the Satterlee Hospital, Philadelphia. He had many symptoms of disturbance of the brain. The scalp Avound healed up favorably, and on July 6th, 1^-65, he Avas discharged from the service for disability. A photograph of the case, taken a feAV days after the reception of the injury, is preserved in tlu- seventh volume of Surgical Photographs of the Army Medical Museum; at page five. It is copied in figure 1 of Plate III, (opposite p. 105.) It is probable that he completely recovered, since his name is not found on the list of applicants for pension. Burke, Eli, Sergeant, Co. A, 183d Pennsylvania Volunteers, aged 26 years, received a contusion of the skull from a fragment of shell Avhich inflicted a large scalp wound and caused a grave contusion of the skull. He Avas removed from a field hospital to the Second Division Hospital at Alexandria on June 7th, and thence to the South Street Hospital, Philadelphia; on June 13th, 1864. He suffered from cerebral trouble, and Avas discharged from service on Alay 30th, 1865. There is no record of his case at the Pension Office. Couch. James A., Sergeant, Co. D, 131st Pennsylvania Volunteers, was Avounded, at the battle of Fredericksburg, Virginia, December 13th, 1862, by a conoidal musket ball which struck the upper part of the left occipital bone. He Avas stunned for a feAV moments, and Avas hardly able to stagger from the field. He Avas admitted to the Armory Square Hospital on December 20th, complaining of pain in the head; he was easily confused, othenvise, his condition Avas normal. He was returned to duty on May 12th, 1863. His name does not appear upon the Pension List. Deri:, Jacob, Private, Co. A, 82d Pennsylvania Volunteers, aged 20 years, received, at the battle of Cold Harbor, Virginia, June 3d, 1804, a gunshot wound of the left side of the scalp. He Avas conveyed to the Second Division Hospital, Alexandria, Virginia; on June 12th, sent to the hospital at Chester, Pennsylvania, and on July llth, 1864, returned to duty. On July 18th, 1864, he was admitted to the Lincoln Hospital, Washington, D. C, with secondary symptoms of concussion of brain. He recovered, and Avas returned to duty on February 7th, 1865. He is not recorded as an applicant for pension. Exglehart, Louis, Private, Co. E, 59th Ncav York A'olunteers, received a gunshot Avound of the scalp, grazing and bruising the cranium. He Avas admitted to Douglas Hospital, Washington, on December 12th, 1863, suffering from concussion of the brain. He recovered, and was sent to the Provost Marshal on February 6th, 1861. 10 122 AVOUNDS AND INJURIES OF THE HEAD. Kyle, John W„ Private, Co. F, 12th Pennsylvania Reserve Corps, received a gunshot Avound of the scalp above the right eye. Avith contusion of the frontal bone and concussion of the brain. He was admitted into Carver Hospital, AVashington, September 1st, 1862, and was discharged from the service, November 5th, 1862. His name is not upon the Pension Rolls. Wiley, Jacob S., Co. K. 18th South Carolina Regiment, received, in an engagement before Petersburg, Virginia, Alay 20th, ISO I, a gunshot wound of the right parietal bone. He was admitted, on Alay 23d, to the Confederate hospital at Petersburg, Virginia, and furloughed on June 13th, 1864, suffering from congestion of the brain. Pyaemia.—Theoretical considerations would lead to the belief that purulent infection, with metastatic foci or visceral abscesses, would be common in gunshot contusions of the skull, in consequence of the entrance of pus into the veins of the diploe in the vicinity of exfoliations. But the returns do not sustain this supposition, and present, indeed, but a single case in which the existence of pysemia is distinctly alleged: Brower, G, Sergeant, Co. F, 16th Ohio A'olunteers, received, at the siege of Vicksburg, Mississippi, December 28th, ls62. a gunshot Avound of the scalp, in the right occipital region, with contusion of the bone. He was conveyed to Paducah, Kentucky, on the hospital steamer City of Memphis, and admitted, on January 13th, into the St. Alark's Hospital. There Avas paralysis of the left leg. Pytemia supervened, and death took place, February 21st, 1863. The case is reported by Surgeon H. P. Stearns, U. S. Y. Tetanus.—But one instance of the occurrence of this complication is reported among the gunshot contusions of the cranium: Krall, Christian, Private, Co. K, 130th Pennsylvania Arolunteers, Avas wounded, at the battle of Fredericksburg, A'irginia, December 13th, 1862, by a musket ball which caused a contusion of the outer table ofthe right parietal bone above and behind the protuberance. The concussion was slight, not even knocking him doAvn, or causing any disturbance of his mental faculties. Excessive haemorrhage folloAved the injury, which was not arrested for five hours. He Avas, on December 17th, admitted to the Patent Office Hospital, AVashington, D. C, and on December 19th, sent to the Jarvis Hospital at Baltimore, Maryland. On admission, the wound looked healthy, and discharged normal pus. No fracture could be detected, but the bone was denuded of periosteum. On December 24th, symptoms of tetanus, confined chiefly to the muscles of the neck, super- vened, folloAved by nausea and vomiting. January 1st, 1863, tetanus Avas general and well-marked. The wound was extremely sensitive, and the scalp around it puffed, indicating a burrowing of pus. The pains in the head became intolerable, and, during the u'.tei v: Is c.f the spasmodic throes, he Avould scream and groan. A free incision of the scalp was made, and the fresh wound alloAved to bleed unchecked for some time. Instantaneous relief followed, the pain in the head abated, and the spasms did not recur the following morning. Still no fracture could be detected, but the parietal bone was somewhat roughened, and Avas evidently exfoliating. On the folloAving day the symptoms had returned. Opium Avas given, and afterward, cannabis indica was substituted, with some benefit. Death occurred on January 4th, 1863. At the autopsy, a film of pus was found under the dura mater, beneath the point of injury, amounting to a half drachm. The dura mater A\'as bruised and discolored; the substance of the brain was normal, but a small quantity of bloody serum existed in the lateral ventricles. The pathological specimens were sent to the Army Medical Museum. One of them is represented in the adjacent Avood- cut, (Fig. 36.) It consists of the vault of the craniuni, showing incipient caries and necrosis of the outer table of the right parietal bone. The scale of bone, around which the line of demarcation has foimed, is elliptical in shape, measuring one inch by one and a half. The inner table presents no pathological appearance. The second specimen is a Avet preparation of the dura mater, thickened, inflamed, and having a deposit of pus upon its inner surface. The specimens and history were contributed by Assistant Surgeon D. C. Peters, U. S. A. FIG. 3(>.—Exfoliation from the right parie- tal, from gunshot contusion. Spec. 613, Sect. I, A. M. M. Trephining.—There were sixteen cases of gunshot contusion of the cranial bones, in which necrosed fragments were remoA^ed by formal operations: Abbott, Henry. Private, Co. B, 32d Maine Volunteers, aged 21 years, was wounded,, at the battle of Tolopotomy Creek, Virginia, May 31st, 1864, by a conoidal ball which struck the right parietal bone, passed forAvard and downward, exposing the squamous suture, and lacerating the scalp for a distance of three inches. He was at once admitted to the hospital of the 2d division, Ninth Corps, and, on June 4th, was sent to the Stanton Hospital, Washington. On the 7th, diarrhoea set in, but soon yielded to treatment. His general health continued good, and by the 17th the wound had nearly healed. On July 12th, a piece of necrosed bone from the outer portion of the temporal suture and the diploe, one inch in length and half an inch in breadth, Avas removed, and on the 14th, another portion, corresponding to the first, and consisting of the inner table, was removed. He was transferred on July 18th. entering Grant Hospital, AVilletfs Point, NeAV York Harbor, on the 21st, Avhence, he Avas returned to duty on the 21st of December, 1864. The case is reported by Surgeon John A. Lidell, U. S. V. The recovery appears to have been complete, as the man's name does not appear on the list of applicants for pensions. GUNSHOT CONTUSIONS OF THK CRANIAL BONKS. 123 FlO. 37.—Exfoliations resulting from gun- shot contusion of tho cranium. Spec. 4943, Sect. I, A. M. M. Internal view of the foregoing Fig. 39.—External and internal view of an exfoliation of the cranium following gunshot contusion. Spec. 26J3, Sect. I, A. M. M. Unknoavn. An infantry soldier, on the Peninsula, in June, 1862, received a scalp Avound from a glancing musket ball, on the side of the head, Avith contusion of the parietal bone. ~lle was treated by Assistant Surgeon Wm. Thom- son, lT. S. A. There were very grave head symp- toms, yet the case Avas treated on the expectant plan. After a while, it was noticed that the external table of the skull Avas necrosed, and, subsequently, that two fragments, one com- prising the Avhole thickness of the bone, the other, the outer table and diploe only, were loosened and detached. These being removed, the patient recovered without any impairment of the mental faculties or physical dis- abDity. The specimens, represented of natural size in the adjoining Avood-cuts, (FiG. 37 and Fig. 38,) Avere sent to the Army Medical Aluseum by Assistant Surgeon W. Thomson, U. S. A., Avho lost his notes of the case in the retreat from the.Peninsula. Unknown. A soldier, wounded in one of the battles between the Wilderness and Petersburg, in May, 1864, receiA'ing a laceration of the scalp, Avith contusion of the vault of the cranium, by a musket ball. He Avas sent to an hospital in Philadel- phia. The bone, at the point at Avhich the pericranium Avas denuded, necrosed and exfoliated, and Avas removed by operation. The specimen Avas received at the Army Medical Museum, without an history, on June 22d, 1864. It is figured at natural size in the adjacent wood-cut, (Fig. 39.) Yetter, November 10th, Fig. 40.—Frag- ments of necrosed bone from the left parietal. Spec. 4178, Sect. I, A. M. M. John, Private, Co. A, llth NeAV Jersey Volunteers, aged 21 years, was Avounded near Petersburg, Virginia, 1864, by a conoidal ball.which lacerated the scalp, and contused the anterior portion of the left parietal bone. He was admitted to the field hospital of the 3d division, Second Corps, and thence transferred to City Point, and thence sent by the hospital steamer Connecticut to the Stanton Hospital, Washington, where he arrived on November 26th. There was a necrosis of the cranium, one-fourth of an inch in diameter. Loav diet and gentle purgatives were prescribed, and, as suppuration became tolerably Avell established, emollient poultices Avere applied to the wound. On the 21st of December, the contused bone had become loosened by the process of absorption and suppuration. The patient Avas placed under the influence of chloroform, and Surgeon Benjamin B. Wilson, U. S. V., made a crucial incision, and removed a piece of the external table of the parietal bone, half an inch in diameter, and another, from the internal table, one-fourth of an inch in diameter. On the 29th, another piece of bone, including a small portion of both tables, was removed from the inferior margin of the Avound. Water dressings were applied. The patient made a rapid recovery, Avithout any untoward symptom; but it Avas thought inexpedient to return him immediately to active service in the field. He did efficient duty for some months as a nurse in the hospital. When discharged, on the general muster- out of troops, June loth, 1865, he Avas in excellent health. His name does not appear on the list of applicants for pension. The specimen (see FiG. 40) and notes of the case were contributed by Surgeon B. B. AVilson, U. S. V. Altman, Samuel, Private, Co. A, 50th Georgia Regiment, Avas wounded, at the battle of Antietam, September 17th, 1862, by a musket ball which laid bare the frontal bone to the extent of tAvo inches in length by three-fourths of an inch in width, but not depressing or fracturing the bone. He was admitted into the Convalescent Hospital, Philadelphia, September 27th, 1862. The wound granulated rapidly, and the patient was apparently doing well, exhibiting no symptoms of injury to the brain, except that he Avas sullen and stupid, which was attributed to other causes. On October 6th, he complained of headache, chills and fever, and, on the 8th, cerebral symptoms appeared, and rapidly increased until the llth, Avhen indications of approaching dissolution were unmistakable, the pulse being rapid and small, pupils natural, but insensible to light. The patient was etherized, and the operation of trephining performed, to evacuate an abscess supposed to exist. A piece of bone Avas removed, and the brain punctured, giving exit to six or seven ounces of offensive sero-purulent fluid, containing fragments of broken doAvn brain tissue, with such a force as to throAV it three feet from the patient. The effect of the operation Avas favorable; the skin became Avarm, the pulse gained strength and Avas less rapid, the breathing was easier, and the patient appeared in every way better. The Avound Avas closed, and stimulants Avere administered, but exhaustion folloAved, and death occurred on October llth, 1862. At the autopsy, it Avas found that the ball bad struck the os frontis on the left side, near the sagittal suture, two and a half inches from the middle line of the cranium. The inner table was necrosed over an irregular circular space, one and a half inches in diameter, the diploe between the outer and inner tables at Fig. 41.—Calvaria trephined in the left frontal region for gunshot contusion. Spec. 1199, Sect. I, A. M. M. 124 WOUNDS AND INJURIES OFTHE HEAD. this point being carious. There Avas an abscess, with greenish indurated Avails, three inches in diameter, in the anterior lobe of the left cerebral hemisphere. It had opened, and its contents had filled the cavitms 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 di- ased bone and the abscess. The pathological specimen is figured in the foregoing Avood-cut, (FiG. 41.) It shows the vault of the cranium, with the disk in place. The internal table is cribriform. The outer table is porous, and discolored to a slight decree. The specimen and history were contributed by Acting Assistant Surgeon G. R. Morehouse. Attn;, William, Private, Co. A, 49th Pennsylvania A'olunteers, aged 25 years, Avas Avounded, near Rappahannock Station, A'irginia, 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 Avas conveyed to AVashington, and admitted into HareAvood Hospital on the 9th, complaining of slight headache over the region of the eyes. His pulse aa as normal, and his appetite poor. On the 17th, chills, with vomiting, supervened, and the eyes became lachrymose. These symptoms continued until the 19th, Avhen he Avas anaesthetized, and Surgeon R. B. Bontecou, U. S. V., made a crucial incision through the scalp, when pus Avas found issuing through the denuded bone. The trephine Avas then applied near the left frontal eminence, giving exit to a small quantity of pus, which was found betAveen 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- Fig. 4-i-Pcrfi.ration of the left o» frontis for head and "Zht e>^ds were cedematous, and the pulse was 75, and feeble. On the a gunshot routes'.>n. followed l>y s.M:ipton:s of 23d, Ioav muttering delirium folloAA'ed, coma ensued, the alvine evacuations became compression. Spec. 20'-.'4. Sect. I, A. M. M. . . , . . , , . , ,. , ,,.., ., involuntary, and his breathing stertorous. At eleven o clock A. m. ot the 24th, the dura mater Avas incised, giving exit to a small quantity of pus, but no relief Avas afforded, and death occurred tAvo hours subsequently. The pathological specimen Avas sent to the Army Aledical Museum, and is represented in the wood-cut (Fig. 42). It A\a^ fonvarded, with its history, by Surgeon R. B. Bontecou, U. S. Y. Baker, Charles K., Private. Co. D, 27th Alassachusetts Volunteers, aged 25 years, Avas wounded, at the battle of New Berne, North Carolina, Alarch llth, 1862, by a conoidal musket ball which made a long furrowed Avound of the right parietal region, lacerating the scalp, and denuding the pericranium. He Avas treated at a field hospital by his regimental surgeon. The right side of the scalp Avas shaven, and a compress, dipped in cold water, was secured over the wound by a bandage. The patient Avas 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 ofthe brain. Careful exploration revealed no injury of the bone. On March 20th, the Avound of the scalp was fairly cicatrizing, and the patient was sent on an hospital transport, up the Neuse river, to the Carver Street Hospital at Ncav Berne, five miles distant. Tavo days subsequently, through the inadvertence of an hospital steAArard, this man's name Avas included in the list of Avounded to be sent noi'tlnvard on the hospital transport steamer New York. Surgeon J. B. Upham, in charge of the transport, reports that he had no cerebral symptoms on the passage. He proceeded to his home in Amherst, Alassachusetts. On April 3d, he complained of headache, and the following day symptoms of compression of the brain Avere manifested. On April 7th, he was trephined by two of the local practitioners, and died a feAV hours after the operation. Assistant Surgeon D. B. N. Fish, 27th Massachusetts A'olunteers, a resident of Amherst, Avrites, in 1868, that the two surgeons Avho performed the operation had died and left 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. 11, 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, Avith a contusion of the bone. He Avas sent to Nashville, aud admitted to Cumberland Hospital on the 25th. The Avound produced little inconvenience until October 4th, when grave head symptoms, such as delirium and convulsions, supervened. There Avas hemiplegia also. On October 5th, the patient Avas in a comatose condition, and trephining Avas resorted to. AVhen the skull was perforated, exit Avas given to a quantity of pus, Avhich had formed betAveen the dura mater and cranium. Consciousness Avas 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 Avas found partially disorganized, and covered Avith a layer of pus, Avhich extended to the longitudinal fissure. The operator, Surgeon C. AIcDermont. U. S. A\. reported the case. Chaprel, Benjamin F., Sergeant, Co. H, 8th New York Cavalry, aged 27 years, Avas wounded, before Petersburg, Virginia, April 1st. 1865, by a pistol ball which entered one inch above and one and a half inches to the left of the occipital protuberance and emerged ju6t below it on the opposite side, denuding the bone of pericranium. He Avas admitted to the hospital ofthe 3d division, Cavalry Corps, and on the 3d, Avas sent to AVashington, Avhere he entered HareAvood Hospital on the 5th. Until the 14th, the patient seemed to be improving, but on that day a slight haemorrhage from the occipital artery occurred, causing the loss of about six ounces of arterial blood. The haemorrhage Avas arrested by means of compression, and the case apparently progressed favorably. On the evening of the 18th, the patient, however, complained of considerable pain in the region of the cerebellum. On the folloAving day considerable gastric irritation manifested itself, and, at intervals, there was slight delirium. Ether Avas administered, and Surgeon R. B. Bontecou, U. S. V.. made an incision two and a half inches in length, just beloAV and parallel to the lambdoidal suture, retracted the scalp, applied the trephine, and removed a disk of bone, giving exit to a quantity of pi- The patient reacted promptly.after the operation, and seemed to be much relieved, but in the GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 125 evening he began to sink, and died on the morning of April 21st, 1865. The autopsy revealed a large abscess in the left lobe of the cerebellum, Avhich contained four or five ounces of pus. The medulla oblongata Avas implicated. The pathological specimen is represented in the adjacent wood-cut, (Fig. 43,) and sIioavs the occipital bone perforated by a trephine, Avith the disk restored to its position. The surrounding portion of the external table is slightly discolored and cribriform. The specimen Avas contributed by the operator. A photograph of the case will be found in the Photographic Surgical Series of the Army Medical Museum, Volume I, page 40. Fig. 43.—Segment of a cranium, showing the occipital perforated for the evacuation of pus. Spec. 434*?, Sect. I, A. M. it. Fig. 44.—Segment of the right parietal, tre phined near the coronal suture. Spec. 334, Sect 1, A. M. M. Foster, Jamks B., Private, Co. F, 5th Alissouri Militia, was, on August 25th, 1863, admitted to the hospital at Kansas City, Missouri, with concussion of the brain. The skull was not fractured, but there Avere symptoms of compression. The trephine Avas applied to the seat of injury, and a button of bone removed. The operation reA'ealed a rupture of the middle meningeal artery, Avith copious haemorrhage. A clot of blood Avas removed from under the pia mater, when clear blood escaped for a few minutes. Death occurred on August 27th, 1863, thirty hours after the operation. The autopsy revealed extra vacation of blood over the entire surface of the brain. The report is signed by Dr. Joshua Thorne. Gay, J., Private. Co. A, 44th Georgia Infantry, received a gunshot Avound of the scalp. He was admitted into the Jackson Hospital at Richmond. Paralysis supervened, and trephining was resorted to on June 2d, 1864. Death took place on June 4th. The case is reported by Surgeon J. S. Welford, C. S. A. Morton, Daries, Private, Co. F, 9th NeAV York Cavalry, was Avounded in a skirmish during General Pleasonton's raid into Virginia, and was admitted, on November 12th, 1862, to the Armory Square Hospital, Washington, Avith a gunshot wound of the scalp, Avith contusion. No particulars of the treatment are recorded. Compression of the brain supervened, and the operation of trephining Avas performed by Surgeon D. W. Bliss, U. S. V. The symptoms of compression Avere not relieved, and the patient died on November 18th, 1862. The pathological specimen was forwarded to the Army Medical Museum. It consists of a segment of the right parietal bone, of a very thin calvaria, trephined near the coronal suture. The outer table of the bone surrounding the perforation is porous and cribriform, and there are traces of contusion of the disk removed. There are no pathological appearances on the inner table. The specimen, Avhich is represented in the adjacent wood-cut, (FiG. 44,) was contributed by the operator, Surgeon D. W. Bliss, U. S. V. Pickard, George, Private, Co. F, lilth NeAV York Volunteers, aged 48 years, was Avounded in the head, at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a piece of shell. He was taken to the regimental hospital, transferred to the Seminary Hospital. Gettysburg, Pennsylvania, and thence sent to the McDougall Hospital, Fort Schuyler, New York Harbor, where he Avas admitted on the 12th. Cold Avater dressings Avere applied, and an antiphlogistic treatment ordered. The patient complained of headache and of stiffness in the cervical region. On July 19th, he became comatose, with fixed pupils, and stertorous breathing. On the 20th, Acting Assistant Surgeon Henry Sanders applied the trephine, giving exit to a small quantity of pus, after which the patient rallied a little, but sank again at night, notAvithstanding the free use of stimulants, and died on July 22d, 1863. The autopsy revealed inflammation of the membranes of the brain, and several ounces of pus beneath them. There Avas pus also on the external surface of the dura mater. The tissue of the brain itself was normal. The case Avas reported by the operator. Resinger, Joseph. Private, Co. E, 151st NeAV York Volunteers, aged 21 years, received, at the demonstration on Mine Run, A'irginia, November 27th. 1863, a gunshot wound of the scalp, OArer the right parietal. He was conveyed to Fairfax Seminary Hospital. There Avas no cerebral disturbance at the time of his admission. The pericranium Avas not removed, and it Avas hoped that the skull had escaped uninjured. He was alloAved to be up and about the wards, and no symptoms of any grave injury appeared until December 13th, 1863, Avhen he AA'as suddenly seized, Avhile seated at the supper table, Avith convulsions, and became immediately unconscious. He was taken to his bed, and Surgeon D. P. Smith, U. S. V., laid bare the calvarium at the seat of injury, and applied the trephine. Pus Avas found immediately beneath the bone and oozed from the diploe. It was thought expedient to make five perforations with the trephine, in order to remove the diseased bone, and to give free exit to pus. Convul- sions did not recur, but the comatose condition continued, and the case terminated fatally twelve hours after the operation. The autopsy revealed diffuse inflammation of the arachnoid and of the dura mater. The dura mater was not incised, as it did not bulge into the perforations made by the trephine. The pus proceeded altogether from the diploe and from betAveen the dura mater and the skull. The specimen Avas contributed by the operator to the Army Medical Museum, and is figured in the adjoining wood-cut, (Fig. 45.) Spradley, L, D., Private, Co. H, 45th Georgia Regiment, Avas wounded, at the battle of the Wilderness, May 5th, 1864, by a conoidal musket ball Avhich produced a wound of the head, Avith denudation ofthe bone of the vault of the cranium. He ^Q^ 45.—Section of a cranium, exhib'ting fivetrephine .;;..:..> f r the evacualionof pus, the result of a gun- mtusioii of the right parietal. Spec. 2000, Sect. 1. 126 WOUNDS AND INJURIES OF THE HEAD. Avas conveyed to the general Confederate hospital at Charlottesville, Arirginia. On Alay 12th. symptoms of compression, of the brain appeared, and, on the folloAving day. trephining Avas resorted to. The patient died Alay 13th, 1864, a feAV hours after the operation. The case is recorded in his monthly report for Alay, 1864, by Surgeon J. L. Cabell, C. S. A. Williamson, L. B., Corporal, Co. G, 100th Pennsylvania Volunteers, aged 23 years, was Avounded, before Petersburg, A'irginia. April 2d. 1865, by a conoidal musket ball which injured the cranium. He Avas admitted on the same day to the hospital of the first division, Ninth Corps, and thence Avas sent to the hospital at Fairfax Seminary. Avhich he entered on April 6th. On April 12th, the operation of trephining Avas performed. No particulars in regard to the operation and the after- treatment are recorded. Death ensued on April 20th, 1865. Thus, of sixteen cases of operative interference, four only had a favorable termination, and these were examples of the secondary removal of exfoliated fragments, Art serving as the handmaid of Nature, who had already nearly effected a cure. In the twelve remaining fatal cases, in which formal trephining was resorted to, pus was found between the skull and dura mater in four instances, beneath the dura mater in one case, and in the substance of the brain in one In two instances, it is alleged that intra-cranial extrava- sation Avas observed; in another that arachnitis was present; in three cases the causes of the symptoms of compression were not specified. Its symptoms were manifested earliest in those cases in which haemorrhage in the cranial cavity was observed. In the six cases in which pus was found, the symptoms of compression arose from the sixteenth to the twenty-fourth day. The patients survived the operations on an average about three days. Of the whole number of three hundred and twenty-eight patients with gunshot contusions of the cranial bones, whose cases have been reported, fifty-five died, one hundred Avere returned to duty, and one hundred and seventy-three were discharged. Forty-eight of the last category were pensioned. In the fifty-five fatal cases, the proximate causes of death were external heemorrhage in two cases; tetanus, pyaemia, intercurrent typhoid fever, and acute dysentery respectively in four cases at least, compression of the brain from extravasated blood or from intra- cranial abscess in seventeen cases, and various secondary lesions of the encephalon in thirty-two cases. The wounds were inflicted by small-arm projectiles in one hundred and twenty-four instances, by shell fragments in forty-four cases, and in one hundred and sixty cases, the nature of the missile could only be conjectured. Lodgment of the missile beneath the scalp is mentioned in eight instances. The seat of injury was specified in two hundred and twenty-one instances. In fifty- four, the frontal bone was struck; in thirty-three, the temporal; in ninety-five, the parietal; in thirty-three, the occipital; and in six cases, the contusion invol\Ted more than one of the cranial bones. The fatality in contusions of the frontal and temporal bones was nearly fifteen per centum; in contusions of the parietals, thirteen; and in contusions of the occipital, nine per centum; results corroborating the observations of Guthrie on the relative danger of injuries of the different regions of the skull.* In the classification, the cases have been grouped under the headings representing the most prominent symptoms, or the causes of discharge or death Avhich they illustrated. Thus, though three cases only are entered under the heading of Hemorrhage (p. 101,) there were at least tAvo others, (cases of Krall, p. 122, and Chappel, p. 124,) in which * Guthrie. Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands, from the Battle of Ro'ica, in 1-u-'. to that of Waterloo, in 1815, with Additions relating to those in the Crimea, in 1854-55. Gth London ed., 1855, p. 299. GUNSHOT CONTUSIONS OF THE CRANIAL BONES. 127 bleeding from the arteries of the scalp was an important complication. The five were all instances of haemorrhage from direct injury of the occipital or temporal arteries or of the principal branches. The bleeding was primary in two cases, and secondary in three cases. The observations on page 64, on haemorrhage after scalp wounds would be applicable to these five cases, save that in one of them it was necessary to ligate the temporal artery. Erysipelas appears to have been neither a frequent nor fatal complication. In only four cases, (Smith, p. 102, Gilkey and Hay, p. 105, Pulliam, p. 107,) in addition to the six cases recorded under the heading on page 101, is it reported as a serious intercurrent affection, and only two of the aggregate of ten cases terminated fatally. Sloughing of the scalp Avas seldom observed. Burrowing of pus in the scalp or beneath the aponeuroses of the occipito-frontalis or crotaphite muscles was reported in only six of the three hundred and twenty-eight cases. Four of the six cases had a favorable issue ultimately, after the elimination of dead bone; in two, the abscesses were associated with other lesions which proved fatal. Early incision, followed by warm emollient applications, and subsequent gentle compression by bandages, constituted uniformly the treatment. Periostitis following gunshot contusions of the cranium resulted occasionally in caries, not infrequently in necrosis, rarely in hyperostosis and induration, sometimes in persistent pain at the point struck. There were several examples of inflammation of the pericranium in which the wounds reopened at intervals and suppurated, yet no exfoliation followed. There were ten cases in which persistence of pain, either in the cicatrices or in distinct spots of the cranium, constituted the prominent symptom. Three of them belong to the class of cases described by Quesnay.* All of these patients were spared the incisions of the scalp or the application of the rugine or trephine, and five recovered and went to duty, while five were discharged for disability, two of whom were subsequently pensioned. I have carefully examined more than forty crania contused by gunshot projectiles without finding an example of the local hyperostosis of the skull which authors describe as a frequent result of this form of injury. There were two instances in which there was abnormal thickening, (Spec. 1199 and 1660 A. M. M.,) but the subjects who furnished these specimens died in twenty-one and twenty-seven days respectively after the reception of their wounds, and it is scarcely possible that the pathological conditions of the skulls were due to such recent injuries.'}" The induration or eburnation of the outer table mentioned by RokitanskyJ as a consequence of contusion, was observed in six or seven of the fatal cases. It is very well illustrated in Specimens 1568, 2523, and 3406, of the Surgical Section of the Army Medical Museum. A few specimens showed traces of the velvety osteophyte described by Lobstein.|| The contusions of the skull by gunshot projectiles were followed by exfoliations in thirty-seven cases. Five of these terminated fatally. Eight cases of this category were those of Confederate soldiers, who so far recovered as to be furloughed or discharged. Of the twenty-five Union soldiers who recovered, twelve had their names on the pension list * Quesnay, Memoires de I' Academie Iloyale de Chirurgie. Nouv. ed. Paris, 1819, T. 1, p. 169. t Specimens 5135, and 5481, Section I, A. AI. M., are good examples of chronic thickening ofthe skull from external violence, and specimen 55 of Section TV, is another fine illustration. But the bruises which were the starting point ofthe morbid alterations in these cases were from bloAvs or falls. f KOKTTANSKY, Lehrbuch der Pathologischen Anatomic. Wien, 1856, Zweiter Band, S. 144. HLobsteix, Traite d'Anatomic Pathologique. Paris, 1833. 12S WOUNDS AND INJURIES OF THE HEAD. in 1870. In six of the thirty-seven cases, the exfoliation included both tables of the skull, in thirty cases the outer plate only, and in one (Smith, p. 112) the inner table only. It is questionable if the latter case should not be regarded as a fracture of the inner table.* In the few cases of caries observed, the disease soon foLWed the injury, there being no instance of its tardy apparition, as described by Sir Charles Bell.f Of the one hundred and seventy-three patients in this category discharged, ninety- eight were discharged for serious physical disabilities, such as protracted headache and vertigo, persistent pain at the point struck, epilepsy, paralysis, impairment of the special senses or mental faculties. Forty-eight of these patients remain on the pension list- Some were discharged on account of other wounds or mutilations more serious than the head injuries, and others at the expiration of their terms of service. It may be stated as a near approximation to truth, that of three hundred and twenty-eight examples of gunshot contusions of the cranial bones, fifty-five, or seventeen per centum, died, ninety-eight, or thirty per centum, were disabled from causes referable to the injuries of the head, and one hundred and seventy-five, or fifty-three per centum, recovered. Gunshot Fractures of the External Table of the Cranium alone.—With the exception of instances of fracture of the outer wall of the frontal sinus, or of the mastoid and zygomatic processes of the temporal, and of grooving of the outer table of the vault of the skull by the sharp angles of shell fragments, the specimens of the Army Medical Museum exhibit no satisfactory examples of this form of injury. Though the reports contain many cases returned under this heading, there are few in which the evidence of the nature of the injury is conclusive. The following are reported as examples of fractures of the external wall of the frontal sinus: Case.—Private George Armstrong, Co. E, 156th NeAV York Volunteers, received, before Port Hudson, Louisiana, on June 14th, 1863, a gunshot wound over the right eye. The missile struck over the right frontal sinus, causing a small wound. He Avas admitted to St. Louis Hospital, Ncav Orleans, on June 17th, 1863, a slight exfoliation causing no inconvenience or complaint. On the night of September 16th, stupor supervened, but passed off in about thirty minutes. It recurred on the folloAving day, and the patient died on September 18th, 1863. At the autopsy, the whole anterior half of the right hemisphere Avas replaced by a large abscess, Avhich Avas divided only by the dura mater from the carious opening consequent upon the wound. Case.—Private William S. Dingman, Co. F, 10th Vermont Volunteers, aged 26 years, was Avounded at the battle of AA'inchester, A'irginia, September 19th, 1864, by a fragment of shell which fractured the outer table of the frontal sinus. He Avas admitted to the 3d division, Sixth Corps, hospital, and on the 24th, sent to the Frederick hospital, Maryland, but shortly afterwards transferred to the Sloan Hospital, in Vermont. The Avound healed and the patient Avas discharged from service on Alay 22d, 1865, at Brattleboro'. In September, 1867, he was in receipt of a pension. In March, 1869, Dr. O F. Fossett reported that this pensioner, having had a fracture involving the frontal sinus, had ulceration with a discharge of fetid sanious matter in the nose, with partial loss of vision and much pain and dizziness, incapacitating him for labor, and producing a disability rated at three fourths, without likelihood of improA'ement. Case.—Sergeant Alajor EdAvin A. Gordon, 57th Ohio Volunteers, Avas Avounded near Vicksburg, Mississippi, December 29th, 1862, by a gunshot missile Avhich fractured the external table of the frontal bone over the right eye. He was on the same day admitted to the hospital steamer City of Memphis. He recovered rapidly, Avas, on January 17th, 1863, admitted to the LaAvson Hospital, St. Louis, Alissouri, and returned to duty on April 2d, 1863. His pension claim is reported as pending. * AA'illiamson informs us that: "Eleven cases of this description of injury, (detachment of pericranium by gunshot injuries), Avere admitted from India, of Avhom six were sent to duty and five invalided for other diseases. In all of them small portions of the external table of the skull came aAvay necrosed. The scalp was not adherent to the bone in any of them." See Specimens 2895, 2896, and 3626, Netley Aluseum. Military Surgery, London, 1863, p. 19. tSir Chaules Bell, A System of Operative Surgery, 2d ed. London, 1814. A'ol. I, p. 381: "The surgeon should be aAvare of the sIoav progress and gradual effect of caries of the skull after contusion. AA'hen the bone has been injured, but not deadened, it falls sloAvly into disease; it becomes carious and spongy, and admits the oozing out of matter. The dura mater does not separate fi-om the bone, as in the more common case of death of the bone from injury; but being the internal periosteum of the bone, it partakes of its disease, and grows into its carious cells. This is a disease of the skull, like to the common diseases of bones, where the external and internal periosteum, and substance of the bone, is diseased Avith decay of internal parts, and the formation of exostosis." GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 129 Case.—Private AVilliam Gritzmacher, Co. C, 5th AA7isconsin Volunteers, aged 19 years, was Avounded at the battle of Spottsylvania. Virginia, Alay 12th, 1864, by an explosive musket ball Aviiich struck the frontal bone at the left supra-orbital ridge and fractured the outer table. He was, on the same day, admitted to the hospital of the 1st division, Sixth Corps, and on the 17th sent to AVashington, D. C, and admitted into the Emory Hospital. On June 6th he Avas transferred to the Patterson Park Hospital, Baltimore, and on August 16th to the Chester Hospital. The treatment so far consisted of simple dressings. He recovered, and was transferred on May 16th, 1865, to the Veteran Reserve Corps, and discharged the service of the United States July22d, 1865. Pension Examining Surgeon John Phillips reports, on May 9th, 1867, that this pensioner's wounds were still discharging, and that the right upper eyelid Avas so contracted as to prevent closure of his eye, and that his vision was impaired. Case.—Corporal D. Hagerty, Co. F, 69th Pennsylvania Volunteers, aged 33 years, was wounded at the battle of Gettys- burg, Pennsylvania, July 3d, 1863, by a conoidal musket ball Avhich fractured the external table of the frontal bone. He was conveyed on July 6th, to the Cuyler Hospital. He recoArered, and Avas transferred to the Veteran Reserve Corps on May 12th, 1864, but Avas readmitted into the hospital on Alay 22d, and finally discharged from service on August 24th, 1864. A fistulous opening in the frontal sinus still existed. The case is reported by Assistant Surgeon II. S. Schell, U. S. A. The name of this patient is not upon the list of applicants for a pension. Case.—Private E. D. Johnson, Co. F, 1st North Carolina Infantry, received a Avound of the frontal region, directly over the sinus, with fracture of the external table of the bone, by a fragment of shell. He was admitted into the No. 3 Chimborazo Hospital, Richmond, on June 4th, 1863, and on June 27th transferred to AVeldon, North Carolina. The case is reported by Surgeon E. H. Smith, P. A. C. S. Case.—Private Henry Koelling, Co. C, 47th Illinois Volunteers, Avas Avounded at the battle of Shiloh, Tennessee, April 7th. 1862, by a fragment of shell which struck in the left supra-orbital region, causing a comminuted fracture of the external table of the frontal bone, and opening the frontal sinus. He Avas conveyed on the hospital steamer D. A. January, to St. Louis, and admitted, on April 14th, into the neAv House of Refuge Hospital. There was occasional vertigo and constant headache. A large depressed cicatrix was visible at the seat of injury. He was discharged from the service on August 30th, 1862, with a disability rated one-half. The case is reported by Surgeon A. Hammer, U. S. V. Drs. E. H. Henry and J. N. Means, of Washington County, Illinois, report, October 29th, 1862, that a portion of the superciliary ridge was removed, and that the pensioner was unfit for manual labor or any employment that produced cerebral excitement. Case .—Private A. McDonald, of the Palmetto Sharpshooters, was admitted to the South Carolina Hospital, at Charlottes ■ ville, Virginia, on September 6th, 1862, AA-ith a gunshot wound of the head, received a feAV days prior to admission. The os frontis at the outer extremity of the left frontal sinus was fractured to a considerable extent. The outer Avail of the sinus was removed; the inner table was uninjured. The case progressed favorably, and on November llth, 1862, the patient was furloughed, being nearly well. The case is recorded by Assistant Surgeon B. W. Allen, P. A. C. S. Case.—Private Albert J. Miller, Co. B, 26th Illinois Infantry, aged 30, Avas wounded at Jonesboro', Georgia, August 31st, 1864, by a piece of shell which fractured and slightly depressed the outer table of the frontal bone above the left eye. He was, on September 5th, admitted to the field hospital of the Fifteenth Corps, and on September 20th he Avas furloughed. No record of the case can be found until December 3d, when he was admitted to the hospital at Jeffersonville, Indiana. He stated that several pieces of bone had come aAvay. On December 5th he was sent to the hospital at Quincy, Elinois, and thence furloughed on December 24th, 1864. He was, on February, 1865, promoted to a lieutenancy in the 147th Illinois Volunteers, and was mustered out on January 20th, 1866. His name does not appear on the Pension List. Case.—Private John Miller, Co. I, 12th New Jersey Volunteers, aged 45 years, was wounded at the battle of the Wilderness, A'irginia, May 6th, 1864, by a conoidal musket ball which fractured the external orbital process ofthe frontal bone. He was admitted to the hospital of the 2d division, Second Corps, and thence conveyed to the Mount Pleasant Hospital, Washington, where he was admitted on May 29th, 1864. Death resulted on the 22d of June. Case.—Private George Mills, Co. M, 8th Illinois Cavalry, aged 33 years, at Beverly Ford, Virginia, June 9th, 1863, was struck in the forehead by a carbine ball which, passing from left to right, fractured the outer table of the frontal bone over the left eye, near the external angle. He Avas conveyed to AVashington and admitted into the Lincoln Hospital on the folloAving day, suffering, from time to time, severe pain and vomiting. Ice water dressings were applied to the head, and a restricted diet ordered; anodynes being employed to relieve the pain. In a few days the severity of the pain subsided. He improved rapidly, and was returned to duty on August 6th, 1863. The case is reported by Acting Assistant Surgeon Wm. Canniff. In May, 1867, Pension Examining Surgeon J. B. Lyman reported, that this pensioner had a permanent enlargement of the pupil of the left eye, and immobility of the iris, and that he considered the functions of the retina permanently impaired. Case.—Private James Murphy, Co. K, 96th Pennsylvania Volunteers, was wounded at the battle of Spottsylvania, Virginia, May 12th, 1864, by a conoidal ball which entered behind the right temporal fossa, passed fonvard and fractured the outer table of the frontal bone at the supra orbital ridge. He Avas conveyed to Washington, D. C, and on May 18th admitted to Douglas Hospital. There was no depression, but the right pupil Avas widely dilated and vision impaired. No brain symp- toms occurred at any time. Poultices Avere applied and portions of bone subsequently removed. The patient recovered, and on June 18th Avas sent to Haddington Hospital, and on July 23d, 1864, returned to duty. He is not a pensioner. Case.—Private Constantine O'Donnell, Co. G, 184th Pennsylvania Volunteers, aged 34 years, Avas wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, receiving a gunshot fracture of the external table of the frontal sinus. He was admitted to the 2d division, Second Corps, field hospital, and on the 7th Avas conveyed to the Carver Hospital at AVashington. Several sequestra were removed, and simple dressings were applied. On the llth he Avas transferred to the Haddington Hospital, Philadelphia, and on June 96th death supervened from compression of the brain. 17 130 WOUNDS AND INJURIES OF THE HEAD. Case—PriA-ate James B. Perkins, Co II, 20th Connecticut Volunteers, aged 23 years, Avas wounded at the battle of Chancellorsville, Virginia, Alay 3d, 1883, by a musket ball which fractured the frontal bone an inch above the right eye and lodged in the frontal sinus. He was taken prisoner, but was paroled on Alay 10th, and admitted two days subsequently into the field hospital of the Twelfth Corps. lie was transferred to Fairfax Seminary hospital on June 14th, and thence to Phila- delphia on the 17th, and admitted into AIoAver Hospital. On the 28th an examination of the wound revealed the external table denuded and slightly depressed. On July 10th the Avound was discharging healthy pus, and on August 5th had closed, except an opening half an inch wide. On November 23d he had sufficiently recovered to be placed on guard duty in the hospital. On December 8th a slight saa elling over the right frontal protuberance was observed. The probe detected small loose fragments of bone. Acting Assistant Surgeon J. M. McGrath made a straight incision an inch in length, extending from the fistulous orifice over the superciliary ridge. The outer table of the skull was found destroyed, and a musket ball almost completely divided through its centre and spread open, Avas discovered partially imbedded in the frontal sinus. The missile, together Avith several fragments of bone, was removed by forceps. The wound was closed by adhesive strips, and cold Avater dressings were applied. The patient improved gradually, and by January 18th, 1864, the wound had healed except at a small opening through which there was a slight discharge of healthy pus. On March 31st he was transferred to New Haven to the Knight Hospital, whence he was returned to duty on May 7th, 1864. The case is reported by Surgeon Joseph Hopkinson, U. S. V. The name of this patient is not upon the rolls of the Pension Office. Case.—Private Henry R. Snap, Co. I, 18th Kentucky Volunteers, Avas wounded at the battle of Chickamauga, Georgia, September 19th, 1863, by a conoidal musket ball which penetrated the external table of the frontal bone at the left superciliary ridge and lodged in the frontal sinus. The missile was extracted, and the Avound suitably dressed at the field hospital where the patient remained until November 27th, when he was sent to Lexington, Kentucky. He was returned to duty December 28th, but being found unfit for service Avas again admitted into a general hospital at Murfreesboro', Tennessee, January 23d, 1864. He noAV fully recovered and Avas returned to duty on March llth, 1864. He is not reported as an applicant for pension. Case.—Private Orrin C. Spencer, Co. F, llth Connecticut Volunteers, aged 18 years, was wounded at the battle of Antietam, Maryland, September 17th, 1862, by a musket ball Avhich fractured the outer table of the frontal bone at its superior portion and to the left of the median line. He was stunned, but after reaction, endeavored to walk, but Avas too faint and giddy to go far. AVith the assistance of two comrades he retired to a field hospital where cold water was applied to the wound. He was transferred to Frederick, and thence to AVashington, entering Capitol Hospital on the 22d. On the 24th he was sent to the DeCamp Hospital, David's Island, NeAV York Harbor, where he arrived on the 28th. The wound was discharging freely. At the expiration of a week erysipelatous action set in, which was, however, readily combatted by a purge and the local application of iodine. On October 26th Iavo pieces of the outer table of the frontal bone were removed. At times he suffered severe pain over his eyebroAVS which extended over the left side of his head, and occasionally he was so dizzy that he could not walk across the ward. He was discharged from the service on November 12th, 1862. The wound had healed, but dizziness occasionally recurred. On January 3d, 1868, the Commissioner of Pensions stated that Spencer was a pensioner, that his disability was rated at one-third, and the prognosis of its duration doubtful. Surgeon S. AV. Gross, U. S. V., reports the early history of the case. Case.—Sergeant Paul P. Starke, Co. H, 95th Pennsylvania Volunteers, aged 21 years, received, at the battle of Spott- sylvania Court-house, A'irginia, May 12th, 1864, a gunshot fracture of the external table of the frontal bone, at the external edge of the left orbit. He was immediately admitted to the hospital of the 1st division, Sixth Corps, and on the 19th trans- ferred to the Carver Hospital. Sequestra Avere removed from the wound and simple dressings applied. The patient recovered, Avas furloughed on Alay 27th, 1864, and returned to the hospital June 29th. He was pensioned, and on October 15th, 1866, Pension Examining Surgeon J. Cummiskey, reported his disability as one quarter, and its duration doubtful. Case.—Private Leonard H. AVashburn, Co. E, 1st Maine Heavy Artillery, aged 21 year=, was wounded at the battle of Spottsylvania Court House, Virginia, May 19th, 1864, by a conoidal ball which fractured the outer table of the frontal bone. He remained in the field hospital until May 24th, when he Avas conveyed to Washington and admitted to the Carver Hospital. On June 1st he was sent to the Mower Hospital, Philadelphia. The patient recovered and was returned to his regiment for duty December 27th, 1864. He served in the field until the middle of Alarch, 1865, when he was again admitted to the field hospital and sent, on April 10th, to the Armory Square Hospital, with aphonia and partial amaurosis, the latter a consequence ofthe old Avound. He was discharged on June 9th, 1865. On August 3d, 1869, Pension Examining Surgeon E. A. Thompson reports that this patient had a constant discharge of pus from the wound, and severe headache after exertion or exposure; that he was unable to perform any labor that requires exertion or mental effort, and that the severe pain affected his general health. Case.—Private Charles F. B------, Co. D, 101st Ohio Volunteers, received, at the battle of Murfreesboro', Tennessee, December 31st, 1862, a gunshot fracture of the outer table of the frontal bone over the right eye by a conoidal musket ball. He Avas treated at the hospital of the 1st division of the Fourteenth Corps until January 7th, 1863. when he was sent to hospital No. 14, at Nashville, whence he was discharged from service on April 26th, 1863, and pensioned. The pension examiner reports that the missile lodged in the frontal sinus whence it was extracted, and that the pensioner suffers from persistent pain in the head and vertigo Avith loss of sight, and that he is unable to perform any manual labor. Next in frequency to the fractures of the outer plate of the frontal sinus, among the cases of gunshot fracture reported as limited to the external table, were those of the mastoidal region of the temporal. In nine cases, in which the injuries are described with precision, the mastoid process was detached or seriously fractured in seven, and the outer lamina of the contiguous portion of the temporal in iavo. One case was fatal. Five of GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 131 the patients were discharged or mustered out, and three of these were subsequently pensioned. Three recovered and were returned to duty. Permanent deafness in three cases, and troublesome caries in two, are reported in the cases of those who recovered. Case.—Private Albert Bradley, Co. E, 13th New Jersey Volunteers, was wounded at the battle of Antietam, September 17th, 1862, by a musket ball which chipped off a portion of the exterior lamina of the left temporal bone, and lodged behind the ramus of the loAver jaAV. On September 24th he was sent to the South Street Hospital, Philadelphia, and on the 26th the missile Avas extracted. In the course of the treatment the Avound repeatedly reopened, but, ultimately, healed firmly, and the patient Avas returned to duty, December 22d, 1862. The case, thus far, Avas reported by Surgeon P. B. Goddard, U. S. V. The patient Avas discharged on May 26th, 1863, aud pensioned. On June 10th, 1869, his pension Avas increased, Pension Examiner A. XV. AA'oodhull having reported that he was entirely deaf in the left ear; that the cicatrix was constantly tender and painful; that he had severe attacks of headache and vertigo, induced by exposure to the sun or by changes of temperature. Case.—Corporal John C. B- Antietam, Maryland, September 17th, 186J Fig. 46.—Segment of skull showing detachment of the mastoid process of the right temporal. Spec. 183, Sect. I, A. M. M. Co. K, 5th Maryland Volunteers, aged 33 years, Avas wounded at the battle of The missile entered the posterior part of the neck, one and one-half inches below the occipital protuberance just forAvard of the ligamentum nuchse, passed upAvard and forward, and emerged above the right ramus of the lower jaw. He was sent to AA'ashington, and admitted to Columbian College hospital on September 20th. No fracture could be discoA'ered. He complained of difficulty in mastication, and there Avas evidently some injury of the facial nerve. In a few days the Avound began to suppurate, and the patient Avalked about the Avard apparently doing well. October 8th, suppuration suddenly ceased. Chills occurred; the frequency of recurrence increased until October 12th, Avhen there was heavy deep breathing, and many symptoms of meningitis. DroAVsiness and stupor followed, and coma and death took place October 14th, 1862. At the autopsy it Avas found that the ball had detached the mastoid process, denuded the occipital and temporal bones of periosteum in the vicinity of the fracture. There Avas some redness and congestion of the blood Aressels, but no traces of inflammation could be found in the brain itself. The specimen was sent to the Army Medical Museum by Surgeon A. Van Derveer, 66th New York Volunteers, and is represented in the adjacent Avood-cut, (FiG. 46.) The process is entirely detached at the base, the mastoid cells are opened, of course, but there is no Assuring or other lesion of the inner table and no attempt at repair. Dr. Van Derveer's report does not refer to any impairment of the sense of hearing prior to the supervention of coma.* Case.—Private John Burke, Co. K, 9th Illinois Volunteers, was wounded at the battle of Corinth, Mississippi, October 3d, 1862, by a conoidal musket ball which perforated the middle portion of the left ear, and passing under the integuments, across the mastoid process, fractured the outer lamina of the bone. He was admitted to the hospital of the 2d division of the Army of the Tennessee, and on October 13th was sent to the hospital at Mound City, Illinois. Simple dressings only Avere employed. Burke was returned to duty on October 28th, 1862. His name is not upon the list of pensioners. Case.—Private AA'illiam H. Bush, Co. F, 27th Massachusetts Volunteers, aged 26 years, was Avounded before Petersburg, June 18th, 1864, by a piece of shell which contused the left temporal bone. He was, on the following day, admitted to the field hospital of the Eighteenth Corps. The injury was considered slight, and the man returned to his regiment for duty. No further record of the case can be found until January 27th, 1865, when he was admitted to the Foster Hospital, at NeAV Berne, with ulceration of the scalp.. He Avas again returned to duty on March 8th, 1865, but on Alarch 31st Avas admitted to the DeCamp Hospital, at David's Island. On April 4th he was transferred to the Dale Hospital, AArorcester, and noAV it was definitely ascertained that the right temporal bone was fractured, though no depression existed. The man Avas mustered out of service on June 17th, 1865. He afterwards made a claim for a pension, but Avithdrew it Avithout aAvaiting a decision. The report to the Pension Office by Examining Surgeon J. II. Waterman, states that the patient had a fracture of the outer table of the left temporal, portions of which had been removed by caries. In October, 1865, the wound Avas healing and the disability was not considered permanent. Case.—Private Alexander J. Clark, Co. D, 63d Pennsylvania Volunteers, was wounded at Charles City Cross Roads on June 30th, 1862. The missile entered behind the left ear and injured the mastoid process of the temporal bone. He Avas admitted, on August 17th, to the hospital at Point Lookout, Maryland, and discharged from the service and pensioned on December 25th, 1862. The wound had healed with an irregular cicatrix, and the hearing was someAvhat affected. He re-enlisted on February 8th, 1864, in Co. F, Pennsylvania Light Artillery, and was mustered out on June 26th, 1865. On July 31st, 1866, Pension Examiner G. McCook, of Pittsburg, reported that his hearing was affected, and there was a purulent discharge from the ear, and pain in its vicinity. Case.—Private Daniel Clymer, Co. B, 38th Ohio Volunteers, received, in an engagement near the Chattahoochie River, Georgia, July 20th, 1864, a gunshot partial fracture of the left mastoid process. He was admitted into the field hospital of the 3d division, Fourteenth Corps, and a few days later sent to the No. 2 hospital, Chattanooga, Tennessee. He was returned to duty September 20th, 1864. His name does not appear on the Pension List. *See Catalogue of the Surgical Section A. M. M., p. 11, and Circular No. 6, S. Gt. O., 1865, p. 12. The history of the specimen was procured subsequently to the date of those publications. l;,,2 WOUNDS AND INJURIES OF THE HEAD. Case.—Lieutenant Joseph S. Heston, Co. D, 4th New Jersey A'olunteers, Avas wounded at the battle of the Wilderness, Virginia, Alav 5th, 1864, by a buckshot which injured the mastoid process of the temporal bone. He was admitted to the hospital of the 1st division of the Sixth Corps, but returned to his regiment in a short time. He was mustered out with his regiment, June 9th, 1865. His name is not upon the Pension Rolls. Case.—Private Henry Meixner, Co. F, 61st Pennsylvania Volunteers, aged 23 years, was- wounded in the defences of AVashington, D. C, on July 12th, 1864, by a conoidal ball which fractured the outer plate of the mastoid process of the temporal bone. He was, on the same day, admitted to the Mount Pleasant Hospital. The Avound became gangrenous, and on July 30th haemorrhage to the amount of ten ounces occurred from a branch of the occipital artery. On the folloAving day haemorrhage recurred, but was arrested by compression. On September 8th Meixner was furloughed, and on November 8th he Avas admitted to the hospital at Pittsburg, and on May 22d, 1865, discharged from the service. His name is not upon the Pension List. Case.—Private Samuel N. Morse, Co. A, 74th Illinois Volunteers, aged 27 years, was wounded in an engagement at Kingston, Georgia, Alay 17th, 1864, by a conoidal musket ball which entered near the right ear, detaching a scale from the mastoid process of the right temporal bone, and passed through the cheek. He was, on the same day, admitted to the hospital of the 2d division, Fourth Corps, and thence sent to Chattanooga and Nashville, and to the Jefferson Hospital in Indiana. On July 26th he was sent to Camp Butler, Illinois; furloughed on September 2d, and on November 2d admitted to the hospital at Quincy, Illinois. He was finally discharged from service on the 29th of May, 1865. At this date, Pension Examiner J. Robbins reports that the patient Avas deaf in the right ear, and that his system was enfeebled by long continued suppuration. In the four following cases, it was believed, after careful exploration, that the outer table alone of the parietal was fractured- Case.—Private O. G. Ayres, Co. A, 22d Virginia Infantry, aged 24 years, received, at the action at Mine Run, Virginia, November 27th, 1863, a gunshot fracture of the outer table of the right parietal bone. He was admitted to the Chimborazo Hospital, Richmond, on November 30th. He had slight feATer with coma, and the pulse was slow, leading to the supposition that both tables Avere fractured; but, on closer examination it was discovered that the outer table only was fractured to the extent of one and one-half inches. The bowels Avere Avell opened with calomel, gamboge, and castor oil, and the coma abated. Cold applications were constantly applied to the wound, and calomel was pushed to ptyalism. The patient became rational and the coma disappeared. On December 5th erysipelas developed itself over the head and face. The parts were painted with iodine and tincture of sesqui-chloride of iron was administered internally. On the 15th the patient had almost entirely recovered, and was furloughed on December 25th, 1863. He appeared before a medical examining board of General Heth's division, September 8th, 1864, and was retired on account of cerebral disturbance accompanied by convulsions. Case.—Private George Atkinson, Co. F, 7th Wisconsin Volunteers, aged 24 years, was Avounded at the battle of the Wilderness, Virginia, May 5th, 1864, by a conoidal musket ball which injured the outer table of the skull. He was sent to the hospital of the 4th division, Fifth Corps, thence on May 12th to the 2d division hospital at Alexandria, thence on the 22d to the Satterlee Hospital, Philadelphia, where the injury is reported as a wound of scalp. Having recovered, he was returned to duty on the 17th of September, 1864. He was discharged on July 3d, 1865, and pensioned. On November 12th, 1868/Pension Examiner G. W. Eastman reported that there then had been fracture of the outer table of both parietals, and that the patient complained of numbness of the extremities. Case.—Assistant Surgeon Levi JeAvett, 14th Connecticut Volunteers, aged 20 years, while attending upon the wounded at the battle of Ream's Station, Virginia, August 25th, 1864, was struck upon the left side of the head by a fragment of shell Avhich fractured the outer table of the parietal hone, and the zygomatic process of the temporal, denuding the skull over an equilateral triangular surface of four inches a side. For a few days he was treated in the hospital of the Second Corps, then transferred to AA'ashington, and on the 29th admitted into the Emory Hospital. So far as recorded cold Avater dressings formed the main treatment. On September 1st he was transferred to the Seminary Hospital in GeorgetoAvn, and thence on December 3d to the Officer's Hospital at Annapolis, Maryland. He remained under general treatment until January 6th, 1865, Avhen he Avas discharged from service. He still complained of a fullness of the head and of imperfect vision of the left eye though there was no perceptible difference in the organs of vision. He was naturally short sighted. The general condition of the patient, however, was good. The case is reported by Acting Assistant Surgeon J. Longenecker. This officer has not applied for a pension. Case.—Private 7T. B. Taylor, Co. G, 38th Alabama Infantry, received, at the battle of Dalton, Georgia, April 9th, 1864, a gunshot fracture of the external table of the right parietal bone. He was admitted into the hospital at Dalton on the same day. Exfoliation of the bone took place. On June 23d, 1864, he was furloughed. Other cases of grooving of the outer plate and diploe are reported, in which the injury appears not to have implicated the inner table: Case.—Private John Anderson, Co. A, 77th Illinois Volunteers, was wounded at the battle of Arkansas Post, January llth. 1863. by a conoidal musket hall Avhich struck at the junction of the frontal and left parietal bones, and passed backward near the sagittal suture almost as far as the lambdoidal, denuded the bone and grooved the outer table for a length of two and one half inches. He was carried on board the hospital steamer D. A. January, and conveyed to Memphis, Tennessee, where he Avas admitted, on the 23d, into Hospital No. 3. No fracture or depression was observed, but exfoliation shortly took place, and several pieces of the external table were removed. The inner table, also, was found to be necrosed, and a month after the reception of the injury a detached piece of the inner plate, three-fourths of an inch in diameter, was extracted, leaving the GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 133 pulsation of the brain clearly visible. Subsequently, other small portions of the external plate were removed as they became loose. The sight of the left eye, though not at first affected by the injury, became, in the course of two or three weeks, to use the expression of the patient, feeble and glimmering, so that, for instance, a printed page would appear blurred. He was discharged from service and pensioned on the 3d of April, 1863. The Wound had not fully healed, but was gradually contracting; the vision remained impaired. The case is reported by Assistant Surgeon Thomas T. Smiley, U. S. V.* On October 1st, 1863, Pension Examiner H. S. Hurd reported that this man had partial loss of sight of the left eye. On August 6th, 1867, Pension Examiner G. W. Spalding reported that the ball penetrated the right parietal, "remaining some time in the brain, Avhich sloughed considerably;" a statement so at variance with previous reports that it was probably derived from hearsay. Case.—Private John Boylan, Co. I, 1st Michigan Volunteers, aged 26 years, Avas wounded at the battle of Gaines's Mill, A'irginia, June 27th, 1862, by a conoidal musket ball Avhich struck the right parietal bone at its superior posterior angle, carried away a piece ofthe scalp larger than a half dollar, and grooved the bone for a distance of three-fourths of an inch. He Avas unconscious for nearly thirty minutes after the reception of the injury, was then taken prisoner, and conveyed to Richmond, Avhere the Avound Avas dressed for the first time, on June 30th, with cold Avater dressings. The left arm had become paralyzed and devoid of sensation, and continued so for about a Aveek. He remained in Richmond about three Aveeks when he Avas exchanged and sent to the De Camp Hospital, David's Island, NeAV York Harbor. The Avound had cicatrized but slightly, and was discharging very offensive pus, and the bone was found to be necrosed. On July 28th a portion of the external table, and on the folloAving day the corresponding portion of the diploe and vitreous table were removed, exposing the dura mater to the extent of an inch and a half. Cold water dressings were applied, and the patient recovered rapidly. At the time of his discharge, November 16th, 1862, the Avound had healed perfectly, the cicatrix presenting a depression sufficiently large to receive the index finger. The parts were very tender, and pressure would produce a sensation of dizziness. Excepting a slight intermittent headache, no symptoms of brain complication occurred at any time. The pathological specimen was Fig. 47.—Exfolia- contributed to the Army Medical Museum, and consists of two exfoliations. The smaller, one inch in the11 grooving of 'the length, consists mainly of diploe; the other, which measures three-fourths of an inch by one and a half parietal bone by a inches, is blackened and perforated in the centre. It is represented in the adjacent Avood-cut, (FiG. 47.) 974, Sect. 1, A. M. ii! The history Avas contributed by Surgeon S. W. Gross, U. S. X. Boylan's name is not upon the Pension Li*t. Case.—Private Noah Frey, Co. I, 54th Pennsylvania Volunteers, aged 22 years, received, at the battle of NeAV Market, Virginia, Alay 15th, l^til. a gunshot wound of the right parietal region, about two and one-half inches above the ear, with partial fracture ofthe cranium. He was sent to the hospital at Cumberland, Alaryland, on Alay 18th. There Avas a longitudinal superficial furrow about tAvo inches in length running in an antero-posterior direction. Some fragments of bone came away in the progress of the case. Simple dressings were used. The wound gradually healed, and he Avas returned to duty October 26th, 1864. The case is reported by Surgeon J. B. LeAvis, U. S. V. The name of the patient is not upon the Pension List. Case.—Private J. M. Hardin, Co. B, 27th North Carolina Infantry, received, at the battle of the Wilderness, Virginia, May 6th, 1864, a gunshot Avound of the scalp in the line of the coronal suture, with loss of a portion of the outer table of the bone. He was admitted, on May llth, into the hospital at Farmville, and he was furloughed June 3d, 1864, Case.—Private Thomas Mahoney, Co. E, 89th Illinois Volunteers, aged 23 years, was Avounded in the engagement near Dallas, Georgia, May 27th, 1864, by a conoidal musket ball Avhich struck the upper part of the right parietal bone, grooving it slightly. He was admitted to the hospital of the Fourth Corps on June 5th, and sent to No. 19, Nashville; on June 17th, to No. 5, NeAV Albany; on June 27th, to Jefferson Barracks, St. Louis, Missouri; and on July 9th, 1864, to the hospital at Quiucy, Illinois, Avhence he Avas returned to duty on August 23d, 1864. His name does not appear as an applicant for a pension. Case.—Private Wilkie Aiartin, Co. H, 6th Pennsylvania Cavalry, aged 25 years, was wounded at the battle of the Wilderness, Virginia, May 6th, 1864, by a conoidal musket ball which struck at the vertex, laid bare the scalp, and grooved the bone for a small distance. He was admitted into the field hospital of the Cavalry Corps on the folloAving day, and on the 23d sent to the 3d division hospital, Alexandria. Simple dressings were used. On June 6th the patient was transferred to the Mower Hospital, Philadelphia, and on November 7th, 1864, he Avas discharged from the service. The case is reported by Surgeon Edwin Bentley, U. S. V. He is not a pensioner. Case.—Private John Alichael, Co. E, 67th Pennsylvania Volunteers, was wounded at the battle of the Wilderness, Virginia, May 6th, 1864, by a conoidal ball which entered the scalp at the vertex and ploughed out a portion of the scalp about three inches in length and one inch in width, and grooved the outer table of the skull. He Avas admitted to the hospital of the 1st division of the Sixth Corps, and on May llth Avas sent to the Columbian Hospital at AVashington, and May 15th to the Patterson Park Hospital, Baltimore, and on May 21st to the hospital at York, Pennsylvania. On May 31st erysipelas appeared and extended rapidly over the forehead and left side of the face, aud the parts around the eye became much swollen. Ice water, tincture of iodine, and acetate of lead to the eye, were employed. On June 3d the Avound had healed and the patient was nearly well. He Avas returned to duty on September 29th, 1864. The case is reported by Surgeon Henry Palmer, U. S. V. The name of this patient does not appear upon the Pension List. * See Boston Medical and Surgical Journal, vol. LXIX, p. 152, September, 1863. 131 WOUNDS AND INJURIES. OF THE HEAD. Case.—Private James AV. Slater, Co. C, 49th Ohio Volunteers, aged 16 years, Avas wounded in an engagement at Lost Mountain, Tennessee, June 14th, 1864, by a fragment of shell which grooved the external table of the frontal bone. He was conveyed, on June 22d, to the Cumberland Hospital at Nashville, Tennessee, where he remained until the 9th of August, Avhen he Avas transferred to the Joe Holt Hospital at Jeffersonville, Indiana. On November 26th, 1864. he Avas returned to duty, and discharged June 3d, 1865. He has a pension claim pending. Pension Examiner W. W. Cake reports, September 22d, 1866, that portions ofthe outer wall ofthe frontal above the right eye had been removed, and that the applicant suffered from cerebral disorder on exposure, and that his disability might be rated at tAVo-thirds and permanent. Case.—Corporal Hendrick J. Smith, Co. E, 137th New York Volunteers, aged 21 years, was wounded at the battle of Chancellorsville, A'irginia, Alay 3d, 1863, by a fragment of shell which fractured the central portion of the right parietal bone, apparently grooving the outer table only. He was partially insensible for the first three days after the reception of the injury, and remained upon the field for eleven days. AA'hen admitted to the hospital of the TAvelfth Corps, Alay 14th. 1863, he Avas greatly exhausted from privation and exposure, and his countenance presented a wild and excited appearance. Cold applications were applied to the Avound, the bowels freely opened and generous diet ordered. On May 20th the wound Avas closing and the patient had much improved, looking well, except the same wild expression ; he talked rationally but the memory Avas lost. He Avas returned to duty on June 1st, 1863. He is not reported as an applicant for a pension. Case.—Private L. A'. Stewart, Co. A, 20th Alassachusetts Volunteers, aged 35 years, was AA'ounded at the battle of Gettysburg, Pennsylvania, July 1st, 1863, by a fragment of shell Avhich fractured the outer table of the parietal bone one inch above the right ear. In the same engagement he received a wound of the back. He Avas treated at the Seminary Hospital until the 16th of July, and then sent to the McKim Alansion Hospital, Baltimore, at Avhich time he was suffering considerable pain in the head, left eye, and face. On the 25th paralysis of the right side of the face supervened by which the mouth was drawn to the left side. In connection with local applications, acetate of opium in camphor water was employed by which the degree of pain Avas lessened, though the paralysis continued the same. On November 8th he was furloughed, and on the 30th transferred to the Jarvis Hospital. He recovered and was transferred to the Veteran Reserve Corps, March 21st, 1864. Acting Assistant Surgeon R. H. Sterling reports the case. The name of the patient does not appear on the Pension Rolls. Case.—Private Frederick Strouse, Co. I, 26th Michigan Volunteers, aged 31 years, received, in the engagement at Deep Bottom, A'irginia, August 16th, 1864, a gunshot scalp Avound at the vertex with fracture of the outer table of the cranium. He Avas taken prisoner, but subsequently paroled and admitted into the hospital at Camp Parole, Annapolis, on September 22d. On February 21st, he was admitted to the Harper Hospital, Detroit, Michigan, and on June 7th, 1865, discharged from service. Acting Assistant Surgeon W. H. Chandler certifies, on the certificate of disability, that there was a gunshot wound of the crown of the head fracturing the outer table of the skull. Case.—Private AA'illiam H. A'oss, Co, G, 5th Delaware Volunteers, aged 35 years, was wounded in the engagement at the South Side Railroad, Virginia, April 1st, 1865, by a fragment of shell which cut the scalp and furrowed the occipital protuberance. He was admitted to the hospital of the 2d division of the Fifth Corps, and on April 7th was sent to the Finley Hospital, AA'ashington. He was returned to duty on July 8th, 1865. He does not appear to have been an applicant for a pension. Case.—Private Jacob Welsh, Co. A, 107th Pennsylvania Volunteers, was Avounded at the battle of Gettysburg, Penn- sylvania, July 2d, 1863, by a fragment of shell which fractured the external table of the right parietal, the bone being driven upon the diploeic structure. He was conveyed to the hospital at York, Pennsylvania, on July 12th. No ill result ensued from the injury. On October 1st small portions of bone were removed. Having recovered, he was returned to duty on November 16th, 1863. The case is reported by Acting Assistant Surgeon H. L. Smyser. The name of the patient is not upon the Pension List. Case.—Private George L. AA'ood, Co. I, 5th New York Volunteers, was Avounded at the battle of Gaines's Mill, June 27th, 1862, by a conoidal musket ball which struck the back of the head obliquely, making a long scalp wound and grooving the outer table of the occipital bone. He was treated at Ira Harris Hospital, Albany, New York, and discharged from service on December 15th, 1862, and pensioned. Pension Examiner S. D. Willard reports, June 18th, 1863, that this pensioner was much disabled, but likely to recover in the course of a few years. Four instances are reported of fracture of the external lamina of the occipital near its protuberance or semicircular ridges: Case.—Private C. J. Adams, Co. H, 21st North Carolina Regiment, aged 19 years, was wounded at the battle of Winchester, A'irginia, September 19th, 1864, by a conoidal ball which fractured the outer table of the occipital bone. Frag- ments of the bone were removed at the hospital of the Nineteenth Corps at AVinchester Avhere he remained until the 20th of November, when he was conveyed to Martinsburg, and thence sent to Baltimore, Alaryland, entering West's Buildings Hospital on December llth. On January 8th, 1865, he was sent to the Prisoner's Camp, Point Lookout, but on the 27th was admitted to the hospital at the latter place, suffering from the effects of the wound. Death from apoplexy supervened April 15th, 1865. Case.—Private Charles D. Fairbanks, Co. E, 2d United States Sharpshooters, aged 18 years, was wounded in front of Petersburg. A'irginia, November 20th, 1864. by a conoidal ball which fractured the external table of the occipital bone. He was conveyed to a field hospital, and on December 4th was admitted to Armory Square Hospital. Simple dressings were applied to the Avound until April 1st, 1865. when a piece of the outer table, an inch square, was removed. The patient was returned to duty April 22d, 1865, suffering no disturbance of his cerebral functions from the injury. His name is not upon the Pension List. GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 135 Case.—Private A. McDonald, Co. E, 4-Jd Illinois Volunteers, aged 28 years, was wounded at the battle of Resaca, Georgia, Alay 14th, 1864, by a round musket ball which fractured the external table of the occipital bone near the junction of the lambdoidal and sagittal sutures. He also received, in the same engagement, a fracture of the spinous proces of the third lumbar vertebra, the ball lodging, and being cut out from the muscles on the left of the spine. He was admitted, on the folloAving day, into the hospital at Chattanooga, Tennessee, and on the 17th sent to the Cumberland Hospital at Nashville, where he remained until transferred on the 10th of July to Jefferson Barracks in Missouri. He was subsequently sent to Keokuk Hospital in IoAva. where he arrived on July 28th, 1864. He was finally sent to Springfield, Illinois, on August 22d, and mustered out of service October 3d, 1864. From the report of Pension Examining Surgeon T. A. Henning, dated November 4th, 1861. information is obtained that the patient then suffered from vertigo and defective vision, and that these Avere increased by any exposure to the beat of the sun. The fracture of the spinous process of the vertebra produced an irritation at the neck of the bladder and weakness in the back. There had also been a flesh wonnd of the lower part of the right leg which had sloughed and left a painful cicatrix near the ankle. The pension examiner regarded the disabilities of this pensioner as total, but likely to diminish in a few years. Case.—Private George Statwood, Co. K, 4th NeAV Hampshire Volunteers, aged 21 years, was wounded at the battle of Cold Harbor, A'irginia, June 4th, 1864, by a conoidal ball which fractured the outer table of the occipital protuberance. He was at once admitted to the hospital of the Eighteenth Corps, thence sent to the HareAvood Hospital, Washington, D. C, and on June 16th transferred to the Knight Hospital, NeAV Haven, Connecticut. On July 18th he was sent to the Ward Hospital, Newark, New Jersey. On January 18th, 1865, denuded and carious bone was discovered through a large gangrenous opening in the scalp. The patient Avas placed under the influence of chloroform and ether, and Acting Assistant Surgeon W. S. Ward, removed the carious bone. Simple dressings were applied and the wound healed rapidly. Statwood Avas discharged from the service on the 29th of May, 1865, by reason of disability resulting from the Avound. He does not appear to have made application for a pension. Many cases appear on the reports as gunshot fractures of the external table of the skull, in which the appearances and symptoms are not defined with sufficient precision to permit a satisfactory judgment as to the accuracy of the diagnosis. Of these, twenty are alleged examples of gunshot fracture of the outer plate of the frontal bone. One was a fatal case, and the diagnosis was probably verified after death. Two were cases of Confederate soldiers, who recovered and were furloughed, and unaccounted for subsequently. One patient deserted. The remaining sixteen cases were of Union soldiers, of whom nine were returned to duty, one to modified duty in the Veteran Reserve Corps, and six were discharged for disability. The Veteran Reserve soldier and one of the discharged men are on the Pension Roll. The fractures are reported to have been inflicted by conoidal musket balls in eleven instances, by round musket balls in two, and by shell fragments in two, while in five cases the nature of the missile was unknown: Case.—Sergeant Major L. M. Andrews, 8th Georgia Regiment, was, on June 3d, 1864, admitted to the Confederate hospital at Farmville, Virginia, with a gunshot fracture ofthe external table of the frontal bone. He was very much debilitated from dysentery of three weeks standing, but he gradually improved, and was, on June 17th, 1864, furloughed for forty days. Case.—Corporal Francis Atwood, Co. B, 48th New York Volunteers, aged 30 years. Fort Wagner, South Carolina, July 18th, 1863. Round musket ball. Treated at Beaufort, McDougal, and DeCamp hospitals. Discharged from service August 25th, 1864. Not on Pension List. Case.—Corporal Hudson Austin, Co. G, 12th Connecticut Volunteers, aged 23 years. Cedar Creek, A'irginia, October 19th, 1861. Conoidal musket ball. Treated at Jarvis and Mower hospitals. Returned to duty January 25th, 1865. Not on Pension List. Case.—Sergeant Benjamin F. Ball, Co. K, 127th Illinois Volunteers, aged 25 years. Atlanta, Georgia, August 25th, 1864. Conoidal musket ball. Treated at field, corps, and Nashville hospitals. Returned to duty November 21st, 1864. Not on Pension List. Case.—Private Nelson W. Chase, Co. A, 6th Vermont Volunteers, aged 21 years. Cold Harbor, Virginia, June 7,1864. Treated at corps, Carver, and Brattleboro' hospitals. Returned to duty August 30th, 1864. Not on Pension List. Case.—Captain James Cross, Co. A. 99th Pennsylvania Volunteers. Fredericksburg, Virginia, December 13th, 1862. Treated at Officers' Hospital, AVashington. Discharged from service January 14th, 1864. Not on Pension List. Case.—Private Charles Dickel, Co. D, 72d Pennsylvania Volunteers. Fredericksburg, Virginia, December 13th, 1862. Treated at Carver Hospital, Washington. Discharged from service February 16th, 1863. Not on Pension List. Case.—PriA'ate Martin Everett. Co. B, 124th NeAV York Arolunteers, aged 37 years. Spottsylvania Court-house, May 10th, 1864. Conoidal musket ball. Treated at corps, Alexandria, Mower, and DeCamp hospitals. Discharged from service October 3d, 1864. Not on Pension List. 136 WOUNDS AND INJURIES OF THE HEAD. Case.—Private G. Gerbaner, Co. F, 19th AVisconsin Volunteers, aged 52 years. Petersburg, A'irginia, June 16th, 1864. Conoidal musket ball. Treated at Hampton and MoAver hospitals. Deserted January 6th, 1865. Not on Pension List. Case.—Sergeant George A. Keeler, Co. A, 20th Connecticut A'olunteers. Fredericksburg, A'irginia, May 3d, 1863. Fragment of shell. Treated at corps, Carver, and Knight hospitals. Returned to duty December 9th, 186!}. Casio.—Private J. E. Key, Co. C, 1st South Carolina Regiment. September 30th, 1884. Treated at Jackson Hospital, Richmond. Furloughed. Case.—Private James L. AIcAIahan, Co. F, 87th Indiana Volunteers, aged 20 years. Chickamauga, Georgia, Septem- ber 19th, 1863. Conoidal musket ball. Treated in hospitals at Nashville. Returned to duty April 18th, 1864. Not on Pension List. Case.—Corporal George Metzger, Co. I, 125th New York A'olunteers, aged 18 years. Gettysburg, July 3d, 1863. Shell fragment. Treated at field and Newark hospitals. Transferred to Second Battalion A'eteran Reserve Corps, February 4th, 1864. Discharged June 29th, 1865, and pensioned. Pension Examiner W. S. Searle, Troy, NeAV York, reports that there is a depression over the left orbit, headache and giddiness, and rates the disability of the pensioner at "two thirds and permanent." Case.—Corporal S. H. Polley, Co. H, 4th NeAV York Heavy Artillery, aged 21 years. Petersburg, Virginia, June 23d, 1864. Conoidal musket ball. Treated at HareAvood and Rochester hospitals. Discharged July 7th, 1865. Pensioned. Pension Examiner Eli F. Hendrich reports, Alarch 25th, 1867, that there was an exfoliation from the right side of the frontal bone, that the vision of the right eye was impaired, and that dizziness and headache was caused by slight exposure or exertion. Case.—Private John L. Pounds, Co. E, 100th Pennsylvania Volunteers, aged 20 years. Spottsylvania, Virginia, May 12th, 1864. Conoidal musket ball. Treated at corps, Harewood, Chester, and Pittsburg hospitals. Returned to duty October 3d, 1864. Not on Pension List. Case.—Colonel Richard Rowett, 7th Illinois Volunteers, aged 35 years. Allatoona, Georgia, October 5th, 1864. Conoidal musket ball. Treated at corps field hospital and Officers' Hospital at Nashville. Returned to duty and mustered out July 9th, 1865. Not on Pension List. Case.—Corporal Dwight C. Rose, Co. C, llth Alaine Volunteers, aged 34 years. Deep Run, Virginia, August 16th, 1864. Conoidal musket ball. Treated at Fort Monroe, DeCamp, and Webster hospitals. Returned to duty January 2d, 1865. Not on Pension List. Case.—Private James Smith, Co. C, 5th New Hampshire Volunteers, aged 22 years. Cold Harbor, Virginia, June 1st, 1864. Buck shot. Treated at Alexandria and Chester hospitals. Returned to duty July 8th, 1864. Not on Pension List. Case.—Private James M. Thompson, Co. A, 70th Ohio Volunteers, aged 24 years. Atlanta, Georgia, July 28th, 1864. Conoidal musket ball. Treated at corps, F'airfax Seminary, and Camp Dennison hospitals. Discharged from service July 9th, 1855. Not on Pension List. Case.—Private Daniel Wei], Co. A, 31st Indiana Volunteers, aged 19 years. Buzzard's Roost, Georgia, May llth, 1864. Conoidal musket ball. Treated at Chattanooga, Cumberland, and Jeffersonville hospitals. Died June 27th, 1864. Of seven alleged cases of fracture of the outer table of the temporal bone, reported without sufficient details to remove all doubt of the accuracy of the diagnosis, four occurred to Union and three to Confederate soldiers. All of the patients recovered. Of the three Confederates, two were furloughed and one was exchanged. Of the Union soldiers, three went to duty, one of them subsequently died a prisoner, and one deserted. Four were wounded by musket balls, one by a fragment of shell, and in two instances the nature of the missile is not stated: Case.—Corporal John Birdsill, Co. I, 101st Illinois ATolunteers, Resaca, Georgia, May 15th, 1864. Right temporal, by conoidal musket ball. Treated at corps, Cumberland, Brown, and Quincy hospitals. Returned to duty January 27th, 1865. Not on Pension List. Case.—Private Jacob Boyer, Co. E, llth Pennsylvania Volunteers, aged 33 years, Avas wounded at the battle of Fred- ericksburg, A'irginia, December 13th, 1862. The missile antered just in front and above the external meatus, passed a little upward aud imvard, and then glanced dowmvard to the mastoid portion of temporal bone, fracturing in its course the external table, and lodging over the mastoid process. He was admitted to the hospital ofthe 2d division, First Corps, and on December 18th was sent to Harewood Hospital, Washington, Avhere, in January, 1863, a conoidal musket ball Avas removed through an incision. On January 20th the wound had nearly healed, and on May 6th, 1863, the patient was returned to duty. This soldier Avas subsequently made a prisoner, and according to the certificate of Assistant Adjutant General S. Breck, died at Salisbury, North Carolina, January 31st, 1865, the cause of death not being stated. In the application for pension by the widow it is stated that he died " by reason of scurvy and diarrhoea." Case.—Private D. W. IMridge, Co. G, llth Alississippi Regiment. Gunshot fracture of outer table of right temporal. Treated at HoAvard Grove Hospital, Richmond, in August, 1864. Furloughed. Case.—Private A. Easley, Co. I, 32d Virginia Regiment. Gunshot fracture of outer table of temporal bone. Treated at Chimborazo Hospital, Richmond. Furloughed July 14th, 1864. GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 137 Case.—Private Louis Fredenburger, Co. D, 55th Ncav York Volunteers. Fair Oaks, Virginia, May 31st, 1862. Left temporal, by a fragment of shell. Treated at field and Mc Kim's hospitals. Deserted August 13th, 1862. Not on Pension List. Case.—Private John S. Haley, Co. I, 3d North Carolina Regiment, aged 20 years, was wounded at the battle of Gettys- burg Pennsylvania, July 2d, 1863, by a conoidal ball which fractured the external table of the temporal bone just above the right ear. He Avas admitted into the Seminary hospital, and the Avound properly dressed. No head symptom's followed the injurv. By the 4th of October the Avound had entirely healed, and the patient Avas transferred to the general hospital at Point Lookout, Maryland. On March 3d, 1864, he Avas exchanged, being at that time in excellent health. The case is. reported by Acting Assistant Surgeon R. N. Wright. Case.—Private William Schueble, Co. E, 32d Indiana Volunteers. Chickamauga, Georgia, September 19th, 1863. Conoidal musket ball. Treated at Chattanooga, Stevenson, NeAV Albany, and Evansville hospitals. Returned to duty March 4th, 1861. Not on Pension List. In twenty-five alleged fractures of the external table of the parietals, in twelve instances, the patients returned to duty after from four to six months' hospital treatment; three patients were exchanged, one deserted, eight were discharged for disability and four of this class are now on the Pension List, and one case terminated fatally. Twenty-one were Union and four were Confederate soldiers. In fifteen cases the injury was inflicted by conoidal musket balls, in three by shell fragments, in one by a grape shot, and in six instances the nature of the missile is not mentioned: Case.—Private William T. Atkins, Co. K, 3d Alabama Regiment, aged 21 years. Chancellorsville, May 3d, 1863. Conoidal musket ball. Treated at Lincoln Hospital. Exchanged and treated at Farmville Hospital. Retired August 12th, 1864. Case.—Private Smith Bailey, Co. E. 9th United States Colored Troops, aged 22 years. Deep Bottom, Virginia, September 29th, 1864. Conoidal musket ball. Treated at corps and Fort Monroe hospitals. Returned to duty March 13th, 1865. Not on Pension List. Case.—Sergeant John T. Banc, Co. C, 23d Virginia Battalion. Winchester, Virginia, September 19th, 1864. Conoidal musket ball. Treated at field and AVest's building hospitals. Exchanged October 25th, 1864. Case.—Corporal Thomas Beisty, Co. A, 43d NeAV A'ork A'olunteers, aged 22 years. AVilderness, Virginia, May 5th, 1864. Conoidal musket ball. Treated at corps, Mount Pleasant, Jarvis, and Ira Harris hospitals. Returned to duty October 13th, 1861. Not on Pension List. Case.—Corporal Francis Bessell, Co. L, 25th NeAV York Cavalry, aged 29 years. Middletown, Virginia, November 12th 1864. Conoidal musket ball. Treated at corps and Mower hospitals. Deserted May 26th, 1865. Not on Pension List. Case.—Private Richard DonoATan, Co. G, 7th Rhode Island Volunteers, aged 28 years. Fort Sedgwick near Petersburg, April 2d, 1865. Conoidal musket ball. Treated at field, Alount Pleasant, and Lovell hospitals. Discharged June 29th, 1865. Not on Pension List. Case.—Private EdAvard Doyle, Co. D, 19th Massachusetts Volunteers, aged 26 years. Antietam, Maryland, September 17th, 1862. Treated at regimental and Annapolis hospitals. Discharged from service April 14th, 1864. Not on Pension List. Case.—Private AA'illiam H. Elder, Co. B, 1st Pennsylvania Cavalry, aged 23 years. AA'hite House, Virginia, June 21st, 1864. Conoidal musket ball. Treated at Carver, Cuyler, and Alower hospitals. Discharged June 3d, 1865. Pensioned at six dollars per month. Case.—Private A. Harris, Co. A, 12th Alabama Regiment. Gunshot fracture of external table of parietals at the vertex. Treated at HoAvard Grove Hospital, Richmond. Furloughed Alay 26th, 1864. Case.—Corporal Ansell Hart well, Co. I, 6th Missouri Volunteers, aged 25 years. Fort McAllister, Georgia, December 13th, 1866. Conoidal musket ball. Treated at corps, and Hilton Head hospitals. Returned to duty March 1st, 1865. Not on Pension List. Case.—Bugler Amos D. Hitchcock, Co. M, 3d Alichigan CaA-alry. Holly Springs, Mississippi, December 20th, 1862. Treated at Keokuk hospital, Iowa. Transferred to Veteran Reserve Corps December llth, 1863. Pensioned, but died of pneumonia early in 1865. Case.—Lieutenant Albert Ivers, Co. C, 82d Pennsylvania Volunteers. Cold Harbor, Virginia, June 1st, 1864. Treated 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, June 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 died on August 31st, 1864. Case.—Private James McCarty, Co. F, 105th Pennsylvania Volunteers, aged 37 years. Petersburg, Virginia, April 2d, 1865. Fragment of shell. Treated at corps and Carver hospitals. Mustered out of service July llth, 1865. Not on Pension List. 18 us WOUNDS AND INJURIES OF THE HEAD. Cask.—Sergeant Daniel AIcDougall, Co. E, 17th New York Volunteers, aged 26 years. Jonesboro , Georgia, September 1st. 1864. Fragment of shell. Treated at corps, Atlanta, and Nashville hospitals. Returned to duty November 29th, 1 St 14. Not on Pension List. Case. —Captain David AIcGauhey, 5th Pennsylvania Reserves. Spottsylvania, May 9th, 1864. Treated at corps and Officers' hospitals, AA'ashington. Mustered out of service July 13th, 1864. Not on Pension List. Case.—Private Thomas Maley, Co. F, 7th Missouri Volunteers, A'icksburg, Alississippi, May 12th, 1863. Conoidal musket ball. Treated at field and LaAvson hospitals. Transferred to the Veteran Reserve Corps December 10th, 1863. Not on Pension List. Case.—Private E. F. Maples, Co. G, 12th Alabama Regiment, aged 21 years. AArinchester, Virginia, September 19th, 1861. Conoidal musket ball. Treated at Winchester, West's building, and Poiut Lookout hospitals. Sent to Provost Marshal for exchange February llth, 1865. Case.—Corporal David Phillips, Co. D, 149th Pennsylvania Volunteers, aged 20 years. Spottsylvania, Virginia, May 6th, 1864. Conoidal musket ball. Treated at Douglas and Pittsburg hospitals. Returned to duty September 23d, 1864. Not on Pension List. Case.—Adjutant John S. Riehl, 26th Pennsylvania Volunteers, aged 34 years. Mine Run, Virginia, November 27th, 1S63. Fragment of shell. Treated at AVolfe street, Alexandria, and Officers', Philadelphia, hospitals. Returned to duty March 4th, 1864. Not on Pension List. G'ase.—Sergeant George Roll, Co. A, 122d Ohio Volunteers, aged 25 years. Petersburg, Virginia, March 25th, 1865. Conoidal musket ball. Treated at corps, Lincoln, and Satterlee hospitals. Alustered out of service May 31st, 1865. Not on Pension List. Case.—Private Charles AV. Rutherford, Co. B, 60th Illinois Volunteers, aged 25 years. Jonesboro', Georgia, September 1st, 1*61. Grape shot. Treated at corps, Nashville, and Louisville hospitals. Returned to duty December 27th, 1861. Not a pensioner. Case.—Private Henry Sheets, Co. H, 13th Pennsylvania Cavalry, aged 20 years. Deep Bottom, A7irginia, August 13th, 1864. Conoidal musket ball. Treated at corps, Emory, and South street hospitals. Discharged from service May 26th, 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, 1*61. Conoidal musket ball. Treated at Carver and Alower hospitals. Transferred to Veteran Reserve 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. Carlin, 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, 1861. Conoidal musket ball. Treated at corps, Emory, Summit House, Satterlee, Camp Chase, and Tripler hospitals. Transferred to Veteran Reserve 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 Run, 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 Avere 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. AVynkoop, U. S. V. The patient was discharged October 2d, 1862, and pensioned. Pension Examining Surgeon C. R. Clark reports, on February 3d, 1863, that this was a 'fracture of the skull, carrying aAvay a portion of its substance." The wound was nearly healed, and the patient suffered from throbbing pain and giddiness on active exertion. His disability Avas rated as total, but probably temporary. Case.—Private Riley A. Davidson, Co. F, 1st Vermont Volunteers, aged 30 years. Cedar Creek, Virginia, October 19th, 1S64. Conoidal musket ball. Treated at corps, Satterlee, and Brattleboro' hospitals. Returned to duty December 13th, 1864. 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, AVest's building, and York hospitals. Alustered out of service June 19th, 1865. Not on Pension List. GUNSHOT FRACTURES OF THE OUTER TABLE OF THE SKULL. 139 Case.—Sergeant Alexander Hayes, Co. I, 84th Indiana Volunteers, aged 32 years. Knoxville, Tennessee, December 17th, 1864. Conoidal musket ball. Treated at Nashville, Jeffersonville, and Indianapolis hospitals. Discharged from service May 13th, 1865. Not on Pension List. Case.—PriATate Joseph Marks, 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. Alartin, Co. E, 3d Ncav Jersey A'olunteers, received, at the battle of Gettysburg, July 3d, 1863, a gunshot fracture of he 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. Pension Examiner F". F. Burmeister reports. March 2d, 1866, that this pensioner suffers from constant pain, and partial loss of memory, and rates his disability at one-half and permanent. Case.—Private AV. H. Parmar, Co. A, 23d Ohio A'olunteers, 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.—PriA-ate TT. A. Potts, Co. K, 53d Georgia Regiment. Gunshot fracture of outer table of occipital. Treated at HoAvard 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 AV. 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 beloAV the external malleolus, passed forward and made its exit about two inches from point of entrance. He Avas admitted to the hospital at Gauley, AVest Virginia, and Avas doing Avell when seen by Surgeon G. G. Shumard, U. S. V., who reports the case. Reed was discharged from the service on December 23th, 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 AVest's building and Point Lookout hospitals. Sent to Provost Alarshal for exchange April 8th, 1865. Case.—Private J. W. B. Robinson, Co. G, 1st Virginia Cavalry. Spottsylvania, Alay 7th, 1864. Fragment of shell. Treated at hospital at Farmville, A'irginia. 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 ofthe 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, llth Alabama Regiment. Gunshot fracture of external table ofthe skull. Treated at HoAvard Grove Hospital, Richmond. Furloughed May 13th, 1864. Case.—Private Napoleon Bombard, Co. K, llth 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, 1860. 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 17th, 1864. Not on Pension List. Case.—Private Hugh H. Cormack, Co. H, 27th IoAva Volunteers, aged 18 years. Nashville, Tennessee, December 16th, 1864. Conoidal musket ball. Treated at Cumberland and Jeffersonville hospitals, and returned to duty February fioth, 1865. His name does not appear on the list of pensioners. Case.—Lieutenant R. F. Felder, Co. I, 25th South Carolhra Cavalry. Gunshot fracture of outer table of the skull, June 18th, 1864. Treated at No. 4 hospital, Richmond. Furloughed July 14th, 1864. Case.—Private Theodore Kestler, Co, F, 17th Ohio Volunteers, aged 18 years. Chickamauga, Georgia, September 20th, 1863. Conoidal musket ball. Treated at corps, Stevenson, and Nashville hospitals. Returned to duty February 5th, 1864. Not on Pension List. Case.—Private A. B. McLain, Co. M, 12th South Carolina Regiment. Gunshot fracture of outer table of the skull. Treated at Jackson Hospital, Richmond. Furloughed September 24th, 1864. Case.—Private Charles V. Marsh, Co. C, 15th Massachusetts Volunteers, aged 28 years. Gettysburg July 3d, 1863. Treated at corps and MoAver hospitals. Returned to duty December 22d, 1863. His name is not upon the Pension List. 140 WOUNDS AND INJURIES OF THE HEAD. Case.—Sergeant Allen F. Miller, Co. G, 34th Ohio Volunteers, aged 22 years. Winchester, A'irginia, September 19th, 1S61. Conoidal musket ball. Treated at diA-ision, Sandy Hook, and Satterlee hospitals. Returned to duty 1 >ecember 2d. 1H14. Not on Pension List. Case.—Sergeant Milton Nash. Co. F, 130th Indiana Volunteers, aged 24 years. Atlanta, Georgia, August 6th, 1S64. Conoidal musket ball. Treated at field, Knoxville, and Louisville hospitals. Discharged from sendee Alay 15th, 1865. Not a pensioner. Case.—Private Louis Nelty, Co. D, 149th NeAV York A'olunteers, was wounded, at the battle of Gettysburg, Penn- sylvania, July 3d, 1863. He Avas admitted to a field hospital, where the injury Avas treated as a scalp wound. On July 16th, he Avas transferred to the Carver Hospital, AVashington, where it was diagnosticated that the outer table of the cranium Avas fractured. He Avas returned to duty on October 19th, 1863. His name is not upon the Pension Rolls. Case.—Private Leon Rheims, 3d New York Artillery. Lee's Mill, Virginia, April 16th, 1862. Treated at Christian street and Fifth street hospitals, Philadelphia. Returned to duty August 8th, 1862. Not a pensioner. Case.—Corporal Lloyd Seville, Co. F, 1st New Jersey Volunteers. Treated at Judiciary Square Hospital, AA'ashington, September 14th, 1862. Discharged from service December 13th, 1862. His name does not appear on the Pension Rolls, Case.—Private D. J. Smoot, Co. G, 4th North Carolina Regiment. Gunshot fracture of outer table ofthe skull. Treated at Chimborazo Hospital, Richmond. Transferred to Salisbury, North Carolina, June 6th, 1864. Case.—Private F. M. Stricklin, Co. F, 33d Alabama Regiment. Dallas, Georgia, Alay 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 Regiment. Gunshot fracture of outer table of the skull. Treated at HoAvard Grove Hospital, Richmond. Furloughed Alay 24th, 1864. Case.—Private Aloses Tonier, Co. K, 47th New York A'olunteers, aged 32 years. Petersburg, Virginia, July 24th, 1864. Conoidal musket ball. Treated at corps, Fort Alonroe, and Whitehall hospitals. Discharged from service February 20th, 1865. Not a pensioner. Case.—Private John Torborg, Co. K, Purnell's Legion. Cold Harbor, A7irginia, June 3d, 1864. Treated at corps, Alexandria, and Satterlee hospitals. Mustered out of service October 27th, 1864. Not on Pension List. Case.—Private S. E. Wood, Co. F, 21st A'irginia Regiment. AA'inchester, A'irginia, September 19th, 1864. Conoidal musket ball. Treated at field and AA'est'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 eleAren 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 Rolls. 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\Tulsions, and several from vertigo' and dizziness. Of the twentv-seven Confederates, three died, six recovered and were exchanged, and eighteen Avere "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 Avithout injury to the inner table, either by projectiles of war or any other external violence, except in the rare instances,.enumerated at the begining of this subsection, of IjIoavs or the impact of implies 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 Brodie, 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 A'itreous 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 Volun- teers, Avho published an account of it at the time.f A more minute history has been found in the case-book of the hospital in which the patient was treated: Case 1 —Private Alatthias A. Tapyer, Co. 1,97th Ohio A'olunteers, at the battle of Alurfreesboro', Tenn., January 3d, 1863, received a slight scalp wound, from a glancing musket ball, near the antero-superior angle of the left parietal. 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. Exam- ination Avith the probe failed to detect any injury of the skull. Simple dressings Avere ordered and the patient AAras alloAved the liberty of the Avard. For the next feAV days he Avas restless and irritable, and kept getting in and out of bed; but these symptoms Avere 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, the blandest liquids being rejected and the bowels were obstinately constipated. The patient 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 Avas ordered fiA-e grains of iodide of potassium thrice daily, and an ounce of castor oil with a drop of croton oil immediately. It is not mentioned Avhether these medicines Avere retained or not, or Avhether enemata were given. But on the 16th, there was no amelioration of the symptoms, and the cathartic was ineffectually repeated. On January 21st the nurse reported that 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, hoAvever, still sufficiently conscious to endeavor to protrude his tongue when asked to do so, and to manifest his aA-ersion to "a more thorough examination of the Avound.'' The propriety of trephining Avas considered, but it was thought that the proximity 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 tAvo drachms of pus escaped. Th» bone was found to be denuded over a space of the size of a dime. The patient died on the following day, January 22d, 1863. 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 Avas 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, 116th Ohio Wolunteers, aged 39 years, was wounded at the engagement at Piedmont, A'irginia, June 5th, 1864, 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 19tb, and then transported to the general hospital at Grafton and placed under the care of Surgeon Socrates N. Sherman, U. S. Vols. He Avas then laboring under symptoms of subacute meningitis, Avith compression of the brain. He died three days after admission, June 22d, 1864. At the post mortem examination a depressed fracture of the inner tables of both parietals Avas discovered, the fissures crossing about the middle of the sagittal suture. Beneath the depressed portion of bone the dura mater Avas extensively diseased and a large abscess had formed. * POTT, Observations on the Nature and Consequences of Wounds and Contusions of the Head, London, 1760, p. 15. Sir Astley COOPER, Lectures, London, Vol. I, p. 302. Saucerotte, Memoire de VAcademic de Chirurgie, T. IV, ed. 1819, p. 322. Hennen, Military Surgery, 2d ed. p. 323. Sir Benjamin C. Brodie. Works collected and arranged by Mr. Charles Hawkins, London, 1865, Vol. Ill, p. 25. Velpeau. De I'Operation du Trepan dans les plaies de Tete, Paris, 1834, p. 27. Medico Chirurgical Transactions, Vol. XVI, p. 331. AA'ILLIAMSON, Military Surgery, London, 1863, p. 28. MACLEOD, Notes, etc., (already cited) p. 177. Mattheav, Med. and Surg. Hist, of British Army in the Crimea. (Op. cit.,) Vol. II, p. 28. GUTH1UE, Commentaries. Chisholm, Manual, etc., (Op. cit.,) p. 292. Teevan, Experimental Inquiries into certain Wounds of the Skull, in British and Foreign Medico-Chirurgical Review, Vol. XXXIA", p. 205. MILLER, A System of Surgery, Edinburgh, 1864, p. G28, PlRRIE, The Principles and Practice of Surgery, London. 1860, p. 273. DENONVILLIERS et GOSSELIN, Compendium de Chirurgie Pratique, Paris, 1851, T. II, p. 578. Adams, in Coslello's Cyclopedia of Practical Surgery, A'ol. II, p. 476. Laxglih, Programma de sinus Frontalis vulnere sinus Terebratione curando, AA'ittemb. 1748. SCHNEIDER, Die Kopferletzunyen, Stuttgart, 1848, p. 69. t American Medical Times, A'ol. VI, p. 113, ilurch 7th, 1863. 142 WOUNDS AND INJURIES OF THE HEAD. A third case is noted in the case-book of Hospital No. 1, Frederick, Alaryland, in charo-e of Assistant Surg;eon Robert F. Weir, U. B. A.: Cask 3.—Private Hamilton AA'est. Co. G. 5th AATest Virginia Volunteers, aged 24 years, at the battle of Opequan, A'irginia, September 19th, 1864, was struck on the left side of the back of the head by a musket ball which, apparently, inflicted only a scalp Avound. Alter 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 R. AV. Mansfield. The wound was doing well, he suffered no pain whatever, his general condition was good, and there Avas, apparently, every likelihood of a speedy recovery. Simple dsessings to the Avound Avere 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 Avere applied over the temporal 'regions and blisters to the nucha, and a terebinthinate enema Avas administered. The convulsions subsided under these measures and did not recur. But there remained a dull pain in the head, hebetude, and a febrile movement. On October 8th there Avere rigors, folloAved by acute pain in the side ofthe chest. Coma supervened, and death folloAved on October 13th, 1864. 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 loAver posterior angle of the left parietal. The line of demarcation was well marked, but there was not the slightest depression ofthe outer plate. On removing the skull-cap an angular fracture ofthe internal table was discovered at a point corresponding Avith. the contusion in the outer table. This fracture Avas depressed to the extent of one line. The dura mater beneath was thickened and ulcerated over a space tAvo inches in diameter. The vessels of the pia mater Avere much congested. Both the gray and Avhite matter of the brain Avere softened. The softening was particularly marked in. the left" hemisphere near the corpus callosum. In the chest firm pleuritic adhesions Avere found, Avith effusion on the right side and Avith old tuberculous deposition at the apices. In the pulmonary parenchyma Avere several metastatic foci, containing a detritus of blood corpuscles mingled with pus. The lung tissue Avas 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 ATolunteers, aged 19 years, was wounded at the battle of Resaca, Georgia, May llth, 1864, by a conoidal musket ball, in the occipital region; another ball injured the right testicle. He Avas at once admitted to the field hospital 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 patient Avas sent, by the way of Chattanooga, 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, Ken- tuckv, on June 26th. The case-books ofthe 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 was not particularly specified in the hospital regis- ter. Insensibility, stupor, aud indications of inflammation ofthe brain finally supervened, and the patient died July 14th, 1864. At the autopsy, when the calvaria was removed, it Avas found that a depressed spicula of the inner table, immediately beneath the wound in the scalp, had penetrated the dura mater, and that there was incipient softening, for an inch rn diameter, of the brain tissue, immediately beloAV this wound of the membrane. »Apart from this limited result of inflammation, and the engorgement of the longitudinal sinus by coagula, the contents of the cranium were found in an apparently normal condition. An examina- tion of the chest shoAved that the heart Avas healthy, that there was some deposition of tubercles in the lungs, and old and extensive adhesions of the right pleura. The abdominal Adscera Avere healthy, Avith the exception of a slight enlargement ofthe spleen, and traces of subacute inflammation ofthe loAver intestines. But the lesions in the thoracic and abdominal cavities Avere 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. AV. Patterson, Co. B, 1st Iowa Volunteers, aged 21 years, was wounded at Tupelo, Alississippi, July 14th, 1864, and is reported by Surgeon J. N. Niglas, 6th Illinois Cavalry, on the casualty list ofthe right Aving ofthe 16th Army Corps, as having a " dangerous gunshot wound of the head," produced by a fragment of shell. The patient being conveyed to the rear, was admitted to Adams Hospital, at Alemphis, Tennessee, on July 21st, and died on July 21th, 1861. 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 external 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 ofthe brain, yet they Avere judged insufficient to justify operative interference. Furthermore, that a post mortem examination Avas made, and that upon the skull-cap being removed, " 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 6.—David H. P------, Co. C, 35th Wisconsin Volunteers, aged 20 years, detailed probably as an orderly, since his regiment Avas not in the action, Avas Avounded, 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, betAveen the sagittal suture and the left parietal protuberance. There Avere no signs of cerebral disturbance. The Avound was dressed simply, and the patient Avas conveyed to Alemphis, Tennessee, and admitted into the Adams U. S. General Hospital on July 23d. He was then perfectly rational and free from head symptoms. Tavo days subsequently indications of compression of the brain were observed, and on the afternoon of the 25th they had rapidly become aggravated. The pulse was sIoav, the respiration labored, the pupils dilated, GUNSHOT CONTUSION OF THECRANIUM,WITH FRACTURE OF THE INNER TABLE 111 I.XlcNii! \| ^ ,.f -,, : , r !\ lull rim \ ■ . > - V \l \1 GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 143 the sphincters relaxed. A very careful exploration of the Avound Avas made, but, of course, no cranial fracture could be detected. The treatment was limited to cold applications to the bead, scarified cups to the nucha, and brisk purging. On the 26th the patient gradually became comatose. The discharges from the bowels and bladder Avere involuntary. The patient continued to sink on the 27th, and died at one A. M. on the 28th of July, 1864. At the autopsy tlje pericranium Avas found 8. Valleriola, Observationum ytedirinalium, lib. 6. - The British and Foreign Med. Chir. Rev. Vol. XXXVI, p. 189. 3Bri?EXGARiu.s, De Frartura Cranii. Bologna 1535. I have not been able to consult the princeps edition; but the passage is repeated in the edition in the Surgeon General's Library, Lugduni Batavorum, 1715. Liber Aureus, Hactenus desideratus. Editio nova, etc. p. 6. *Paue. Oeuvres, ed. 1653. T. X, p. 225. (tarexgeot, Traite des Operations de Chirurgie. Paris, 1738. 2d ed. T. 3, p. 122. 1 Sai CEROTTE, Mem. sur les svjets proposes pour les Prix de VAcademie Royale de la Chirurgie. T. IX, p. 322. ;TuLi'ius. Observationes Mediae. Lugduni Batavorum, 1716, p. 3. Guthrie seems to think that the cracks in the inner table Avere made by the surgeon. See Injuries ofthe Head, etc. London, 1842, quarto, p. 73. 8Le Dran. Obs. de Chir. T. I, obs. 17. GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 151 been performed unsuccessfully. Pott1 relates two examples of fracture of the inner table alone: one of a young woman pitched from a wagon, and striking on the head on a flat pavement, trephined on the fourth day, but dying from suppuration between the skull and dura mater; the other of a porter knocked down by an iron hook, who walked home, but next morning lost the powers of speech, power, and locomotion; after his death, on the third day, a piece of the vitreous plate of the right parietal, an inch and a half long, was found detached. Pott adds that these are the only instances he had met of fracture of the inner table alone ; but that he made no doubt, that some of those " thought to have been destroyed by concussion,'have sunk under this kind of mischief." Bilguer2 relates that "at the battle of Torgau in 1760, Colonel von Lossau, Chief of the Grenadier Battalion, was wounded by a small bullet on the centre of the right frontal bone, in such a manner as to leave visible neither fissure, mark of impression, nor fracture. For three days the colonel would not consent to trepanning, but on the fourth day, beginning to fall into a stupor, he permitted the operation. It was not performed in vain. Four large pieces were found to have been knocked off the inner plate, and the trephine had to be applied three times before these could be extracted. The colonel recovered perfectly and holds at present a command in the army." 3 Ravaton4 describes the case of a grenadier at Philisbourg, who received a contusion from a ball on the anterior part of the right parietal. At Landau, six weeks afterward, he had terrible convulsions, and died. On removing the skull-cap, Ravaton found "la seconde table des os enfoncee et deux depots de matiere purulente dans la substance du cerveau." Samuel Cooper5 trephined at Brussels after the battle of Waterloo, a patient who had been struck on the right parietal bone by a musket ball, with urgent symptoms of com- pression. " He had not sawn long before the external table came away in the hollow of the trephine, leaving the inner table behind, which was not only fractured but driven at one point more than half an inch into the membranes, and substance of the brain. No sooner were the fragments taken out with a pair of forceps, than the man instantly sat up in his bed, looked around, and began to speak with the utmost rationality. It is a most extraordinary fact that this patient got up and dressed himself the same day, without leave from the medical officers, and never had a bad symptom afterwards." Baudens, in one of his earlier works,6 gives the case of a soldier in Algeria, who received a scalp wound apparently over the right parietal. Except paralysis of the arm, there was no indication of affection of the brain. He was bled; but died of acute encephalitis in four days. At the autopsy, Baudens found: " une brisure de la lame vitree dont une esquille longue d'un demi-pouce s'etait detached et comprimait le cerveau; le crane n'offrait a l'exterieur ni felure ni contusion apparente." i pOTT> Observations on the Nature and Consequences of Wounds and Contusions of the Head. London, 1760, p. 16, and Chirurgical Works, Am. ed. Philadelphia, 1819, Vol. I, p. 170. 2 Bilgiter, J. U. Chirurgische Wahrnehmungen. Berlin, 1763, p. 30. 3Velpeatj, De VOperation du Trepan. Paris, 1834, p. 29., cites another case from Bilguer, caused by a blow from a brick; but it does not properly belong to this class, as there Avas an external linear fissure. 4 Ravaton, Pratique Moderne de la Chirurgie. Paris, 1776. T. I, p. 210. 6 Cooper, Surgical Dictionary, 8th ed., p. 899. Hennen, op. cit. p. 327, and Brodie, in Med. Chir. Trans., vol. XVI, p. 231. 6 Baudens, Clinique des Plaies d'Armes a Feu. Paris, 1836, p. 80. 152 WOUNDS AND INJURIES OF THE HEAD. Bernhard Beck1 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 seal]) 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:2 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. JSTo cerebral symptoms at first; but in three weeks menin- gitis and pyaemia 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. Ochwadt3 records the case of a Danish soldier who received in the Schleswig-Holstein war, an oblique gunshot wound over the 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 groschen. Near the upper anterior angle of the parietal, there was a small abscess beneath the cranium and dura mater, at the seat of injury. Guttenberg4 records tlae 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 symptons 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. Guthrie5 has carefully examined the literature of this subject, and adds an interesting case which Mr. Dean 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 further. There was an extrava- sation of blood beneath, between the bone and dura mater. Guthrie6 also details a case of injury of the internal table without lesion of the outer, related by Mr Trye,7 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 1 Beck, Die Schusswunden. Heidelberg, 1850. S. 99, und Uber isolirten Bruch der Glastafel in Langenbeck's Archiv. Berlin. 1862. B. 2, S. 547. 2 Beck, Kriegschirurgische Erfahrungen. Freiburg, 1867. S. 167. 3 Ochwadt, Kriegschirurgische Erfahrungen. Berlin, 1865, S. 321. 4 Guttexberg, Ueber Schadelbriiche mit Eindruck, in Langenbeck's Archiv. B. IV S. 596. 5 Guthrie, Commentaries, Sixth ed. London, 1855, p. 342. 6 Guthrie, Op. Cit.—Injuries ofthe Head, etc., quarto. London, 1852, p. 73. 7 Trye, Medical Communications. London, Vol. II, 1790. GUNSHOT FRACTURES OF THF INNER TABLE OF THE SKULL. 153 the inner table had been removed by absorption. There were granulations springing up, but whether from the dura or pia mater, or brain, could not be accurately ascertained. This man recovered. La Motte1 supposed that when 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 Stromeyer2 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 pysemia, 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 frac- tured 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 sub- cutaneous 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; 1La Morn:, Observations de Chirurgie. T. II, p. 303. 2Stuojieyer, Op. cit.—Maximen, U. S. V. ZAveite Aufiage, S. 331, und 546, und549. 20 IM WOUNDS AND INJURIES OF THE HEAD. yet the symptoms wore generally aggravated, and trepanning was resorted to a second or third time, and not until the secondary operations were great quantities of pus disclosed. Thus, as usual, one mistake brought about another, and one ill-advised use of the trephine rendered its repetition necessary. The main symptans 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 who 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 Flensburg, the following day. He vomited several times, and was drowsy and complained of headache. His pulse was weak and slow. On April loth, 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 applications employed 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- FlG. 63.—Gunshot fracture of the inner lable of the left parietal. [After STROMEYER, Maximen, Fig. 16.] neath the Fi... 64.—Iik liint exfoliation of the outer table of the < s Fig. 65.—Gunshot fracture of the inner table of the frontal bone. •■i,,tis. [Alter STiJOMEYEIt.] dUTCl DlRt CT. [After S'llMMKYER.] GUNSHOT FRACTURES OF THE INNER TABLE OF THE SKULL. 155 Dr. Stromeyer attributes the death to pysemia. 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 blood- less 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 headache 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.1 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 preserved. One is numbered 29, A, in the Dupuytren Museum.2 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 Reuilly. There was a furrowed scalp wound over the occipital an inch and a half in length. The skull was denuded, but there was no alter- ation 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. Denon- villiers trephined over the spot struck, evacuated about three ounces of offensive sanguim olent 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. Legouest3 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,4 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 the separated portions of the inner table Avith the dura mater, which was not even separated by the process of suppuration that bad taken place in the 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 Avhich 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 reco\rered in spite of bis doctor.' The failure in the treatment of my case occurred undoubtedly in the first eight days, during Avhich the patient Avas said to have been in a good condition. Pott would baAre undoubtedly trepanned in tbis case, but what modern surgeon Avould expect success in a case in which the autopsy revealed an abscess in the liver V' Op. cit. S. 546. ' Compendium de Chirurgie Pratique. T. II, p. 573. This specimen is figured at page 283 of M. Legouest's Traite de Chirurgie d'Armee. 'Legouest. Op. cit. p. 283. I think the specimen is hoav deposited in the collection at Val de Grace. 'See Williamson's Military Surgery, p. 29; Holmes's System of Surgery, vol. II, p. 47. The patient, Private James Burke, aged 19, received, August 24th, 1835, before Sevastopol, a wound AA'hich grazed his head on the side of his scalp, from a musket ball. He walked from the trenches to the field hospital. The bone Avas found bare, but no fracture or depression could be discovered. There were no general symptoms of serious injury of the head. The scalp Avas shaved and cold water dressings applied. Five days subsequently the wound became unhealthy and there was slight hemiplegia 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 Avere observed, and a coagulum the size of a Avalnut avms found under the parietal protuberance. The fissure, limited to the internal table, ran parallel to the course of the ball. The specimen is No. '2?'J3, in the Surgical Museum at Netley. 156 WOUNDS AND INJURIES OF THE HEAD. Mr. Preseott Hewett1 reports, in an analysis of seventy-eight cases of injuries of the head, 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,2 in August, 1862, presented to the Medico-Chirurgical Society of Edin- burgh, 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. Demme3 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 Yirchow's Archives, Dr. Hermann Friedberg,4- 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,5 in his Sepulchretum, states that Oortesius 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.6 But a sufficient 1 Medico-Chirurgical Transactions. 2d series, vol. 18. London, 1853, p. 338. The 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. * Edinburgh Medical Journal. Vol. 8, part 1, 1862, p. 191. Edinburgh, 1863. 3Demme. Speeielle Chirurgie der Schusswunden nach erfahrungen in den Xorditalicnischen Hospitaehrn von 1859. Wiirzburg, 1861, S. 38. 4Virchow. Archiv filr pathologiscJle Anatomie und Physiologic Berlin, 1861. B. 22, S. 84. 5Theophllus Boxetus. Sepulchretum sive Anatomica Fractica. Ed. altera by J. J. Mangetus. Folio, Geneva, 1700. "Other cases are reported by Scultettjs, (Armamentorum Chirurgicum. Editio tertia, Hagse-comitum, 1662, 8vo, p. 212. Olis. XV and XVI,) AA'ho describes the injury as "rima et depressio cranii laminae intcrioris, exteriore salva;" by SOULIER, of Montpelier, in the Mcmoires del'Academie de Chirurgie, ed. 1819, T. 1, p. 158; by Salmuthius, (Observationum Medicarum Centuria tres. Brunsvijae, 1648, p. 14;) by Platxer, (Institutiones Chirurgice ralionalis. Lipsise, 1758, p. 286;) by Batting, (Chirurgical Facts relating to Injuries of the Head. Obs. VIII;) by Smethius, (Miscellanea. Liber X, p. 570;) by Dorixo, (Xassauische Mcdicinische Jahrbiicher, p. 308; by Ktjhk, (Rust's Magazin, B. XL, S. 58.) Examples of this form of fracture are ascribed also to Arcetjs, (De recta curandorum Vulnerum ratione, cap. 3, p. 17. Amstelodami, 1658;) to Valleriola, (Observationum Mcdieinalium, lib. 6;) and to Borel, (Historiarum et Observationum, Centuries 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 haA^e produced 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, hoAvever 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 diploe placed betAveen it and the outer table, and thus cause irritation or pressure on the brain, few persons who had received a knock on the head, folloAved by any serious symptoms, without fracture or depression, Avould escape the trephine, and the Avorst 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, u-hich cannot be relieved by other means."—(On Injuries of the Head, <$r., 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 greater brittleness of the inner table,1 and this explanation was accepted by the leading surgical authorities until 1865, when the experimental inquiries of Mr. W. F. Teevan,2 of 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.3 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 ^--^VV^\ of this form of fracture.4 As when a stick is bent, the atoms along the proximal curve at which pressure is made are brought near together or Fig. 1« COmpreSSed, and the atoms along the distal CUrVe . FIG- 66.—Diagrams to show the mechanism of fracture of the r ' o inner table of the skull alone. [After Teevan.1 'Brodie expressed the belief of the English surgeons: "The 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. Chir. Trans. Vol. XIV, p. 331.) Vidal de Cassis, (Pathologie Externe, T. 11, p. 545,) gives the views of the modern French surgeons: "La table externe percutee, peut r<§sister, tandis que la table interne se fracture immediatement au-dessous, parcequ' elle est plus cassante, aussi l'a-t-on appelee vitree." Velpeau, (De I'Operation du Trepan, p. 29,) is of the same opinion: "Plus mince, moins etendue en surface, plus irreguliere, plus dense que la table externe, la couche vitree 6clate et se fendille sous un effort manifestement moindre que la prec^dente." Legouest, (op. cit. p. 283,) says: "Lorsque 1' os frapp6 est epais, resistant et a diploe solide, la table interne, plus mince et plus friable que 1' 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 VirchoAv's Archiv. for 1861. B. Beck, (loc. cit.,) aa'Iio performed many experiments on the dead subject, striking the skull Avith bullets, and often producing, by oblique impact, fracture of the inner table when the outer was neither depressed nor fissured, believed that the result was due partly to the brittleness of the inner table, and partly to its lesser superficies. He stated that a projectile striking the outer table obliquely, and setting it in vibration, caused a stretching and depression of its tissue; the shorter brittle tabula vitrea folloAving the process, but not quickly enough, was fissured or broken. According to his experiments, the outer table can be depressed from half a line to one line without breaking. It may be asserted that all surgeons, prior to Mr. Teevan, assigned as the cause of this fracture the greater brittleness of the inner table, and that Dr. Beck gave as an additional explanation its shortness. -Teevax. British and Foreign Medico-Chirurgical Review. Vol. XXXVI, p. 189. London, October, 1865. ! Specimen 1082 70, in Guy's Hospital Museum, is the calvarium of a suicide, who shot himself in the right temple. The pistol ball traversed the brain and struck the inside of the left portion of the frontal bone, and remained within the skull. At the point of impact there is a black mark, but no fissure or fracture; but at the corresponding point outside is a starred fissured fracture of the outer table only. 41 quote Mr. TeeA'an's explanation ofthe diagrams: "Let A B, Fig. 1, be a section ofthe skull. DraAv two vertical lines, C e, and D F, parallel to one another. Noav, if pressure be applied at G, temporary depression takes place, and the bone assumes the shape of H k, Fig. 2, and the lines C e, d F, are no longer parallel to each other, but converge toAvards each other at the upper surface I L, j m, so that the distance from I to J is less than that from C to D, but the distance from L to M is greater than 158 WOUNDS AND INJURIES OF THE HEAD. are extended, or separated, and when the stick breaks, the rent begins at the spot in the distal curve where the extension is greatest, and opposite to where the pressure is made; so when violence is applied to the external vault of the cranium, insufficient to cause complete fracture, yet depressing the bone enough to cause partial fracture, the solution of continuity will always be in the inner table opposite the part struck. I have satisfied myself, by a large number of experiments, of the accuracy of Mr. Teevan's conclusions. I have had no difficulty in producing, by slight blows with a hammer upon the outer or inner surfaces of calvaria, fissures or stellated fractures of the outer table only or of the inner table only.1 In some of my experiments, portions of the vitreous table were detached without visible injury to the outer table; but in striking the inside of the skull, I was able to make fissures only in the outer table without injuring the inner. Dr. Beck's opinion that fracture of the inner table of the skull alone only in those parts where there is but little diploe is erroneous. It generally occurs, in cases resulting from accident, in parts of the skull where the diploe is abundant, and can there be more readily produced experimentally. The explanation offered in the Surgical Keport of 1865. from this Office,2 of the causation of this form of fracture is imperfect. It is true that the fracture often results "from a small projectile striking the cranium very obliquely," or sometimes, as Legouest suggests, from a "comparatively slight blow from a body with a plane surface." But it is the force and not the direction of the violence to the exterior of the skull that is the essential point. A spent bullet, striking at right angles, may produce this fracture. If moving at a high rate of velocity, it will fracture both tables, or penetrate or perforate the skull. It is because the ball which glances, or strikes slantingly, acts with but little force at the point of impact that it is the frequent cause of this injury. In the many cases in which I produced it experimentally, I hit the skull at right angles with moderate force, with a hammer a half inch in diameter at the face. It cannot be doubted that many cases of this form of injury terminate favorably, and are never recognized. It is obvious that the diagnosis must always be obscure. The accident may lead to a fatal result in various ways; either by causing contusion of the brain, or a laceration of its membranes or substance by the jagged edges or detached spiculae of the vitreous table; or else by these same causes leading to acute or chronic that from E to F, signifying that the atoms of bone in the upper surface from I to J have been brought nearer to each other, or compressed, whilst the atoms of bone in the loAver surface, from L to m, have been extended or separated from each other; there- fore, if any fracture take place, it is clear it must do so in the line of extension L M, and at that point in the line where the greatest extension is going on, which is at x, exactly opposite the spot o, where the pressure was applied. Proof: Take a cane slightly bent, say a b, Fig. 1, and insert two pins or wires, c E, D F, vertically, and parallel to each other, the more the pins project at each surface the more manifest will be the result. Exert pressure at G till the cane is made natter, H K. It will now be found that the wires are no longer parallel to each other, but converge along the upper surface, so that the distance between them from I to J is less than that from c to D, but the distance from L to m is greater than that from E to F, shoAving clearly that the atoms along the line I j have been compressed and brought nearer to each other, whilst those along the line l m have been extended; consequently, if any fracture takes place, it must commence at X. If the pressure on the cane be continued till it breaks, it will be found that it commences to break at the point x."—Teevax, (op. cit. p. 194.) 1 Brcxs, (Handbuch der Practischen Chirurgie. Tubingen, 1854, B. 1, S. 297,) Avho has devoted much attention to this subject, says that only once was he able to cause, by a blow with a round hammer on the convexity of the skull, a fracture of the inner table alone. But if the directions of Mr. Teevan are followed, any one, Avith a little practice, may product; such frac- tures at will. The following is his method: "A skull-cap, stripped of all its soft parts, with a Avet cloth inside of it, is to be laid Avith its convexity in the palm of the left hand, which is to be protected with several layers of moist cloth, to obviate an incon- venient amount of pain. If the inside of the skull be noAV struck by the hammer with a slight degree of force, fracture of the external table will be produced AA'ithout any fracturing or Assuring of the inner."—Teevax, op. tit. p. 193. - Circular No. 6, War Department, Surgeon General's Office, Washington, November 1, t86.">. Reports on the Nature and Extent of the Materials available for the preparation of a Medical and Surgical History of the Rebellion. Printed for the Surgeon General's Office. By J. B. Lippincott A: Co., Philadelphia, 1865, p. 12. GUNSHOT FRACTURES OF BOTH TABLES OF THK SKULL. i-OJ encephalitis; or producing compression of the brain; or by the line of fracture crossing the course of the middle meningeal artery, and producing, if this should happen to be enclosed in a bony canal, a fatal intracranial extravasation. The most common immediate cause of death is compression from abscess in the vicinity of the injury.1 It is evident that the treatment of this form of injury must be determined by those principles which guide us in treating scalp wounds, contusions of the cranial bones, con- cussion and compression of the brain. When symptoms of compression are urgent and persistent, and especially if there is paralysis of the side opposite to the seat of injury, the application of the trephine is undeniably justifiable. In at least four cases, reported by Mery, Bilguer, Samuel Cooper, and Trye, recovery took place after trephining, the operation having been attempted in eleven only of the cases I have cited. Gunshot Fractures of both Tables of the Skull.—The cases of this class reported during the war were so numerous, that it is practicable to present only abstracts of some of the more interesting examples of each variety or subdivision, with brief notes of others, supplemented by numerical tabular statements of the whole number returned. Linear or Capillary Fissure.—Nineteen cases of gunshot fracture of the skull, twelve of which had a favorable, and seven a fatal issue, were reported under this head. On reviewing the histories, I am not satisfied with the correctness of diagnosis in any of them. In four of the fatal cases, autopsies were made; and injury to the membranes or substance of the brain were found in each, and in two, very marked depression of the vitreous table. The following is an abstract of one of the cases: Case.—Corporal William Barthaul, Co. D, 45th New York Volunteers, aged 35 years, was wounded, at the battle of Gettysburg, Pennsylvania, July 1st. 1863, by a conoidal ball which produced a Avound of the scalp about an inch in length, over the left occipital region. He remained in the field hospital until the llth of the month, when he was transferred to the Turner's Lane Hospital at Philadelphia. The wound was suppurating slightly. He improved steadily until the 23d, when the parts in the region of the wound became highly inflamed, creating considerable sympathetic fever. Flaxseed poultices were applied, and by the 27th the wound suppurated freely. Milk punch was now given during the day, the diet otherwise being restricted. The patient became prostrated, and on the 2d of August, was attacked with a slight delirium. Death followed on the 6th of August, 1863. At the autopsy a fissure of the occipital bone was discovered, one and a half inches in length, involving both tables. About one ounce of purulent matter surrounded the line of fracture outside of the dura mater. The case is reported by Acting Assistant Surgeon David Burpee. In the Army Medical Museum there are few examples of capillary fissure from gun- shot, except those which have been referred to in the discussion of fractures of the inner table alone; but good illustrations of this form of injury, as described by systematic authors, but caused by falls or blows, are furnished by specimens 130, 2970, and 2876, Section I, figured at pp. 38, 43, and 49, of this work. Specimens 393 and 2492, furnish the nearest approximation to this form of fracture produced by gunshot. In both cases there is linear fissure with very slight depression of the inner table: Case.—Private Francis B------, Co. A. 10th Vermont Volunteers, aged 40 years, was Avounded in one of the engagements at the crossing of the Rapidan River. Virginia, in May, 1864, in the forehead by a gunshot missile, probably a musket ball, which caused only very little external injury. He was admitted to the Baptist Church, 3d division, Sixth Corps Hospital, at Fredericksburg, thence conveyed to Washington, and admitted May 26th into the Lincoln Hospital, being then 'Mr. Teevax asserts (op. cit. p. 198) that: "There are two cases in which the diagnosis may be made with almost certainty. Firstly, when a person recovers immediately after the bloAV, but finds there is paralysis of some part of the body opposite to the side struck, and examination fails to detect any injury to the bone. Secondly, Avhen, after the blow, no evil con- sequences arise at first, but in the course of time the patient begins to complain of fixed pain in the part struck, and all the symptoms of chronic cerebral irritation sIioav themselves, althongh the surgeon cannot find any injury to the external table." lr>o WOUNDS AND INJURIES OF THE HEAD. Flo. (>7.—Section of the frontal bone showing a linear I'nicture over the rig-lit superciliary ridge. Spec. 2492. Sect. I. A. M. M. Fig. 68.—Exterior view of the foregoing specimen. extremely prostrated. No serious injury to the head Avas suspected, but an attack of typhoid fever Avas anticipated, the tongue being someAvhat coated. The intellect Avas unimpaired. He seemed to improve and avus soon able to leave the Avard. He continued so for tAvo 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 tendinum super- vened; discharge of blood and pus from the right, and pus only from the left, ear occurred, and death ensued on June 6th, 1864. At the autopsy a slight linear fissure of the frontal bone was obserA-ed, 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 ofthe fracture Avas softened. The adjoining Avood-cuts (Figs. 67 and 68) shows the linear but slightly depressed fracture which existed over the right superciliary ridge, and a portion of the fragment of the internal table which Avas detached. The frontal sinuses are unusually capacious; the walls are very thin. The specimen and notes of the case Avere contributed by Assistant Surgeon J. C. McKee, U. S. A. 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 appears quite probable that this fissure was produced in removing the skull cap, as not infrequently happens in using a chisel as a lever after sawing the bone: -, Co. A, 35th Massachusetts Volunteers, aged 21 years, Avas wounded at the battle of South Case .—Private H. S. L- Mountain, Maryland, September 14th, 1862, by a round musket ball on the right side of the frontal bone, at a point about one and a half inches anterior to the coronal suture, producing apparently only a scalp wound. He Avas conveyed to the NeAvton University Hospital, Baltimore, on the 20th of the month. The wound looked healthy, and the patient was free from pain in his head. On the 25th, secondary haemorrhage occurred from a small branch of the temporal artery which was promptly arrested by diA'ision and the application of a compress for a few hours. The case progressed favorably until the 6th of October, Avhen a state of Ioav muttering delirium supervened. When spoken to the patient would become conscious for a feAV moments, but Avould 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 inflammation over a surface tAvo inches in diameter. A feAV 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 Avith a fissure one inch in length running downAvard. There is a stellate fracture of the inner table with slight depression, the longest fissure being tAvo inches in length. Tavo small wart-like exostoses existed near the centre of the frontal bone, one on either side of the groove for the longitudinal sinus. The specimen and history Avere contributed by Acting Assistant Surgeon J. H. Currey. Specimen 1951 shows linear fissures of the inner table beneath a necrosed portion of the outer plate, which appears to be 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 Avounded in the engagement at BristoAV Station, Virginia, October 14th, 1883, by a conoidal ball which struck near and external to the left frontal eminence, slightly depressing He was admitted to the hospital of the 2d division, Second Army Corps, and on October 19th Avas sent to Lincoln Hospital, Washington. No cerebral symp- toms existed for some time after admission. On November 6th, hemorrhage, Aviiich was arrested by ligation, occurred from the anterior temporal artery. Haemorrhage recurred on November 20th, and on the following day the wound became gangrenous. The patient greAV comatose and died on November 29th, 1863. At the autopsy the external table Avas found necrosed, the diploe Avas filled Avith fungous granulations. 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 subarachnoid space. A large abscess existed in the anterior ofthe left hemisphere just beneath the seat of injury, extending into the lateral ventricle, filled Avith thick, sanious and foetid pus. The right ventricle was normal, The pathological specimen is figured in the cut (Fig. 69.) The inner table of the cranium presents a T-shaped fissure Avithout depression, and is spongy. A thin plate of bone one inch in diameter is necrosed on the external table, and the adjacent osseous tissue is porous and cribriform. The specimen Avas contributed by Assistant Surgeon II. Allen, U. S. A. the external and Assuring the internal table. Fig. tiil.—Linear fis-ure of the inner table of the skull. Spec. 1951, Sect. 1, A. M. M. GUNSHOT FRACTURES OF BOTH TABLES OF THE SKULL. 161 Gunshot Fra.ctures 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, llth Pennsylvania Volunteers, aged 29 years, was Avounded at the battle of wound and the patient was able to be about all the time. He was in good condition and appeared to do well until May 31st, when he became irritable, and complained of severe pain in the head. The external Avound still looked Avell. On the folloAving day be 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 head, and the patient was rational though dull. On the 25th the pulse Avas Aveak 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 J. K. BaldAvin, yet his Avard 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 Avas 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 pus was found upon the dura mater of the anterior lobe ofthe 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 born of the left lateral ventricle was found beneath. A large effusion of serum Avas found at the base of the brain, and a yelloAV deposit Avas found on the pons Varolii and medula 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 and abdomen were in a normal condition. The clinical history was furnished by Acting Assistant Surgeon J. K. Bahiwin, 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 measuring one-fourth by one inch, a small fragment of Avhich is depressed one line and surrounded by a slight groove, indicated an incipient exfoliation. At the upper 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, Avas wounded at the battle of Fredericksburg Virginia, December 13th, 1862, by a canister shot Avhich 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 Avas 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 Avell until the morning of the 22d, Avhen he Avas seized with violent pain 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 ofthe 21th, chills supervened, attended with delirium. A feAV hours later insensibility of the right 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 Avas 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 January, 1863, no convulsions having occurred at any time. The autopsy revealed a circular depression ofthe external table ofthe left parietal 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 a line. About an ounce and a half of a sanguine, purulent fluid had collected betAveen the dura mater and the cranium. The brain itself, however, appeared healthy. The pathological specimen is No. 623, Sect. 1, A. M. M., and Avas contributed, Avith the history, by Surgeon John A. Lidell, U. S. V. It is quite remarkable to observe that several of the fragments of the vitreous plate are very firmly re-united, the patient having survived the injury only tAventy-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 21 162 WOUNDS AND INJURIES OF THE HEAD. who presented a remarkable illustration of an injury of this 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 bail which fractured the shaft of his left humerus. The fracture united kindly, with very slight 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 Avith 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 Hatcher's 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 hackAvard and upward, removed a piece of the squamous portion of the temporal bone, Avith 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. There was considerable h.-cmorrhage, but not from any important vessel. Respiration was sIoav; the pulse 40; the right side Avas paralyzed and there was total insensibility. On February 8th, the missile was removed from the substance of the left hemisphere, by Surgeon Vanderveer. It Avas 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 Avound. He was kept on very light diet and remained very quiet for ten days, answering direct 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 23th he was able to walk about the ward. On March 18th the Avound was nearly healed. The patient Avas sent northward on a hospital transport to Fort Richmond, NeAV York Harbor. He recovered perfectly, and in May Avas furloughed, and on May 18th be wrote to Dr. Vanderveer, that he Avas doing well at bis 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, 1865, on surgeon's certificate of disability. At this date he was photographed at the Army Medical Museum. The Avound in the head was then nearly healed. There Avas 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 Avere 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 30th, 1870, he Avrote to the editor of the surgical history from his home in Suffield, Connecticut, as MIoavs: 'I am still in the land of the living. My health is very good considering what I have passed through at Hatcher's Run. My head aches some of the time. * * I am married and have one child, a little tfirl 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: tt , Cif.E•7"Private WiUiam B- Brock' Co- B, 110th Ohio Volunteers, aged 32 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 Washington; on June 18th, was transferred to the Summit House Hospital, and ZT^f t?' thet?atter!ee HfPita1' P1^delphia. The wound had healed, but the patient was nervous and could not bear Fr-brnarv Qtll5^ T V1S1°n * ^V**1* e^e was imPaired> and the right arm was nearly useless. He was discharged on 11 2r! !'lt 6 ' ^ • • °D September 24th' 18G7' Pensi0n Exami»- W" S- Parker -ported that the wound, which, i sun o 1 ea and" TT " P°rtl°n ^ ^ WM ab°Ut * **** * ^^' th« Pat"nt is unable to bear eXP0SUre t(' the sun or heat, and suffers from vertigo. His disability is rated total and doubtful. N^-iS^SS^SS T" B°Wen' ?• Vth Illinois' Volunteers, aged 21 years, was wounded during the siege ot incf ^^^^J^n^iT^r'oT fraCtTdithe ^ ^^ ^ -™-ay a piece one Fourth Corns nnd t,W«. a t T rl breadth- 0n the sa™e day he was admitted to the hospital of the 3d division, «:: lcz?a 1:7:112£\°z2 n£rtr 12th' ? ?ospitai N°-13>Me; j«h'im'to jefferson April 18th 1865 Hi, ™1 I ' HosPltal< St- L™is, Missouri, where he was discharged from service on ^permanent " ™ """^ ""^ md his ^ ™^- He was pensioned, his disability being rated total May 15th,8^,nb?l^OTSCiS0h5 ^ ^° Y?Unteera> aSed 23 ^ars, was wounded at the battle of Resaca, Georgia, admitted to the 'hipitai" t MdM^ Fo^c" ^*-f" of *. skull without known depression. He was thence was sent to the C.mihPrlnnH w •♦ i °u™ LoiP8' and on May 23d was conveyed to the field hospital at Chattanooga; .he -P^il^^^K^^" "Zft ? ™ fUr,™ghe'1 !" AUS"8t' "''" °rdere,° ^"' Examiner C. J. Neff reported on February 22d ifirfl 'th, MM. Upon removing the calvaria at the autopsy, an abscess Avas found directly under the point of injury, over the longitudinal sinus, containing half an ounce of dark green offensive pus. The dura mater Avas much thickened, but there was little evidence of congestion of the brain. The liver AA*as 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 pleuritic and hepatic indications as to escape notice. Acting Assistant Surgeon W. P. Moon, reported the case from notes furnished by Dr. Fell, and subsequently published an abstract of it in an article on gunshot Avounds ofthe head, in the American Journal of the Medical Sciences for July, 1866, and fuller data have been derived from the hospital registers. Case.—^Private A. Stanton, Co. G, 1st NeAV York Dragoons, received, at the battle of Winchester, Virginia, September 19th, 1864, 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 inflicted the injury was chipped off by the outer table of the frontal. He Avas 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, Avithout convulsions, October 16th, 1864. In the following cases the ball lodged in the diploe or sinuses Case.—Private Jacob Miller, Co. K, 9th Indiana Volunteers, aged 25 years, was wounded at the battle of Chickamauga, September 19th, 1863, by a buck-shot, Avhich penetrated and lodged in the frontal bone near the nasal eminence, causing fracture of the left orbit and exophthalmia of the eye. On the same day he Avas admitted to hospital No. 5 at Nashville, and on October 20th Avas transferred to No. 13, Louisville, whence he Avas transferred on the 25th to NeAV Albany, Indiana, and thence on March 19th, 1864. to the hospital at Madison, Indiana. The missile Avas extracted on June 15th, 1864, and expectant treatment only Avas used. The patient, recovering, was transferred to Indianapolis September 2d, 1864, to be mustered out of service, and was discharged September 17th, 1864, 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 Avhen the wound discharges much, and at times complete prostration. A subsequent report from Pension Examiner J. K. Bigelow, dated January 7th, 1870, confirms previous statement of patient's conditiou, and rates his disability as total and permanent. Case.—Private Charles R------■-, 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, which 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 impacted 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 extract- ed. Cold water dressings were applied, and the case was treated on the expectant plan. Symptoms of com- pression of the brain soon supervened; yet the patient survived until October 25th, 1862. At the autopsy it was found that there was an abscess 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 Avidth, aa ith 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 Avhich penetrated the frontal sinus projects slightly into the cranial cavity to the left ofthe longitudinal ridge ofthe os frontis. The specimen was sent to the Army Medical Museum from NeAV Berne, and is represented in the accompanying Avood-cuts, (Fig. 74, and Fig. 75,) and was accredited to Surgeon C. A. CoAvgill, U. S. V.; but Dr. CoAVgill verbally informs the editor that he has no recollection of the case or ofthe specimen. The specimen is a very inter- esting one, and was probably sent to the Surgeon General's office by one of the assistants at the Academy Green Hospital, Avithout the name ofthe donor, and only the brief memorandum, the chief points of which are recapitulated above. Case.—Private John D. Clark, Co. I. 53d Ohio Volunteers, aged 18 years, was wounded near Resaca, Georgia, May 25th, 1864. by a conoidal ball, which fractured the frontal bone above the right eye, and lodged. On May 29th, he Avas 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; July 15th, to Cleveland, Ohio; Augtist 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 the left side. His disability is rated one-half and permanent. Case.—Private Samuel II. McCartney, Co. K, 36th Illinois Volunteers, aged 22 years, was Avounded at the battle of Pea Ridge, Arkansas, March 8th, 1862, by a conoidal musket ball, which struck the frontal bone about two inches above the right Fig. 74.—Section ofthe frontal bone with a fragment of ball embedded in the frontal sinus. Spec. 546, Sect. I, A. M. M. Fig. 75.—Interior view ofthe preceding specimen. GUNSHOT FRACTURES OF BOTH TA ISLES OF THE SKULL. 165 superciliary ridge, passing from the left to the right, crushing the bone at point of contact and lodged about one and a quarter inches from point of entrance. The dura mater was not injured. The Avound healed in about four months, and on July 25th, 1862, he Avas discharged the service. On February 15th, 1866, Pension Examiner John Young reports that he was troubled with pain in the head at the point of injury, Avas subject to vertigo and could not bear exposure! to sun. His mind Avas also impaired. He is not a pensioner. Case.—Sergeant J. A. Thompson, Co. E, 45th Georgia Regiment, 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, Viiginia. There was a sanious discharge from the frontal sinus; othenvise the case progressed ftworably and the patient Avas alloAved to go home on furlough. Case.—Private Jacob Fisher, Co. D, 82d Ohio Volunteers, was Avounded by a spent ball at the battle of Chancellorsville, Virginia, May 2d, 1863, AA'hich impinged upon the frontal bone above the left eminence, and produced a slight fracture, lie Avas conveyed to the HareAvood Hospital at Washington; on May 9th Avas 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 Avas returned to duty on July 7th, 1863; was discharged July llth, 1863, and pensioned, being subject to pain and vertigo. His disability is rated one-half, and perhaps permanent. Case.—Private Thomas M------, Co. C, 4th NeAV York Volunteers, was wounded near Antietam, Maryland, September 16th, 1862, by a conoidal ball which fractured the mastoid portion ofthe left temporal bone. He remained in the field hospital until the 26th, wheu he Avas admitted into the Mount Pleasant Hospital, Washington, D. C. Phlegmonous erysipelas attacked the scalp, and the inflammation extended to the membrane of the brain and death supervened on the 5th of October. The pathological specimen is represented in the adjacent Avood-cut, (Fig. 76.) The injury of the outer table involves a little over one square inch of surface; that ofthe inner table measures one by one and a fourth inches, and includes the groove for the lateral sinus. Tavo fragments are attached, the free edge of one being depressed tAvo lines. The fractured surfaces 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 April 5th, 1865, admitted to the Jarvis Hospital, Baltimore, Maryland, with Rehire of the mastoid process. Spec 161, Sect. I, A. typhoid fever. He had partially recovered from fever, Avhen he died on July 2d, 1865. The autopsy revealed an indented fracture of the frontal bone, above and external to the right frontal eminence. The rim of depression Avas 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 plates, all of which were firmly consolidated, and all the fissures were filled up by a deposit of neAV bone; the depression of that table being tAvo 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 Avas contributed, Avith the history, by Assistant Surgeon D.C. Peters, U. S. A. Case.—Private D. L. Underwood, Co. D, 18th Georgia Regiment, received a gunshot Avound of the head involving the frontal sinus. He was admitted into the Jackson Hospital, division No. 1, Richmond, February 17th, 1865. A fistula after- Avard formed. He was furloughed for sixty days. Case.—Sergeant Augustus Reinwald, CoG, 42d Pennsylvania Volunteers, was Avounded 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 Avas admitted to the Patent Office Hospital, Washington, and on October 5th sent to Laches' Home Hospital, New York City. The portio dura and third pair of nerves were paralyzed. There Avas loss of vision of right eye, and of sensation and mobility of right side of face. The patient Avas unable to s Aval low or open his mouth. Febrile action set in, Avhich, together Avith pain in head and profuse suppuration of wound, rapidly reduced the strength of the patient. He became pale, weak, and emaciated; skin Avas moist, appetite poor; pulse regular, slow, and compressible; the eye was lachrymose, and the mouth drawn to opposite side. The Avound in the face healed, but the posterior Avound continued to discharge profusely. He Avas discharged on March 21st, 1863, and pensioned, his disability being rated one-half, by Pension Examiner A. B. Mott. 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 years, was Avounded at Chickamauga, September 19th, 1863, by a conoidal musket ball, which fractured the upper portion of the right side of the frontal bone; he also received a 166 WOUNDS AND INJURIES OF THE HEAD. gunshot Avound of the band. 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, 1861, and Avas discharged June 3d, 1864. In September, 1867, he was a pensioner, his disability being rated three-fourths and permanent. Cask.—Captain R. P. Andis, Co, B, 99th Indiana Volunteers, aged 34 years, was wounded near Atlanta, (Jeorgia, July 21st. 1864. by a conoidal musket ball, Avhich fractured the left temporal bone. Treated at hospital of the 4th division, Fifteenth Corps, until August 13th, when he Avas 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, 1868, he was'a pensioner, his disability being rated tAvo-thirds and temporary. Case.—Sergeant Stephen Aldrich, Co. E, 141st Ncav York Volunteers, aged 26 years. Fracture of the occipital bone by a conoidal musket ball. Dallas, Georgia, May 25th, 1864. Treated at the hospital of the 1st division, TAventieth Corps, the field hospital at Chattanooga, the Sherman Hospital at Nashville, and the hospitals at Jeffersonville and Elmira. Discharged from 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 NeAV 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, 1864, 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.—Private 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, Avhere simple dressings were applied; on September 5th, Avas sent to the hospital of the Fifteenth Corps, and on November 30th, to Camp Butler, Illinois. Discharged from service April 8th, 1865. In July, 1868, he was a pensioner, his disability being rated 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 Camp, and Dale hospitals. Discharged May 9th, 1865. Not a pensioner. Case.—Private Jacob Burnes, Co. K, 100th Pennsylvania Volunteers, aged 27 years, 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. He was admitted to Carver Hospital, Washington, on April 5th, 1865, and Avas 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 Run, 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 bone. Treated in the hospital of the 1st division, Second Corps, and at the Armory Square, White Hall, McClellan, and MoAver hospitals. Discharged from service July 31, 1865. Not a pensioner. Case.—Private J. A. Dietz, Co. G, 3d NeAV York Volunteers, aged 24 years. Fracture of cranium and wound of shoulder, by a tAvelve-pound shot. Drury's Bluff, Virginia, May 16th, 1864. Treated in the hospital of the 1st division, Tenth Corps, and at MoAver, De Camp, and Ira Harris hospitals. Discharged June 15th, 1865, "able to earn partial subsistence." Case.—Private 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. Casio.—Private Augustus Juno, Co. G, 147th NeAV York Volunteers, aged 40 years, was wounded at the battle of Cold Harbor, A'irginia, June 3d, 1854, by a conoidal ball, which fractured the cranium. On the same day he was admitted to the hospital of the 4th division, Fifth Corps. The injury was considered slight, and, apparently, caused little or no inconvenience, as the man served with his regiment again until February 1st, 1885, Avhen 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, 1868, 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 NeAV York Volunteers, aged 19 years. Fracture of the frontal bone by a conoidal musket ball. Petersburg, April 2d, 1865. 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 communication 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 L.wa Volunteers, aged 39 years. Fracture of the frontal hone by a conoidal musket ball. Resaca, ({eorgia, May loth, 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 various parts of his body, supposed to have been caused by vaccination. Discharged June 21st, 1865. and pensioned, his disability being rated one- third. There Avas impairment of cerebral functions. DEPRESSED GUNSHOT FRACTURES OF BOTH TABLES OF THE SKULL. 167 Case.—Private EdAvard B. Ockington, Co. (i, 37th Massachusetts Volunteers, aged 28 years, Avas wounded at Winches- ter, Virginia, September 19th, 1864, by a fragment of shell, Avhich produced a stellate fracture of the frontal bone, lie Avas treated at corps, Sandy Hook, and McClellan hospitals. The patient had nearly recovered in December, and Avas sent to Camp Distribution, Virginia, but be was returned to the Carver Hospital at Washington, on December 16th, and on March 13th, 1865, was transferred to Dale Hospital, Massachusetts, Avhere he Avas discharged the service on May 24th, 1865. Not a pensioner. Case.—Private Owen F. Prentice, Co. C, 35th Illinois Volunteers, aged 32 years. Fracture of the frontal bone above the left eve, 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, Avas doing well, but the patient Avas unable to undergo any active exertion. He Avas discharged from service June 9th, 1864, on account of total disability. Not a pensioner. Case.—Private John Spurrier, Co. A, 142(t NeAV York Volunteers, aged 22 years, was wounded in an engagement on the DarbytoAvn Road, Virginia, October 26th, 1864, by a conoidal musket ball, which fractured a portion of the parietal bone. On October 29th, he Avas admitted to the Balfour Hospital, Portsmouth, Virginia, where he remained under treatment until March 10th, 1865, when he Avas admitted to the Grant Hospital, Ncav York Harbor. At this time, the conjunctiva Avas 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, Avas 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 M. L. H. ------, Co. E. 21st Virginia Regiment, aged 20 years, Avas wounded at Petersburg, Virginia, in the assault on Fort Steadman, March 25th, 1865, by a musket ball which struck the forehead. He Avas made a prisoner and admitted to the hospital of the Ninth Army Corps at City Point. On March 27th he Avas conveyed in the hospital transport steamer "State of Maine" to Washington, and placed in the Lincoln Hospital on March 28th, Avith a wound over the left supra-orbital ridge, apparently inflicted by a glancing musket ball. There were no cerebral symptoms when the patient was admitted, and he seemed to be doing Avell for seA'eral days, being quite free from pain or any febrile movement. The pulse was normal and the bowels in good condition. On April 1st, he complained of a dull deep-seated pain over the left eye. Later in the day he Avas feverish and restless, his countenance Avas pale, and his pulse sIoav and Aveak. On April 2d, he failed rapidly. On the night of the 3d, he Avas 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 Avas found extending into the right orbit, and upward beyond the left frontal prominence. The vitreous table beneath Avas largely depressed. There was a small abscess in the anterior lcbe 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 ofthe 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.) Fio. 77 —Section of the frontal.bone, exhibiting a fissure over the left supra-orbital region.—Spec. 24, A. M. M. Flo. 78.—Internal view of the foregoing specimen, showing the extensive splintering of the 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.—Private George V- -, Co. C, 84th New York Volunteers, was wounded at Chancellorsville, May 3d, 1863, and admitted into Carver Hospital at Washington, D. C, on May 7th, 1863. His injury Avas supposed to be a simple scalp wound from a musket ball. It Avas situated over the right parietal protuberance, and on admission Avas granulating kindly. Ten days subsequently the patient, after a walk out of doors and sitting in the hot sun, had headache and nausea, and the wound gaped and its edges ulcerated. On May 17th there was headache, and his stomach would not retain food. On May Ms WOUNDS AND INJURIES OF THE HEAD. l-fh the probe detect-11 denuded bone; hut no fracture was discovered. There Avere no febrile or cerebral symptoms. On May 2Uth a depression of the outer table of the skull Avas detected. At night there was delirium, and the folloAving day the pulse became feeble and irregular, the stomach irritable, the tongue heavily furred. On this and the folloAving nights the patient had tAvo and a half grains of opium at bedtime. His diet Avas Ioav, though chicken broth and custard Avere alloAved. On this day there was a decided icteric hue over the Avhole surface. The patient died on May 2'Jd, 1863. being conscious and rational to the last. At the autopsy, extensive inflammation of the dura mater Avas observed, and softening of the middle lobe of the right cerebral hemisphere. The notes of the case were drawn up by Assistant Surgeon E. F. Bates, U. S. V., and were contributed with the specimen, which is represented in the wood-cuts above, (Fig. Fio. 79—Gunshot fracture of the right 79 and FiG. 80,) by Surgeon O. A. Judson, U. S. V. parietal bone. Spec. 1257, A. M. M. The fracture of the external table is half an inch 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 feAV hairs are Avedged in among th fragments. The surrounding bone is porous and cribriform. Fig. 80.—Interior view of the foregoing specimen. Army The classical " punctured" fracture of authors was not infrequently observed, and the MedicalMuseum possesses many specimens of this form of injury, one of the best of which is figured below: Case.—Private James K- -, Co. G, 6th Ncav York Cavalry, Fio. 81.—Fracture of the frontal bone by a pistol ball. Spec. 1G73, A. M. M. Avas wounded at the battle of Gettysburg, July 3d, 1863, by a pistol ball, which produced a punctured fracture ofthe os frontis. He Avas 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 convul- sion. The wound, which was nearly healed, Avas laid open, and depressed bone being detected, an effort 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 feAV hours sub- sequently. At the autopsy, the extended depression of the inner table Avas discovered, and a large abscess of the brain. Fk;. 82.—Interior view of the foregoing specimen. Another common form is illustrated in the following case: Case.—Private Leonard L------, Co. F, 74th NeAV York Volunteers, was wounded at the battle of Williamsburg May 5th, 1862, and Ava? admitted into Broad and Cherry streets Hospital at Philadelphia, May 13th, 1862. A musket ball had 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 Avas admitted, and there was no cerebral disorder. This favorable condition continued unaltered till May 20th, when a febrile movement set in, accompanied by nausea and vomiting; droAvsiness and stupor folloAved, and the patient died comatose on May 23d, eighteen days after the injury. At the autopsy a small clot was found beneath the depressed portion of the vitreous plate; the dura mater was uninjured; the arachnoid near the seat of injury Avas opaque and studded Avith deposits of lymph; the gray matter of the brain was softened. The external fracture was found to be circular 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 bone three-fourths of an inch in diameter was driven imvard to the depth of tAvo lines. The specimen, which is well represented in the foregoing wood-cuts, (Fig. 83 and Fig. 84.) was presented to the Army Medical Museum by Acting Assistant Surgeon John Neill. It may be well to give a few more illustrations of the differences in the appearances of the outer and inner tables after gunshot fracture: Case.—Sergeant Oscar B. L------, Co. A. 22d IoAva Volunteers, aged 25 years, Avas Avounded at the battle of Cedar Creek, Virginia, October 19th, 1864. by a musket ball Avhich fractured and depressed the right parietal bone. He Avas at once admitted Fig. 83.—Portion of left parietal, show- ing a slightlv depressed fracture of the outer table. 'Sjiec. 224, A. M. M. Fig. 84.—Interior view of the fore- going specimen, exhibiting extensive splintering of the vitreous table. DEPRESSED GUNSHOT FRACTURES OF THE SKULL. Ki!) to the Sheridan field hospital., and on October 24th sent to the .Jarvis Hospital, Baltimore, Maiyland. On October 29tl hemiplegia of the left side was noted. Inflammation of the brain folloAved. On October 31st, 1861, death took place At the autopsy a piece of skull about the si/.e of a silver dollar, was found driven in upon the dura mater at the seat of injury. The veins of both hemispheres Avere in- tensely engorged. A large abscess immediately beneath the fracture and the lateral ventricle of the brain, was filled with purulent-fluid. The pathological specimen fig- ured in the preceding wood- cuts, (Fig. 85, and Fig. 86,) together with the notes ofthe case, Avere contributed by Acting Assistant Surgeon B. B. Miles. The openin diameter. The fragments of the inner table measure one by one and a half inches, and consist of two pieces touching at their inner edges. The apex of the angle of depression is half an inch below the general surface ofthe inner table of the skull. Fio. 8.">.—Vault of a cranium showing a depressed gunshot fracture. Spec. 3415, Sect. I, A. M. M. Fig. 86.—Interior view of foregoing specimen. in the outer table is three-fourths of an inch in Very commonly in fractures of the skull by musket balls, long fissures extend from the point at which the outer table of the skull is crushed by the direct impact of the missile: Case.—Private Edwin L. C- Fig. 87.—Section of cranium showing a complete fissure n the left parietal and temporal, caused by a musket ball. Spec. 4255, Sect. I, A. M. M. —Interior view of the foregoing specimen -, Co. I, 34th Massachusetts Volunteers, aged 26 years, was Avounded at the battle of NeAV Market, Virginia, May 15th, 1864, by a musket ball Avhich fractured and depressed the left frontal, temporal, and parietal bones. On the 18th, he Avas conveyed to the hospital at Cumberland, Maryland, in an insensible condition. Great prostration ofthe nervous and vascular system was apparent. Consciousness never returned, though death did not occur until May 21st, 1864. At the autopsy the meninges were found much congested and covered with slight patches of pus. Fragments of the frontal and tem- poral bones had been driven upon the brain substance causing soften- ing and discoloration. The whole hemisphere was highly injected, and in the left ventricle was found an effusion of blood. The pathological specimen is represented in the foregoing wood- cuts, (Fig. 87 and Fig. 88,) and shoAvs a complete fissure two and a half inches in length in the left parietal and a depressed fracture of the frontal and parietal and temporal bones at their junction. A portion of the vitreous lamina nearly three-fourths of an inch in diameter is depressed one line at the point of impact in front of the anterior angle of the parietal. The specimen Avas contributed by Surgeon J. B. Lewis, U. S. V. Case.—Private Thomas Brennen, Co. I, 65th New York Volunteers, aged 30 years, was Avounded at the battle of Cedar Creek, Virginia, October 19th, 1864, by a musket ball Avhich fractured the frontal bone near the median line, a portion of the missile entering the brain. He was conveyed to Baltimore, and on the 24th was admitted to the Jarvis Hospital. Hemiplegia of the left side had already ensued. Death resulted October 25th, 1864. At the autopsy the opening in the bone was found to measure three-fourths by one and one-fourth inches. A fissure four inches in extent passed upward, across the coronal suture, into the right parietal bone, and two others passed downAvard and laterally. A piece of the inner table, measuring one-fourth by one inch, was partially fractured and depressed one-fourth of an inch. Two circular pieces of bone, three-fourths of an inch in diameter, were found driven into the dura mater, the brain substance in the vicinity being much softened. The left hemisphere was covered with clotted blood. The missile Avas found lodged in the third ventricle, left side. The pathological specimen is No. 3413, Sect. I, A. M. M., and, with the history, was contributed by Acting Assistant Surgeon B. B. Miles. Case.—Private John H. Wingert, Co. E, 14th Indiana Volunteers, received a depressed fracture of the frontal bone at the battle of Fredericksburg, December 13th, 1862. The missile produced an opening two and a quarter inches in length and three-fourths of an inch in Avidth, extending from the inner angle of the right eye upward and outAvard. He was sent to the hospital of the 3d division, Second Corps, and on December 18th Avas admitted to HareAvood Hospital, Washington. The dura mater Avas found lacerated, but no fragments of bone were in the wound. Inflammation of the brain and its membranes existed, and the surrounding integuments presented an erysipelatous appearance. The pulse Avas one hundred and twenty and 170 WOUNDS AND INJURIES OF THE HEAD. bowels costive. No paralysis existed, and the patient ansAvered questions correctly. Oft December 19th stupor supervened, muttering delirium followed, and death occurred December 20th, 1862. On removing the calvaria, the anterior half of the dura mater was found thickened, and the superior portion of the anterior lobe of right hemisphere was completely disorganised. The ventricles were filled with a sanguineious fluid, and the corpus callosum Avas softened. The skull-cap avus fissured. Other examples of fissures extending from the point of impact on the skull of gun- shot projectiles are shown in specimens 2904, 3150, 3413, and 3051. The many varieties in the form of depressed fractures of the cranium produced by gunshot projectiles, and depending on the size, weight, velocity, and angle of incidence of the missiles, are very amply illustrated in the surgical cabinets of the Army Medical Museum. It is doubtful, however, if drawings, however carefully made, would enable surgeons to make such deductions as they might reach by examining the specimens themselves; and it is better to occupy the space by a large number of abstracts of cases in which the facts have been carefully verified, than by profuse illustration of minute variations in the forms of such fractures, especially as in treating of penetrating and perforating fractures of the skull and of exfoliation and trephining, additional illus- trations will be introduced. Therefore, but a few more speci- mens will be noticed here. That represented in the adjacent wood-cut was believed by Surgeon Vanderkieft, U. 8. V., who presented it, to show a fracture produced by a musket ball at very long range, in the case of a Confederate sharpshooter, posted in a tree at the summit of South Mountain, whence he was dislodged by the Union skirmishers. All of the depressed fragments are adherent by their outer edges. The fracture is so unlike any others produced by musket balls that it is questionable if it did not occur in falling from the tree, or, perhaps, post mortem, by a blow from a musket. The next case illustrates a fracture, in which the fragments were much displaced, caused by a pistol ball at short range: Case.—Sergeant Charles A. C------, Co. A. 3d Virginia Cavalry, was wounded in a skirmish near Culpeper, Virginia, October llth, 1863, by a pistol ball which fractured the superior portion of the frontal bone a little to the left of the median line. He was taken prisoner, conveyed to Washington, and taken to the Emory Hospital on the 13th. He was free from pain and conscious when admitted, but had some tendency to stupor. Spiculae of bone Avere re- moved from the Avound, sim- ple dressings applied, and a cathartic administered. On the 14th the tendency to coma increased, and a venous haemorrhage from the Avound occurred, and cerebral matter exuded. The pulsations of the brain were distinctly IG. !>U.—Calvaria and fragments of bone and pistol visible at the onenino- At . Spec. 1707, Sect. I, A. M. M. . , ,, , . , °' eight o clock in the evening, these symptoms Avere still graver, and the patient could be aroused only with great difficulty. He gradually sank and died on the following morning, October 15th, 1863. The autopsy showed that the ball had split upon the skull, one portion passing underneath the scalp for a short distance, the other entering the brain. The left lobe of the cerebrum was greatly disorganized and broken (Ioavii. The exact point of lodgment of the ball could not be ascertained, as it dropped through the disorganized Fig. 89.—Indented fracture of the frontal bone. Spec. 1223, Sect. I, A. M. M. ieo Fig ball Fig. 91.—Internal view of the foregoing specimen. DEPRESSED GUNSHOT FRACTURES OF THE SKULL. 171 tissue at the dissection. The calvaria and fragments of ball are represented in the adjacent wood-cut. The frontal bone is fractured and depressed one inch above and internal to its left eminence. The opening measures one-half by one inch externally, being slightly more extensive on the inner table. The specimen and history Avere contributed by Surgeon N. R. Mosely, U. S. V. The next case illustrates not only the fracture, but a synostotic cranium curiously deformed by the premature union of the sutures: Case.—Private A. P. H----, Co. A, 50th Georgia Regiment, aged 21 years, was Avounded at the battle of South Mountain, Maryland, September 14th, 1^62. A musket ball struck the frontal bone near the left frontal eminence, causing fracture and depression ; another ball entered the left arm just below the head of the humerus, fractured the bone and escaped at the inferior angle of the scapula. On October 27th, he was admitted to the hospital at Frederick, Maryland, in a very Ioav condition and suffering from diarrhoea. Tonics and stimulants were freely given. No symtoms of paralysis, compression of the brain, or other cerebral disturbance presented themselves. The arm Avas put in a splint. Profuse and unhealthy discharge from the wounds soon Aveakened the patient, and he died November 25th, 1862, from exhaustion At the autopsy the brain on the injured side Avas found softened. The depressed portion Avas ovoid, measuring externally three-fourths by one and three- fourths inches. The inner table was fractured more extensively than the outer. Wure^fTh^ef^ The pathological specimen is represented in the adjoining wood-cut, (FiG. 92,) Sect. I, A. M. M. and was contributed by Assistant Surgeon G. L. Porter, U. S. A. In the following cases of gunshot depressed fracture of the cranial bones, the patients were discharged on account of disabilities of a serious nature, resulting from their injuries: Case.—Lieutenant Jacob Fryburger, Co. K, 51st Pennsylvania Volunteers, aged 28 years, Avas wounded in an engage- ment before Petersburg, Virginia, June 18th, 1864, by a conoidal musket ball, which slightly injured and depressed a portion of the frontal bone. He Avas admitted to the hospital ofthe Ninth Army Corps ; on June 21st, was sent to the 1st division hospital at Annapolis, Maryland; and on August 25th to the Officers' Hospital at the latter place. He was discharged the service October 5th, 1864, and was pensioned, his disability being rated as total and probably temporary. Pension Examiner E. SAvift, of Easton, Pennsylvania, reported on February 22d, 1865, that in the case of this officer, any slight exposure caused great dizziness or vertigo. Besides the head injury, he had received a bad gunshot flesh wound of the back, Avhich, however, had healed at the date of Dr. SAvift's report. Case.—Private Louis Starnkopf, Co. A, 33d New Jersey Volunteers, aged 36 years, was wounded at the battle of Buzzard Roost, Georgia, May 9th, 1864, by a conoidal musket ball which fractured and depressed a portion of the frontal bone. He Avas sent to the hospital of the 2d division, Twentieth Corps, thence was sent via Chattanooga and Nashville, Tennessee, to the Jefferson Hospital, Indiana, where he remained under expectant treatment until the 27th of July. He was"then furloughed, and at the expiration of his leave Avas admitted to the Ward Hospital, New Jersey. On the 28th of September, 1864, he was returned to duty. On June 23d, 1865, Assistant Surgeon P. Adolphus, U. S. A., reported the patient suffering from chronic cerebritis with softening ofthe brain ; whereupon he Avas discharged the service June 29th, 1865, and pensioned, his disability being rated three-fourths. Case.—Private William McQuown, 1st Regiment Veteran Reserve Corps, was admitted to the Armory Square Hospital, Washington, from his company on September 18th, 1864, with a depressed fracture of the frontal bone. The records do not show Avhere or when the injury Avas received. The patient recovered and was discharged the service October 24th, 1864, on account of anchylosis of the right elbow-joint and fracture and depression of the frontal bone, causing derangement of the functions of the brain. The case is reported by Surgeon D. W. Bliss, U. S. V. The patient made a claim for pension, but it Avas not allowed for lack of evidence. Case.—Private Thomas C. Little, Co. E, 20th Maine Volunteers, aged 42 years, was struck by a conoidal musket ball at the battle of Gettysburg, July 2d, 1863, which wounded the scalp and fractured a portion ofthe external table of the frontal bone. He Avas admitted into the Satterlee Hospital at Philadelphia on July 10th, aud on the 1st of September a portion of exfoliated bone about one inch square was removed from the Avound. Cerate dressings Avere afterAvard applied, and the patient continuing to improve, Avas, on November6th, placed on light duty in the hospital, Avhere he remained until December 23d, 1863, Avhen he was transferred to the Veteran Reserve Corps, and shortly afterward returned to duty. The case is reported by Acting Assistant Surgeon J. Roberts. He Avas discharged the service June 28th, 1865, and pensioned, his disability being rated total and permanent. Subsequent reports show the patient to be gradually failing from the effects of the wound, and suffering from general derangement of the nervous system. Case.—Private Jeremiah Donovan, Co. A, 9th NeAV York Volunteers, Avas wounded in an engagement at Roanoke Island, North Carolina, February 8th, 1862, by a conoidal musket ball which fractured and depressed a portion of the frontal bone in the vicinity of the right eminence. The patient recovered, and Avas examined in 1866 by Pension Examiner James Neil, Harlem, New York, Avho reported him complaining of headache, dizziness, confusion of ideas, and of being easily tired. There Avas impairment of sight in the right eye and a large depression existed over seat of original injury. He Avas discharged the service April 22d, 1862, and pensioned, bis disability being rated five-eighths, permanent, and liable to increase. 172 WOUNDS AND INJURIES OF THE HEAD. Case.—PriA-ate David D. Lathrop, Co. K, 18th Connecticut Volunteers, aged 21 years, was wounded at the battle of Piedmont, West Virginia, June •">, 1^34, by a conoidal musket ball which fractured the external table of the frontal bone, lie was conveyed to Frederick, Maryland; was there admitted into hospital on the 20th, and on July 3d was sent to the Knight Hospital, Ncav Haven, Connecticut; thence was sent on October 18th to Readville, Massachusetts, and on February 13th. 1>65, was transferred to the Veteran Reserve Corps. He Avas discharged the service June 5th, 1865, and pensioned, his disability being rated one-half and permanent. A report since received states that the wound had healed, Avith defective audition in the left ear. Case.—Private Daniel MrGinish, Co. B, 47th Alabama Regiment, was admitted to Confederate hospital at Lynchburg, Viiginia, Avith a gunshot Avound of forehead. Both tables ofthe os frontis were destroyed. He Avas discharged February 2d, 1863. Case.—Private George H. Murphy, Co. E, llth Pennsylvania Volunteers, was wounded at Bull Run, August 30th, 1H62, by a musket ball which entered behind the mastoid process of the left temporal bone, fracturing a portion, and emerged immediately exterior to right ala nasi. He was conveyed to Alexandria, and on September 3d, was admitted to the 3d division hospital. The muscles of the loAver jaw were rigid, and spiculae of the mastoid process were discharged from time to time. At the time of his discharge from service, October 23d, 1862, the wound had not entirely healed. Pension Examiner J. H. AnaAvalt, in a communication dated March 6th, 1837. reports that the left lachrymo-nasal duct had closed, the sac constantly becoming distended with secretion; that there Avas hypersesthesia of left side of face; and that the patient could not bear exposure to cold Avithout much suffering. In March, 1868, his disability was rated one-half and permanent. Case.—Private NeAvton Black, Battery I, 2d Pennsylvania Artillery, aged 19 years, was wounded at the battle of Chapiu's Farm, Virginia, September 29th, 1864, by a conoidal ball, which fractured the occipital bone. He was admitted to the Base Hospital of the Eighteenth Corps at Point of Rocks, Virginia, on the next day; thence was conveyed, on the 5th of October, to the hospital at Fort Monroe, and on the following day sent by steamer to the Lovell Hospital, Portsmouth Grove, Rhode Island. In December, he was furloughed, and on the 19th of May, 1865, discharged from service, being still subject to attacks of vertigo and headache. In July, 1868, he was a pensioner, his disability being rated total and permanent. Case.—Corporal Isaac Clapp, Co. E, 84th Indiana Volunteers, aged 28 years. Fracture of occipital bone by a piece of shell. Near KenesaAv Mountain, June 23d, 1664. Treated at division hospital, hospital No. 19 at Nashville, Brown Hospital at Louisville, and at the hospital at Madison, Indiana. Discharged March 4th, 1865, and pensioned. According to certificate of disability, there Avas loss of bone to the size of a dollar, and the patient suffered from frequent attacks of dizziness. Case.—Private Andrew Wolfran, Co. C, 118th Ohio Volunteers, aged 35 years, was wounded at Resaca, Georgia, May 14th, 1864, by a conoidal ball, which entered near the lambdoid suture, and emerged in front and beloAV the left ear. He was discharged June 26th, 1365, and pensioned. The hearing of the left ear was destroyed, the muscles of the left side of the face were paralyzed, and he was unable to close the left eye, the sight of which is affected. His disability is rated total and temporary. Case.—Private Alexander Hunter, Co. H, 54th Massachusetts Volunteers, was wounded in action at Morris Island, South Carolina, August 18th, 1863, by a fragment of shell, which caused a partial fracture of cranium. He was treated in regimental hospital, and apparently recovered, as he was returned to duty April 24th, 1864; but he was discharged from service June 30th, 1864, from Avhich date he has been pensioned, his disability being rated one-half, and, probably, temporary. Case.—Private Edward J. Whitmore, Co. A, 57th Illinois Volunteers, aged 25 years, was wounded at Allatoona Pass, (Jeorgia, October 5th, 1864, by a conoidal musket ball, which fractured both tables of the right parietal bone. He was admitted on the same day to the hospital of the 4th division, Fifteenth Corps, and remained in field hospital until January 23d, 1865, when he Avas sent to Hospital No. 1, Beaufort, South Carolina; thence he Avas corn-eyed per hospital steamer Ben Deford to Ncav York, where he was admitted to the McDougall Hospital on January 29th, 1865. The treatment consisted in the application of simple dressings. On March 8th, he Avas sent to the St. Joseph Hospital, Central Park, and was discharged from service on March 14th, 1865. The vision of the right eye was destroyed. Not a pensioner. Case.—Private Harvey Piatt, Co. A, 7th Indiana Volunteers, aged 25 years, was wounded at the battle of Spottsylvania Court House. May 12th. 1864, by a conoidal musket ball which fractured the skull. In the same engagement, he received a wound of the right leg. He was admitted to the hospital of the 4th division, Fifth Corps; thence was sent to the Mount Pleasant hospital at Washington on the 16th, and was transferred, on the 18th, to McKim's Mansion Hospital, Baltimore. After several other transfers, he was finally admitted into hospital No. 4, at Madison, Wisconsin, on September 1st, 1864, and discharged fi-om sei-A-ice on January 20th, 1865, and pensioned. Pension Examiner M. H. Harding states that the patient is disqualified for manual labor during the warm season, owing to vertigo and pain in the head, which seriously impair his health. He rates his disability three-fourths. Case.—Private J. D. Spencer, Co. K, 3d Virginia Cavalry, received at the battle of Bull Run, July 21st, 1861, a gunshot fracture of both tables of the right parietal bone. He was conveyed to the hospital at Farmville, where he was discharged April 2.'d. 1664. There was extensive derangement of the nervous system, and the patient was unfit for duty. Case.—Private James D. Potter, Co. F, 99th Ncav York Volunteers, was Avounded in an engagement near Suffolk, Virginia, in April, 1883, by a conoidal ball which fractured the left parietal bone three-fourths of an inch anterior to the protuber- ance. He was sent to the regimental hospital, and on May 26th, was sent to the Hampton Hospital, Virginia, where partial recovery took place; and on August 6th, 1863, was transferred to the Veteran Reserve Corps. He was discharged the service June 13th, 1864, and pensioned. On March 13th, 1869, Pension Examiner J. T. Burdick reports his condition very fair for one ot his age. which was sixty-tAvo years, and adds: "he is subject to frequent and irregular attacks of vertigo, and has impaired memory." He rates his disability one-half, permanent. DISABILITIES FOLLOWING DEPRESSED GUNSHOT FRACTURES. 173 Case.—PriA-ate Porter C. Johnson, Co. B. 3d Pennsylvania Reserves, received, during the Peninsular Campaign, July, 1665, a gunshot wound of the skull. On July 3d, he Avas conveyed to the steamer State of Maine, and on July 7th, Avas admitted to Satterlee Hospital. Pennsylvania. The wound healed, and on September 25th, 1862, he was discharged the service, and pensioned. There Avas constant headache and vertigo, inability to bear exposure to heat, and the patient was mentally and physically imbecile, according to the report of Pension Examining Surgeon T. B. Reeve. Case.—Sergeant William Shaftoe, Co. K, 57th Massachusetts Volunteers, aged 41 years, was Avounded at the battle of Cold Harbor, Virginia, June 2d, 1834, by a fragment of shell AA'hich struck over the right eye, causing a slight depression. He Avas admitted to hospital 1st division, Ninth Corps; on June 6th sent to Mount Pleasant Hospital, Washington, D. C, and on June 19th to Mower Hospital, Philadelphia, Avhence he Avas returned to duty September 5th, 1864. Discharged June 13th, 1865. Pension Examiner P. L. Stickney, of Chicopee, Massachusetts, reports, February 13th, 1869, that this man was on the Pension List, and that his disabilities had so much increased since his discbarge that he was incapable of enduring labor. He had lost his hearing in the right ear, and he suffered from headache, giddiness, and fainting fits, and that his disability was undoubtedly permanent. Case.—Sergeant Flavius G. Arrowsmith, Co. G, 115th Pennsylvania Volunteers, Avas wounded at the battle of Gettys- burg, Pennsylvania, July 2d, 1663, by a conoidal musket ball Avhich fractured and depressed a portion of the frontal bone a little to the left of the median line and just in front of the coronal suture. He Avas admitted to the regimental hospital, and on July llth Avas sent to McClellan Hospital, Philadelphia. The patient recovered and was returned to duty April 14th, 1864 ; Avas discharged the service June 24th, 1.865, and pensioned, his disability being rated three-fourths. Case.—Sergeant John Sowers, Co. H, 10th NeAV Jersey Volunteers, aged 26 years, Avas Avounded at the battle of Cold Harbor, Virginia, June 2d, 1864. by a conoidal musket ball Avhich fractured and depressed a portion of the frontal bone above the superciliary ridge. He Avas admitted to the 1st division hospital ofthe Sixth Corps, thence Avas conveyed to Alexandria on June 16th, and was treated at the Soldiers' Rest until June 21st, Avhen he Avas sent to the Haddington Hospital at Philadelphia. After other transfers he Avas finally sent to the Ward Hospital at NeAvark, NeAV Jersey, October 13th, 1864, and was returned to duty April 15th, 1865; Avas discharged the service July 1st, 1865, aud pensioned, his disability being rated one-third and permanent. Case.—Private Albert Le Clear, Battery C, 1st Ohio Artillery, was wounded at Chickamauga, September 20th, 1863, by a fragment of shell, which fractured and carried aAvay a portion of the right parietal bone. On the 12th of October, he Avas admitted to the Cumberland Hospital at Nashville, was transferred, on the 16th, to No. 2 hospital, Louisville, and thence, to Camp Chase, Ohio, December 19th, 1863. There was paralysis, with impairment of the mental faculties, which existed at date of his discharge from service, February 2d, 1864. Information from the Pension Office states that Le Clear is a pensioner. There is a deep groove in the parietal bone, with partial paralysis of the right side. His disability is rated total and doubtful. Case.—Private John E. Davidson, Co. E, 22d Wisconsin Volunteers, aged 19 years, was wounded at the battle of Kenesaw Mountain, Georgia, June 27th, 1864, by a conoidal musket ball, which fractured the left parietal bone tAvo inches above the ear. He was admitted to the hospital of the 3d division, Twentieth Corps, and tAvo days later was sent to hospital No. 1, at Chattanooga, Tennessee. On the llth of July, he was admitted into the Cumberland Hospital at Nashville; thence was sent, on the 9th of September, to Madison, Wisconsin. He was discharged at expiration of term of service, May 12th, 1865, suffering from giddiness and constant headache, and Avas pensioned from that date, his disability being rated at one-third and temporary by the pension examiner, Dr. Joseph Hobbins. Case.—Private Lawrence Redding, Co. B, 89th Blinois Volunteers, aged 21 years, was Avounded at the battle of Mission Ridge, Tennessee, November 25th, 1863, by a conoidal musket ball, which fractured the left parietal bone near the junction of the sagittal and lambdoid sutures. He was admitted on the same day to Hospital No. 4 at Chattanooga. On November 19th, 1864. he was sent to the Brown Hospital, Louisville, Kentucky, and on the 29th, to the hospital at Mound City, Illinois. The AA-ound was open as late as January 4th, 1865, suppurating freely and causing pain, vertigo, and prostration. He was discharged from service on January 22d, 1865, being entirely unable to undergo any active exertion. The case is reported by Acting Assistant Surgeon A. H. Kellogg. His name is not on the Pension List. Case.—Private Peter Balinzifer, Co. A, 44th Blinois Volunteers, aged 38 years, was Avounded at the battle of Franklin, Tennessee, November 30th, 1864, by a conoidal ball, which fractured the frontal bone. On December 23d, he Avas admitted to hospital No. 15, Nashville, from Franklin; on January 3d, sent to the Joe Holt Hospital, Jeffersonville, Indiana; and on January 5th, transferred to the Jefferson Barracks Hospital, St. Louis, Missouri, Avhere he Avas mustered out of service on June loth, 18G5. He was pensioner at 84 per month until March 8th, 1868. Since that time he has received an increased pension of §8 per month. Case.—Private John Worrall, Co. E, 59th NeAV York Volunteers, was wounded at Antietam, September 17th, 1862, by a fragment of shell, Avhich struck the left temporal bone above the eye, and, cutting through the skull, passed obliquely backAvard over the top of the head. At the same time, while going to the rear, he received a bullet Avound through the middle third of the left arm, Avith injury to the nerve. On the 19th, he was admitted to the hospital ofthe Second Corps at the Hoffman House, and on the 27th, was transferred to the Satterlee Hospital at Philadelphia, Avhere he is reported as a deserter, on NoA-ember 3d, 1862; but, as (according to pension certificate) he Avas discharged from service on October 7th, 1864, (from which date he is pensioned,) the probability is, that he returned to duty, and Avas mustered out Avith his regiment. Pension Examiner E. O. Huntington, under date of July 13th, 1869, states, that the patient's arm was numb and Aveak, and that, being a blacksmith and left handed, it Avas very inconvenient; and that the effect of the skull wound Avas such that a stooping position produced dizziness, dimness of vision, and nausea. His disability is rated total and permanent. 171 WOUNDS AND INJURIES OF THE HEAD. Case..—Corporal John B. Frank. Co. D. 33d Missouri Volunteers, aged 30 years, Avas wounded in an engagement at Nashville, Tennessee, December 16th, 1864, by a piece of shell, which fractured the cranium. He Avas, on the same day, admitted to the Cumberland Hospital at Nashville; on January 10th, sent to the Jefferson Hospital, Jeffersonville, Indiana, Avhence he was furloughed on February 13th, 1865. On March 24th, he Avas admitted to the Marine Hospital, St. Louis, Missouri, and on May 5th, 1865, mustered out of service. In July, 1868, he avus a pensioner at $6 per month, his disability being rated three-fourths by Pension Examiner J. C. Whitehill, of St. Louis. Case.—Private John Parkhorst, Battery E, 2d NeAV York Heavy Artillery, aged 50 years, was Avounded at Farmville, Virginia, April 7th, 1865, by a conoidal ball, which fractured the upper portion of the right frontal bone. He was admitted to the hospital of the 1st division, Second Corps, and on April 16th, Avas sent to the Harewood Hospital at Washington. Simple dressings only were required. On May 29th, he Avas sent to the White Hall Hospital, Bristol, Pennsylvania, and on June 16th, 1865, was discharged the service and pensioned, his disability being rated three-eighths, and permanent. A communication from Pension Examiner T. M. Flandreau, dated November 20th, 1868, says, that since his examination in July, 1867, the patient's general health had greatly failed, Avhich he attributed to continued pain in the head, producing nervousness and drowsiness. The action of the heart was violent and excessive, and, for six months, there were symptoms of ascites, which diminished under treatment. He Avas a night Avatchman in a mill, but lost much time. His disability was then rated seven-eighths, and probably permanent. Case.—Private Nicholas Rhoade, Battery K. 10th NeAV York Heavy Artillery, aged 21 years, was wounded before Petersburg, July 4th, 1864, by a conoidal musket ball, which fractured and carried away a portion of the right temporal bone. He Avas admitted to the hospital of the Eighteenth Corps, thence on the 8th, sent to the Fort Monroe hospital, and after four days' treatment was again transferred, by hospital steamer, to the Grant Hospital, New York. He continued in the hospitals of that State until returned to duty from De Camp Hospital on the 22d of November, 1864. He was finally discharged from service on January 27th, 1865, and pensioned. Dr. C. C. P. Clark, of OsAvego, reports, in January, 1865, that there was a large loss of substance of the right temporal bone, and that the patient complained of pain and dizziness and loss of memory. The cicatrix Avas firmly healed. Case.—Private John Gool, Co. II, 71st Ohio Volunteers, aged 21 years, was wounded in front of Nashville, Tennessee, December 16th, 1864, by a conoidal musket ball, which fractured and carried away two inches of the frontal bone. He was admitted to hospital No. 1, Nashville, on the 18th, and remained in the different hospitals of that city until the 8th of January, 1865, Avhen he was transferred to Jeffersonville, Indiana. On July 24th, 1865, he was sent to Camp Dennison, Ohio, where he Avas discharged the service on the 28th of September, 1865. A communication from Pension Examiner W. Y. Kisher, states that the patient is "unable to bear exercise," and rates his disability one-half, permanent. Case.—Corporal John G. Whigam, Co. I, 116th Pennsylvania Volunteers, aged 22 years, was wounded near Petersburg, June 16th, 1864, by a piece of shell which fractured the frontal and left parietal bones, carrying aAvay a piece two inches in diameter. He Avas conveyed to the hospital of the Second Corps, thence Avas sent by way of City Point to Alexandria, Avhere* he AAras admitted to the 2d division hospital on June 28th. The brain was exposed, but the Avound healed kindly, and the patient Avas discharged the service June 25th, 1865, still incapable of any exertion. Until September 14th, 1869, he was pensioned at six dollars a month. His pension Avas then increased to fifteen dollars, Pension Examiner W. M. Henson, at Allegheny City, reporting that the pensioner suffered constant pain in the head, and Avas totally and permanently unfitted for manual labor. Case.—Private Jacob Livingston, Co. I, 21st Illinois Volunteers, aged 22 years, Avas wounded at Rocky Face Ridge, Georgia, May 9th, 1864, by a missile which produced a fracture, without depression, of a portion of the frontal bone. Previous to this a ball passed through the body of the inferior maxillary bone, causing fracture, the destruction of four front teeth, and defective articulation. He was sent to the general hospital at Chattanooga, thence to hospital No. 8 at Nashville, and subsequently to the BroAvn Hospital at Louisville. Finally he was transferred to Quincy, Illinois, and was mustered out of service August 16th, 1864, and pensioned. A communication from Pension Examiner F. R. Paine, June 15th, 1869, reports patient "able to go about and seeming tolerably AArell," and rates his disability total, but not permanent in its present degree. Case.—Private M. Wilcox, Troop I, 6th NeAV York Cavalry, aged 22 years, Avas wounded at the battle of Boonsboro', Maryland, July 8th, 1863, by a projectile, which fractured the left parietal bone Avithout knoAvn depression or involvement of the brain. He remained in the field hospital until the 18th, when he Avas conveyed to hospital No. 1, Frederick, Maryland. Simple dressings Avere applied to the wound. On May 17th, 1864, he was transferred to Baltimore, and was transferred to the Veteran Reserve Corps, August 10th, 1884. He was discharged at Point Lookout, Maryland, (probably at expiration of term of service,) November 2d, 1864, and pensioned. On October 23d, 1867, Pension Examiner Thomas Williams reported that the patient's mental faculties Avere deranged and the functions ofthe brain disturbed, and rated his disability one-half and probably permanent. The following cases of gunshot fiacture of the cranial bones were accompanied by hemiplegia or paraplegia, and are selected from a large number of such cases : Case.—Corporal Charles Breitenbach, Co. K, 7th Ohio Volunteers, Avas struck by a musket ball in the squamous portion of the temporal bone Avhich entered the skull and wounded the brain, producing partial hemiplegia, at the battle of Antietam, Maiyland, September 17th, 1862. On October 5th, 1862. he was admitted to the hospital at SmoketoAvn, Maryland, and Avas discharged the cervice December 19th, 1862. In March, 1868, he Avas pensioned, his disability being rated total and temporary. Case.—Private Henry S------, Co. E, 118th Pennsyhrania Volunteers, aged 38, Avas wounded at the battle of the Wilderness, Virginia. May 9th, 1864, by a conoidal musket ball Avhich fractured and depressed the skull between the frontal DISABILITIES FOLLOWING DEPRESSED GUNSHOT FRACTURES 175 eminences. He Avas sent to the hospital ofthe 1st division, Fifth Corps, and on May 15th transferred to Washington, D. C, and admitted into the Mount Pleasant Hospital. So far, simple dressings only had been applied. On May 27th he Avas transferred to the Satterlee Hospital, Philadelphia. The day folloAving his admission, he was attacked with a profuse diarrhoea, and complained of pain in the head; was dull and droAVsy, and at times delirious. On June 1st his mental faculties were completely obscured, and paralysis of motion on the left side Avas observed, though there was hyperesthesia of the whole surface. Convulsions of an epileptic character occurred on the 2d, and it was observed that the muscular poAver of the left side was now restored, and that the right Avas paralyzed. The pupils, Avhich had hitherto been dilated, Avere now somewhat contracted; the tongue was dry ; the lungs full of coarse Wiles. Repeated convulsions recurred on the 4th, exhibiting the same remarkable features heretofore mentioned in respect to the side paralyzed. No control over the sphincters remained. Death occurred in the afternoon of June 4th, 1864. At the autopsy the fractured portion of bone Avas found to be ovoid in shape and corresponding in dimension to the external wound. There Avas a fracture of the inner table Avith depression of a portion near the longitudinal sinus to the depth of two lines, and a fissure extended into the frontal sinus. Beneath was a black slough of the dura mater, measuring two inches in length by one in Avidth. The anterior and lateral surfaces of the right hemisphere Avere bathed Avith pus, which also filled the great longitudinal fissure and the parts in the region of the ethmoid plates. At the base of the brain Avas an effusion of serum. The meninges on this side presented evidence of a high degree of inflammation, and could be easily separated in large patches from the convolutions, Avhich were slightly softened, one containing a large abscess. The membranes of the other side Avere little more than congested. Further than this the brain Avas healthy. The pathological specimen, an extraordinarily thin calvaria, is No. 2758, Sect. I, A. M. M., and was contributed, with the history, by Acting Assistant Surgeon W. W. Keen, jr. Case.—Private Charles Lucia, Co. A, 14th United States Infantry, Avas wounded at the battle of Gettysburg, July 1, 1863, by a missile Avhich entered the frontal bone a little to the right of the nasal eminence, and emerged from the outer canthus, destroying the eye, and fracturing the malar bone. He was admitted to the general field hospital at that place on the 3d, and on the 24th Avas transferred to the Mulberry street Hospital, Harrisburg, where meningitis supervened, causing death August 8th, 1863. The case is reported by Assistant Surgeon EdAvard CoAvles, U. S. A. Case.—Lieutenant William T. Simms, 82d NeAV York Volunteers, Avas wounded at the battle of the Wilderness, Virginia, May 6th, 1864, by a conoidal musket ball, Avhich penetrated the mastoid process of the left temporal bone and seriously injured the internal ear, leaving a small external opening. The missile, which was removed on the field, had become elongated. He Avas admitted to the hospital of the 2d division, Second Corps, and on May 16th, Avas sent to Washington for treatment. Until the latter date, he had been speechless; his intellect was greatly impaired. He partially recovered; on June 25th, was trans- ferred to the 59th NeAV York Volunteers as Major; April 18th, 1865, was mustered out of service. The Avound Avas still open, and there was partial paralysis of left side of face, and partial hemiplegia of right side. Case.—Private Lorenzo D. Kase, Co. G, 188th Pennsylvania Volunteers, aged 18 years, was wounded before Petersburg, Virginia, September 20th, 1864, by a conoidal musket ball, Avhich fractured the skull. He Avas at once conveyed to the general hospital at Fort Monroe; thence was sent on the 8th of October by steamer to the Lovell Hospital in Rhode Island. The details in the progress of the case are not recorded. He Avas discharged from service on May 22d, 1865. A communication from the Commissioner of Pensions, dated March, 1868, states that he is a pensioner, and that his disability is rated at two-thirds and permanent. A communication from Pension Examiner W. H. Bradley, dated July 21st, 1889, recommends an increase of pension because of paraplegia. Case.—Private Jesse Coty, Co. A, 6th Vermont Volunteers, aged 30 years, was Avounded before Petersburg, Virginia, April 2d, 1865, by a piece of shell, which fractured the posterior superior angle of the left parietal bone and injured the brain. On the same day he Avas taken to the regimental field hospital, and thence transferred to the Stanton Hospital at Washington, where he was admitted April 8th, 1835. The treatment, so far as recorded, consisted of simple dressings. He recovered, and was discharged July 1st, 1865. In July, 1868, he was pensioned for an incapacity resulting from dimness of sight and partial hemiplegia of the right side. His disability is rated three-fourths and permanent. Case.—Private Levi Bittenbender, Co. E, 95th Pennsylvania Volunteers, aged 22 years, Avas Avounded by a fragment of shell, at Spottsylvania Court House, May 13th, 1864, which fractured the right side of the cranium. He Avas at once admitted to the hospital of the 1st division, Sixth Corps; on the 24th, was sent to the 2d division hospital at Alexandria. On the 13th of June he was transferred to York, Pennsylvania. Paralysis of the lower extremities had ensued. On the 21st of September he Avas sent to the Turner's Lane Hospital at Philadelnhia, and on the 7th of October, 1864, he was discharged from service. Not a pensioner. Case.—Private Charles C. DreAv, Co. C, 16th Connecticut Volunteers, aged 18 years, was wounded near Plymouth, North Carolina, April 20th, 1864, by a fragment of shell, Avhich fractured a portion of the left parietal bone. He was taken prisoner, Avas exchanged October 20th, admitted to 2d division hospital at Annapolis, and thence he Avas transferred as folloAvs: On November 27th, to Patterson Park Hospital, Baltimore; on January 10th, 1865, to hospital at York, Pennsylvania; on February 9th, to Knight Hospital, New Haven, Connecticut, Avhence he Avas discharged the service June 9th, 1865, and pensioned. On June 6th, 1866, there was right hemiplegia with vertigo and general debility. Case.—Private Joseph A. Hall, Co. G, 16th Maine Volunteers, aged 27 years, Avas Avounded at the battle of Hatcher's Run, Virginia, February 7th, 1865, by a conoidal musket ball, which fractured the frontal bone Avithout causing depression. On the same day, he Avas admitted to the hospital of the 3d division, Fifth Corps; on February 10th, 1865, Avas sent to McKim's Mansion Hospital at Baltimore, and on March llth, 1865, Avas transferred to the hospital at York, Pennsylvania, Avhere he Avas discharged the serA-ice, May 16th, 1865, and pensioned. On July 24th, 1865, Pension Examiner A. Blossom reported the patient physically and mentally incapacitated, and hemiplegia of right side existing. He rated his disability three-fourths, and probably permanent. 17(5 WOUNDS AND INJURIES OF THE HEAD. Case.—Sergeant James R. Morrison, Co. K, 13th Ncav Hampshire Volunteers, aged 24 years, aa;is Avounded before Petersburg, June 23d, 1834, by a fragment of shell, which fractured a portion of the left parietal bone. He was admitted to the hospital of the Eighteenth Corps; thence, he Avas transferred as folloAvs: on the 25th, to the Chesapeake Hospital at Fort Monroe; on July 4th, by steamer, to Sixteenth and Filbert Streets hospital, Philadelphia; and on January 24th, 1865, to the Webster Hospital in Ncav Hampshire. Paralysis of the right arm and hand had supervened. He Avas discharged the service May 27th, 1665, and pensioned, his disability being rated one-half and permanent. Case.—Sergeant Slade Wooten, Co. C, 27th North Carolina Regiment, aged 24 years, received, in an engagement near Petersburg, Virginia, August 15th, 1864, a gunshot fracture of the left parietal bone severing the longitudinal sinus. He Avas retired on January 20th, 1865, by an examining board. The patient afterAvard suffered from partial paralysis of the left side accompanied by intense headache, and Avas 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.—Private John Oxspring. Co. G, 109th Pennsylvania Volunteers, aged 36 years, Avas wounded at the battle of Chancellorsville, Virginia, May 1st, 1863, by a conoidal musket ball, Avhich fractured the frontal bone betAveen the eminences probably causing a depression of the inner table. He was conveyed to Washington, and on the 6th Avas admitted into Lincoln Hospital, where the Avound was properly dressed. Frequent epileptic convulsions ensued after a time. In July he Avas transferred to the Cuyler Hospital, near Philadelphia, Avhere he continued under treatment until the 24th of March, 1861, Avhen he was transferred to the Turner's Lane Hospital. The convulsions continuing, resort was now had to the introduction of an issue pea in the back of the neck, Avhich, however, failed to afford relief, and was soon withdraAvn on account of a severe attack of erysipelas folloAving. On May 19th, 1864, he was discharged from serA-ice. In January, 1868, his disability Avas rated as three-fourths and permanent. The case is reported by Acting Assistant Surgeon W. W. Keen. Case.—Sergeant John Daley, Co. C, 57th Massachusetts Volunteers, aged 36 years, Avas wounded in the head at the battle ofthe Wilderness, Virginia, May 6th, 1864, by a conoidal musket ball. He was sent to Washington on the 16th, and was admitted into the Lincoln Hospital, where no fracture Avas suspected. On July 18th he Avas sent north, and on August 25th Avas admitted to the hospital at Readville, Massachusetts. On October 24th he was sent to the Dale Hospital, Worcester Avhere it Avas ascertained that the frontal bone Avas fractured and depressed. Convulsions of an epileptiform character supervened, but the patient finally recovered, and Avas discharged the service January 16th, 1865. He was pensioned, and on July 20th 1867, was reported by Pension Examiner Oramel Martin, to be completely and permanently disabled. Case.—Corporal Otis G. Straub, Co, I, 98th Ohio Volunteers, aged 26 years, was wounded at Chaplin's Hill, Kentucky, October 8th, 1862, by a fragment of shell, which fractured and slightly depressed the frontal bone at its centre. Remaining at the field hospital about one month, he was sent to Hospital No. 1, Lebanon, Kentucky, on November 10th, and two days aferward was transferred to Hospital No. 18, Louisville. On January 10th, 1863, the patient Avas admitted to the hospital at Gallipolis Ohio, and on October 12th, 1863, was transferred to the Veteran Reserve Corps, still subject to epileptic convulsions, which followed any active exertion. His name is not upon the Pension List. Case.—Corporal Ludwig Schweitzer, Co. E, 12th New Jersey Volunteers, aged 23 years, was wounded before Petersburg Virginia, October 20th, 1864, by a conoidal musket ball which fractured a portion of the frontal bone on the ri»ht side He was sent to the hospital ofthe 2d division, Second Corps. On the 22d was sent to the depot field hospital at City°Point and on December 15th was transferred to Washington, D. C, and admitted on the following day into the Finley Hospital The treatment so far as recorded was expectant. On the 5th of March, 1865, the patient was transferred to the hospital at Beverly Jvew Jersey, thence was sent on the 5th of April to the White Hall Hospital, Bristol, Pennsylvania, and was discharged the service May 17th, 1865, and pensioned, his disability being rated total and permanent. Subsequent information shows that the patient suffered constant pain, vertigo upon slight exertion, and epileptiform convulsions. r •CTrJ^jiTb Yager'f?.K1,i ^i1- 0hi° V°lunteerS' a°ed 23 W was wounded in an engagement near Atlanta, Georgia July 20th, 18o4 by a conoidal ball which fractured the os frontis over the left eye. He was admitted to the hospital of the 3d division, Twentieth Corps, and on July 25th, he was sent to hospital No. 3, Chattanooga, where he remained until April llth, !<*>, when he Avas transferred to hospital No. 1, Nashville. Epilepsy had supervened. On May 4th he was sent to the Crittenden Hospital, Louisville, Kentucky; on June 13th, to the BroAvn Hospital of the same city; and on June 22d, to Camp Dennison, Ohio, where he Avas mustered out on July 18th, 1865. T 1CR«rJ'^C7l rlG,eT-f i^' C°; B.' 1Si L°UiSkna V°lunteers> ™*™d a gunshot wound of the head at Port Hudson, June 1863. On July 24th. 18o3 he was admitted to St. Louis Hospital, New Orleans, and was discharged the service 0.t»be 22d lso3, and pensioned. His disability Avas complicated with hemiplegia and epilepsy, and Avas rated, on October 22,1, 1863, by Pension Examiner George Kellogg, as total and permanent, " A tCmh ^7'If 1 "^"^f' ^^ D' 6th XCW Y°rk CaVdry' WaS admitted t0 the Harewood HbBpital, Washington, August 17th, 1863, with a fracture of the cranium, produced by a piece of shell, and on October 28th, he was sent to DeCamp hospital. Epilepsy supervened, and on January 8th, 1864, he was discharged the service. He subsequently re-enlisted, but the epilepsy continuing, he Avas again discharged from service, May 21st, 1864. Not a pensioner. CASE.-Private James T. Gammon, Co. K, 2d New Hampshire Volunteers, was wounded at Bull Run, August 29th, 1862, by buckshot, which fractured the cranium at the junction of the coronal and sagittal sutures, and slightly depressed the external able Cold water dressings Avere applied. On September 2d, the patient was conveyed to Philadelphia, and was received into the Broad and Cherry Streets Hospital on the following day. The missile was found lodged at the seat of fracture and w„ DISABILITIES FOLLOWING DEPRESSED FRACTURES OF THE SKULL. 177 removed. The case progressed satisfactorily. Near the end of October, however, a necrosed fragment of the external table, which had caused considerable irritation, Avas extracted. He Avas returned to duty on March 4th, 18(5:5. On January 1st, 18(54, he re-enlisted, and at the battle of Cold Harbor, June 3d, 1*34, Avas Avounded in the hand. He was admitted to the Finley Hospital at Washington, on June 8th, and Avas transferred to Knight Hospital at Ncav Haven, Connecticut, on June 19th, 1864. He Avas still suffering from the original injury of the head and Avas subject to epilepsy. He Avas transferred to Concord, Ncav Hampshire, AA'here, on May 20th, 1865, he Avas discharged the service and pensioned, his disability being rated three-fourths, and probably permanent. Assistant Surgeon John Neill reports the case. Case.—Sergeant Charles H. Norton, Co. D, 157th New York Volunteers, aged 23 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal musket ball, Avhich struck the right side of the head. He was admitted to a field hospital on the same day. The injury seemed very slight, and he was probably soon returned to duty, as no record of the case can be found until October 6th, 1864, Avhen he Avas admitted to the Hilton Head Hospital, Avhere a fracture of the right parietal bone Avas discoA-ered. Simple dressings Avere applied, and'on November 21st, the patient was returned to duty; but, on February 18th, 1865. he Avas again received into the hospital at Hilton Head, suffering from epilepsy. He Avas finally discharged from service on March 30th, 1865, and pensioned, his disability being rated total and doubtful. On June 25th, 1868, Pension Examiner G. W. Bradford reports the Avound still discharging, Avith epileptic fits from time to time, causing physical and mental disability. Case.—Private John Rummerfield, Co. F, 51st Illinois Volunteers, aged 35 years, was Avounded at the battle of Chick- amauga, Georgia, September 20th, 1863, by a conoidal musket ball, which fractured a portion of the left parietal bone above the eminence. He remained in the field hospital until October 20th, when he was sent to the hospital at Stevenson, Alabama, and thence, on October 23d, to hospital No. 13, at Nashville. He continued in the hospitals of that city until the latter part of January, 1864, Avhen he Avas sent to Camp Parole. He was discharged the service on February 3d, 1865, and pensioned. On November 15th, 1867, Pension Examiner D. L. Dieffenbach reported that the wound was covered with integuments, which were soft and painful; that the patient had attacks of epilepsy, and was unsteady in his gait; and that there was partial hemi- plegia of right side, and impairment of memory. His disability is rated two-thirds and permanent. Case.—Private James Rouey, Co. G, 15th Alabama Infantry, received a gunshot fracture of the temporal bone. He was admitted to the No. 9 hospital, Richmond, July 14th, 1863. Epilepsy resulted. The subsequent history and disposition of the patient is unknoAvn. Case.—Private Daniel P. Roth, Co. A, 42d Indiana Volunteers, aged 26 years, received, in an engagement near Resaca, Georgia, May 24th, 1864, a gunshot fracture of the frontal bone. He Avas conveyed by Avay of Chattanooga to Nashville, Tennessee, and admitted to hospital No. 1, on May 27th, 1864. The injury healed rapidly, and the patient Avas returned to duty on August 4th, 1864. The wound, however, reopened, and he was admitted to the hospital of the 1st division, Fourteenth Corps, on September 24th, but was again returned to duty on October 12th, 1864. On January 30th, 1865, he was, for the third time, sent to a hospital. He was this time admitted to the post hospital at Bridgeport, Alabama, where he died from epilepsy on March 14th, 1865. Case.—Private Adolph Stahl, Co. B, 119th New York Volunteers, aged 20 years, Avas Avounded at Fredericksburg, May 3d, 1863, by a piece of shell, which fractured the right parietal bone. He was treated in the field hospital for several Aveeks, and on June 16th, he was admitted to the Lincoln Hospital at Washington, suffering from epilepsy. On July 9th, he Avas conveyed to Philadelphia, and was admitted to the Christian Street Hospital. Epilepsy continued. In March, 1864, he Avas transferred to the Turner's Lane Hospital, and on May llth, 1864, Avas discharged from service. Not a pensioner. Case.—Private Lucius Veasey, Co. G, 5th New Hampshire Volunteers, was wounded at Antietam, September 17th, 1862, by a fragment of shell, which caused a compound fracture of the occipital bone. On October 4th, he was admitted to hospital No. 1, at Frederick, Alaryland, where he was discharged the service April 22d, 1863. In March, 1868, he received a pension on account of incapacity resulting from epilepsy. His disability was rated total and permanent, by Examining Surgeon Thomas Sanborn, of the Pension Bureau. Disorders of the nerves of special sense often followed depressed gunshot fractures of the skull, lesions or functional derangements of the optic and auditory nerves being the most common. The subject will be more fully discussed in connection with penetrating and perforating wounds of the skull, but a few cases may be adduced here. Various forms of impaired vision were of very frequent occurrence after depressed fractures of all portions of the periphery of the cranium: Case.—Private Absalom Mower, Co. G, lilth Ohio Volunteers, aged 23 years, was wounded at the engagement at Atlanta, Georgia, July 24th, 1864, by a conoidal musket ball, which fractured the cranium over the right eye. He was taken to the hospital of the TAventy-third Corps, and was transferred as follows: on August 8th to the Holston Hospital, Knoxville Tennessee; on November 28th, to hospital No. 8, Nashville; on December 1st, to Jefferson, Indiana; and on April 26th, 1865' to the hospital at Cleveland, Ohio, where he Avas mustered out of service on June 9th, 1865. The sight of the right eye had been partially destroyed. Case.—Private William Slantinger, Co. A, 41st New York Volunteers, aged 20 years, Avas Avounded at Gettysburg, July 3d, 1863, by a fragment of shell which fractured the os frontis. He was admitted into the Satterlee Hospital, at Philadelphia, on the 5th, Avhere simple dressings Avere applied. Partial blindness resulted. He was discharged from service December 30th, 1863. Surgeon I. I. Hayes, U. S. V., reports the case. Not a pensioner. 23 ITS WOUNDS AND INJURIES OF THE HEAD. Case.—Private Abraham Strauss, Co. C, 31st Ncav York Volunteers, was admitted, on October 31st, 1662, to Camp Hanks, near Alexandria. Virginia, with a gunshot fracture of the parietal bone. He was discharged the service November 29th, 1862. and pensioned. Subsequently to the patient's discharge. Pension Examiner E. Bradley reports him suffering from vertigo and impaired sight in the left eye, also valvular disease of the heart, and rates his disability total and permanent. Case.—Private Charles Owen, Co. F, 179th New York Volunteers aged 31 years, avus wounded near Petersburg, Virginia, June 17th, 1864, by a piece of shell which fractured the right parietal bone. On the same day, he Avas admitted to the hospital of the 1st division, Ninth Corps; thence Avas conveyed to Washington, and admitted into the Mount Pleasant hospital on July 2d. On July 22d, he Avas transferred to the MoAver Hospital at Philadelphia. Simple dressings, tonics and stimulants Avere employed in the course of the treatment. He Avas discharged from service June 10th, 1865. Pension Examiner Barchvell reports on February 1st, 1668, that the patient's vision was impaired and that he Avas subject to nausea and prostration when excited. He rated his disability as one-half and probably permanent. Case.—Private Lyman B. Pollard, Co. G, 16th Maine Volunteers, was Avounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a conoidal ball, which fractured the left parietal bone at its anterior superior angle. He Avas admitted to hospital 2d division, First Corps, and on December 19th was sent to Fairfax Seminary Hospital, where he was discharged on March 31st, 1863, and pensioned. On February 23, 1866, Pension Examiner James Bell reported that exfoliation of bone has occurred from time to time, and that the patient suffers much from pain and vertigo. Plis disability was then rated at three- fourths and permanent. On October 9th, 1866, Pension Examiner John Benson reported that the exfoliation still continues and that the vision of the right eye is materially affected. His disability is rated total. Case.—Private George R. Williams, Co. I, 1st Wisconsin Cavalry, Avas Avounded at Jonesboro', Arkansas, August 2d, 1862, by a projectile which fractured and tore away a portion of the occipital bone near the protuberance. On November 29th he Avas admitted to the post hospital at Detroit, Michigan, and Avas discharged the service November 29th, 1862, and pensioned. Pension Examiner W. F. Breakey, under date of January 22d, 1870, reported the patient suffering from partial amaurosis and loss of memory, with great nervous prostration, and rates his disability total. Case.—Private Hugh Ward, Co. H, 2d Massachusetts Volunteers, Avas wounded at Gettysburg, July 2d, 1863, by a conoidal ball, which fractured the cranium at the vertex. He was admitted to the Satterlee Hospital, Philadelphia, on the 7th; thence, on August 4th, was transferred to the Mason Hospital at Boston. Simple dressings only were required, and the wound healed in a short time. The patient, hoAvever, Avas unable to undergo any severe exertion, as it would immediately produce dizziness. He was discharged from service on October 1st, 1863, and pensioned in consequence of total disability, the result of impaired vision and nervous derangement. Case.—Private Morris Wingler, Co. C, 26th Wisconsin Volunteers, was wounded at Gettysburg, July 1st, 1863, by a musket ball, Avhich penetrated the frontal bone near the right eminence, and exposed the membranes. He was sent to a field hospital, and on July 8th, Avas sent to South Street Hospital, Philadelphia, where the ball Avas extracted. The patient had nearly recovered by September 29th, 1864, Avhen he was transferred to the Veteran Reserve Corps. He was discharged the service, June 30th, 1865, and pensioned. A subsequent report from Pension Examiner L. D. Mcintosh informs that bony union has not taken place; that the patient has dimness of vision in the right eye, with pain and dizziness, and rates his disability total and permanent. Case.—Sergeant William McKenzie, Co. D, 4th Michigan Volunteers, aged 30 years, Avas wounded at the Wilderness, on May 5th, 1864, by a conoidal ball, which fractured the right external angular process of the frontal bone. He Avas conveyed to Washington, and admitted, on the llth, into the Stanton Hospital; thence was transferred, on the 18th, to the Satterlee Hospital at Philadelphia. The sight of the eye Avas partially destroyed. The case progressed favorably, though there was a slight discharge from the wound. On examination, the ball was found lodged in the bone, and on the 16th of June, the opening was enlarged and the missile, firmly imbedded in the orbital ridge, extracted. The patient recovered rapidly, and on August 3d, 1864, Avas transferred to Adrian, Michigan, to be mustered out, his term of service having expired. A communication from the Commissioner of Pensions, dated December 8th, 1869, states the patient has nearly lost the sight of his right eye and suffers from hemicrania, OAving to Avhich he receives a pension, his disability being rated five-eighths and permanent. Case.—Private James Baker, Co. G, 10th Louisiana Infantry, received a gunshot wound of the temporal region, causing depressed fracture of the skull, on November 26th, 1863. He was admitted to the Louisiana Hospital, Richmond. Blindness resulted. The subsequent history and disposition of the case is unknoAvn. Case.—Private William Wolven, Co. B, 98th New York Volunteers, aged 17 years, was Avounded in front of Petersburg, June 24th, 1864, by a conoidal ball, Avhich fractured the frontal bone over the left eye. He was admitted to the hospital of the Eighteenth Corps, and on June 25th Avas sent to Hampton Hospital, Fort Monroe; on July 19th, to Lovell Hospital, Portsmouth Rhode Island, and on August 22d to Ira Harris Hospital, Albany, New York, where he was discharged the service June 30th, b-65, and pensioned, his disability being rated one-fourth and probably permanent. A report from Pension Examiner A. Hasbrouck, about one year subsequently, says that the patient's condition, both physical and mental, appears good, but that he cannot bear exposure to heat. The wound had impaired his eye-sight. Case.—Private George W. D. Bair, Co. II, 55th Hlinois Volunteers, Avas admitted to the Marine Hospital, Chicago, Illinois, with a gunshot fracture of the occipital bone at the right of the protuberance. He was discharged from service October 17th, 1862, and pensioned. He had partial amaurosis of right eye, and frequent attacks of neuralgia. His disability is rated three-fourths and temporary. Case.—Private Jeremiah N. Featherstone, Co. G, 70th Indiana Volunteers, aged 22 years, Avas wounded at the affair of Golgotha, Georgia, June loth, 1864, by a fragment of shell, which produced a fracture of the frontal bone, with but slight depression. He was treated in division hospital, was sent, via-Chattanooga, to Nashville, and was admitted to hospital No. 14 on the 25th. On September 3d, he avus sent to the City Hospital at Indianapolis, and on March 6th, 1865, was discharged from DISABILITIES FOLLOWING DEPRESSED FRACTURES OF THE SKULL. 179 service. On March 10th, 1865, Pension Examiner G. M. Mears reported the Avound entirely healed, but painful after mental or physical excitement. The patient's sight and hearing Avere much impaired, and he Avas incapacitated for any kind of Avork. His disability Avas then rated three-fourths and doubtful. Case.—Private George Nash, Troop L, 1st Michigan Cavalry, aged 24 years, Avas Avounded at Dinwiddie Court House, Virginia, by a pistol ball, Aviiich caused a compound comminuted fracture of the external table of the left parietal bone near the lambdoid suture. On April 1st, he Avas admitted to the hospital of the cavalry corps; on April 4th, sent to the Mount Pleasant Hospital, Washington; and on May 22d, 1865, was transferred North. He Avas discharged May 30th, 1865, and pensioned. Pension Examiner M. L. Green reported on November 19th, 1868, that the patient suffers from impaired vision and disturbance of the cerebral functions. His disability is rated at three-fourths and permanent. In many cases of gunshot fractures of the temporals, occipital, and parietals, partial or total deafness resulted. The following cases are examples: Case.—PriA-ate F. W. Clayton, Co. I, Palmetto Sharp-shooters, aged 22 years, a healthy and robust man, was Avounded in an engagement near Petersburg, Virginia, October 7, 1664, by a conoidal ball which fractured the occipital and right parietal bones. The missile struck directly over the lambdoid suture, producing a linear fissure of the outer table, and comminuting and depressing the inner. He Avas insensible for tAventy-four hours, but was not paralyzed. The loose spiculae of bone Avere removed and simple dressings applied. The patient was sent to Richmond, where more fragments Avere removed as they became detached, and occasionally a disinfecting lotion Avas applied. On December 15th the Avound had cicatrized, and the patient Avas sent home. For two months he had constant neuralgia of the head, face, and neck on the right side, and was a little deaf; the deafness being aggravated by the severity of the neuralgic symptoms. In March, 1866, he was perfectly healthy, but incapable of much exertion, either mental or physical. Vertigo and dizziness would attack him on suddenly stooping, or on continued excitement of mind. He could not indulge in stimulants. His deafness was gradually disappearing. The case Avas recorded by Surgeon F. S. Parker, P. A. C. S. Case.—Private William Harlin, Co. A, 116th Pennsylvania Volunteers, was Avounded at Chancellorsville, May, 3d, 1863, by a piece of shell, which fractured portions of the left temporal and occipital bones. On May 6th, he Avas admitted to hospital of the 2d division, Second Corps; on June 14th, was sent to Point Lookout Hospital, Maryland; and on October 1st, to MoAver Hospital, Philadelphia. He improved steadily, and was discharged on February 9th, 1864, and pensioned. The patient was deaf, had a constant roaring in his head, and could not bear exposure to the sun. His disability is rated one-half, and probably permanent, by Pension Examiner J. H. Gallagher, M. D. Case.—Private Charles Roche, Co. D, 1st Wisconsin Cavalry, aged 21 years, was Avounded near Buzzard Roost, Georgia, May 8th, 1664, by a conoidal musket ball Avhich fractured a portion of the right parietal bone. He Avas admitted to the hospital of the 1st division, Cavalry Corps; on May 12th he was sent to hospital No. 1, Nashville, Tennessee, and on May 16th Avas transferred to Clay Hospital, Louisville, Kentucky, whence he was furloughed October 23, 1864. He Avas readmitted November 23d, 1864, and discharged the service March 23d, 1865, on account of deafness and otorrhcea. Case.—Captain William H. Winsor, Co. F, 18th Massachusetts Volunteers, Avas wounded by a shell at the battle of Fredericksburg, December 13th, 1862, which fractured a portion of the left side of the cranium. He was admitted to the hospital of Griffin's diAdsion, Fifth Corps, and thence was sent to Washington for treatment. He resigned March 15th, 1863. The power of hearing was somewhat impaired. Case.—Private Peter Peterson, Co. D, 100th Illinois Volunteers, aged 24 years, was wounded in the head, at the battle of Chickamauga, Georgia, September 19th, 1863, by two balls; the first lodging betAveen the tables of the frontal bone near the vertex; the second taking effect in the left parietal and occipital bones, causing fracture without known depression. On Septem- ber 21st, he was admitted to the field hospital at Chattanooga, where he remained under treatment until October 3d, when he was taken to Stevenson, Alabama; thence he Avas transferred, on October 12th, to hospital No. 14, Nashville. On January 19th, 1864, he Avas sent to the Marine Hospital, Chicago, Illinois, and was discharged from service on April 2d, 1864, and pensioned. On April 20th, 1864, Pension Examiner J. McCann reports that the wound has healed, leaving an indentation in the skull, and that the patient's hearing is imperfect. His disability is rated three-fourths and permanent. Case.—Private James Fitzgerald, Co. C, 81st New York Volunteers, aged 29 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball which entered the anterior part of the right squamo-parietal suture, passed downward and backward, and cut off the right ear. He was admitted to the hospital of the 1st division, Eighteenth Corps, and was transferred, on June 8th, to the 2d division hospital, Alexandria, and on June 12th, to the hospital at Chester, Pennsylvania. He Avas discharged January 3d, 1865, and pensioned, owing to deafness in the right ear, headache, and dizziness, Avhich partially incapacitated him for work. His disability is rated one-fourth and temporary. Case.—Private Charles Rowe, Co. K, 139th New York Volunteers, aged 21 years, was Avounded at the battle ot Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, which fractured a portion of the left parietal bone. On the same day, he was admitted to the field hospital of the Eighteenth Corps, and transferred as folloAvs: on June 8th, to the Fairfax Seminary Hospital; on June 29th, to the McClellan Hospital, Philadelphia; on December 10th, to the Filbert Street Hospital; and on May 12th, 1865, to the Satterlee Hospital, where he Avas discharged on June 16th, 1865, and pensioned. On October 30tb, 1865, Pension Examiner Charles Rowland reported the patient suffering from partial deafness, constant pain in the head, and impaired memory. He rates his disability one-half, and temporary. Case.—Private Richard Ridgely, Co. H, 54th Massachusetts Volunteers, (colored,) Avas Avounded in the engagement at Olustee, Florida, February 20th, 1864, by a conoidal musket ball which entered the left ear and passed through the mastoid process. On February 22d he Avas admitted to the hospital at Jacksonville, Florida, and on February 26th he was sent to the hospital at Beaufort, South Carolina, at which time there Avas some discharge from the ear and pain in the head, with obstinate ISO WOUNDS AND INJURIES OF THE HEAD. constipation. The patient Avas treated on the expectant plan, under AA-hich there Avas marked improvement by March 31st, and on July 10th, 1S61. he Avas returned to duty, though still deaf. (_\vse.__Private R. XV. Wilder, Co. H, 7th Ncav York A'olunteers, Avas wounded at Fredericksburg, December 13th, 1862, by a conoidal musket ball Avhich passed from behind forward through the mastoid process and the concha. He also received a Avound in the right side of the abdomen, near the terminal costal cartilages. The patient Avas conveyed to the hospital of the 1st division, Second Corps, where cold Avater dressings were applied. On December 20th he Avas sent to Lincoln Hospital, Washington, and on January 17th, 1863, Avas transferred to the HoAvard Hospital. He recovered, except from the deafness of the right ear, and was returned to duty on April llth, 1863. Case.—Private William Thompson, Co. B, 48th Georgia Regiment, received a gunshot fracture of the head at the battle of Chancellorsville, May 3d, 1863. He was admitted to hospital No. 16 at Richmond, and recovered, with the exception of defective audition of the left ear. He was allowed to go home on June 6th, 1863. In the following case the sense of taste was lost as well as the sense of hearing: Ca^e.—Sergeant William B. Hutchinson, Co. F, 12th New Jersey Volunteers, was Avounded at Chancellorsville, Virginia. May 3d, 1863. The missile entered in front of the external meatus, and lodged in the internal ear. He Avas admitted to the hospital of the 3d division, Second Corps; on May 9th, Avas sent to Carver Hospital, Washington, and on June 27th, to South Street Hospital, Philadelphia, whence he Avas discharged the service, April 6th, 1865, and pensioned. The ball remained in the Avound, and could be felt in its place of lodgment. The sense of hearing was completely lost in the injured ear, and the patient had lost the sense of taste and suffered from vertigo. Balls Splitting on the Cranial Bones.—Military surgeons have long known that it was not very uncommon for musket balls impinging obliquely upon the skull to be split. According to the velocity of the ball, it would be partially or completely divided. In the former case the missile would remain astride, as it were, of the wall of the skull; in the latter, one fragment would penetrate into the brain cavity and the other would fly off or lodge under the aponeuroses or scalp. Larrey and Hennen and Guthrie refer to such instances. It was believed by Macleod and others that with the general introduction of the conoidal ball, such forms of injury would be seldom observed; but experience has shown that, when moving at a low rate of velocity, the elongated ball is as liable to split on striking sharp angles of bone as the round ball. Mr. Wall, surgeon of the 38th, and Dr. Longmore, of the 19th British regiments, record1 examples from the Crimean cam- paign of conical balls splitting on the cranial bones. The Army Medical Museum possesses many such specimens. In addition to those referred to at page 163 and page 170 of this work, the histories connected with a few others of the more interesting specimens may be noted: Case.—Lieutenant Charles W. Burd, Co. F, 4th Maine Volunteers, aged 26 years, was admitted to the Hygeia Hospital at Old Point Comfort, Virginia, on February 20th, 1862, from the prison in Richmond in which he had been incarcerated. He had been struck at the first battle of Bull Run, July 21st, 1861, on the left side of the frontal bone by a round musket ball, aud Avas supposed by his comrades to have been mortally Avounded. He was made a prisoner and conveyed to Richmond. A projection Avas felt under the scalp about four inches from the wound in the integument and an incision Avas made over it, from AA'hich half a bullet with a polished cut surface Avas extracted. He remained seven months at Richmond, during Avhich time the Avound in his forehead continued open and suppurated freely. On his release he was examined at the hospital at Fort Monroe, by Surgeon John M. Cuyler, U. S. A., who discovered a metallic substance deep in the Avound, after dilating the small fistulous opening by tents and an incision upward. The foreign body was extracted and proved to be a portion of the ball having imbedded in it a small fragment of bone. On February 27th, after repeated efforts, the remainder of the ball was extracted and a piece of the inner table of the skull which had been driven before the ball Avas also removed. It Avas found that the ball having split upon the external table, and one-half passing imvard, impinged against the inner table, and again Avas nearly divided and firmly embraced a portion of the inner table in the fissure thus formed. On February 28th tAvo pieces of the inner table Avhich had been driven down before the ball, Avere extracted, one measuring ten lines in length and five lines in breadth, the other piece Avas small. The patient afterAvards came under the care of Dr. John Mason Warren, of Boston, who has printed an account of the case in his instructive work.2 The case is also reported in the surgical report in Circular 6, of this Office, for 1865.;J Lieutenant Burd recovered and rejoined his regiment and served during the Avar, and Avas mustered out on August 2d, 1866. and pensioned. Pension Examiner John G. Brookes reports in July, 1667, that this officer had fullness and giddiness of the head, and some pain and mental dullness if he took cold. He resided at Belfast, Maine, and his disability was rated at three-fourths and permanent. The history of the case is compiled from various sources, the notes at Fort Monroe being recorded by Medical Cadet Charles A. DeA-endorf, V. S. A. i Addenda to the Sixth Edition of Guthrie's Commentaries, p. 64~', et seq. -Warren, Surgical Observations and Cases, Boston, 1867. p. 543. "Circular No. 6, S. O. 0., 1865, p. 18. GUNSHOT FRACTURES OF BOTH TABLES OF THE SKULL. 181 Case.—Corporal John N-----, aged 18 years, Co. II, 159th NeAV York Volunteers, was struck on the left side of the forehead, on April llth, 18(53, an in engagement at Irish Bend, Louisiana, by a round musket ball. He was admitted to the University Hospital, at New Oilcans, on April 17th. The ball had been removed on the field. Several depressed fragments of bone were removed, and cold water dress- ings Avere applied. The case progressed Avithout a bad symptom until April 30th, when there Avere clonic spasms, which, after a feAV hours, were followed by a semi-com- atose condition, which continued until death, on May 2d, 186:5. A necroscopic examina- tion revealed extensive meningitis, and a large abscess of the left cerebral hemisphere. The lateral ventricles were filled Avith sero- purulent matter. The surfaces of the pons i Varolii and of the medulla oblongata Avere covered with lymph. The specimen H. Conner, U. S. A., and is represented in the adjacent wood-cuts, (Fig. 93 Fio. 93.—Section of a frontal bone, with a split musket ball impacted at the left frontal eminence. Spec. 1293, A. AI. AI. Pig. 94.—Interior view of specimen No. 1293, A. M. M. Avas forwarded by Assistant Surgeon P and Fig. 94.) Case.—Private C. C. W----, Co. I, 6th Wisconsin Volunteers, aged tAventy-one years, Avas Avounded at Spottsylvania, May 12th, 1864, and Avas taken to the field hospital of the 4th division of the Fifth Corps, and after the application of cold lotions to the scalp, Avas sent to City Point, and thence to Washington, where he was admitted into Douglas Hospital four days after the reception ofthe injury. Here it Avas ascertained that the cranium was fractured; but the symptoms Avere not urgent, being limited to slight paralysis of the right upper extremity, and operative interference was deferred. On May 31st a conoidal musket ball and se\-eral fragments of the left parietal were removed by Assistant Surgeon W. F. Norris, U. S. A. One large fragment of the vit- reous plate "was pressing on the dura mater; and this was elevated and re- moved. The next day, symptoms of compression of the brain were mani- fested. An exploration of the wound was made, and a quantity of pus was evac- uated. On June 4th, 1864, twenty-three days after the injury, the case terminated fatally. At the autopsy the arachnoid was found little altered. There Avas an abscess in the posterior lobe of the left hemisphere, near the longitudinal sinus, of the size of a Avalnut, with Avails of a greenish-yellow color, and communicating with the lateral ventricle. The right ventricle Avas filled with sero-sanguinolent fluid. There was a deposition of lymph at the base of the brain, extending from the medulla oblongata to the optic commissure. The specimen and facts connected with it were contributed by Assistant Surgeon William Thomson, U. S. A. The inner surface of the left parietal, near the fracture, is carious. Externally both parietals present over their entire surface the traces of the results of periostitis. Fio. 95.—Skull-cap, fractured near the vertex, by a musket ball which has split. Spec. 3543, Sect. I, A. Ai. M. FIG. 96.—Interior view of the specimen, No. 3543, A. M. AI. CASE.-Sergeant J. N. H------, Co. K, 19th Maine Volunteers, aged 36 years, was struck on the right side of the head by a musket ball, in a skirmish at Morton's Ford, on the Rappahannock, February 6th, 1864. The ball was smoothly cut in two, one half lodging under the scalp, and the other passing into the brain. The patient was perfectly rational until February llth, Avhen his mind Avandered at times. On the 12th, Surgeon Justin DAvinelle, 106th Pennsylvania Volunteers, extracted the fragment of the ball which had buried itself in the brain. Its track communicated with the right lateral ventricle. The other portion of the ball had been removed from under the scalp immediately after the injury. When the patient recovered from the influence of the chloroform, he avrs rational, and continued so for tAventy-four hours or more; but coma came on gradually, and death took place on February 15th, 1864. The left ventricle was found filled Avith pus. The specimen Avas contributed by Dr. Dwinelle, and is figured in the adjacent Avood-cuts, (Figs. 97 and 98.) Fig. 97.—Section of right parietal on which a conoidal musket ball has split. Spec 2121, Sect. 1, A. Ai. AI. Fig. 98.—Interior view of speci- men 2121, Sect. I, A. AI. AI. 182 WOUNDS AND INJURIES OF THE HEAD. Case.—Sergeant Simon B. Scholl, Co. E, 82d Pennsylvania Volunteers, aged 21 years, was Avounded at the battle of Spottsylvania, May, 1864, by a musket ball Avhich penetrated and fractured the frontal bone a little to the left of and involving the median line, making an opening three-fourths by one-half inch; then split into two parts, one of Avhich lodged beneath the scalp at a corresponding point on right side, the other splintered the crista galli in its course and lodged just over the ethmoidal cells, the roof of Avhich it partially destroyed. The patient Avas insensible a short time previous to being admitted to the 3d division of the Sixth Corps Hospital. On May 24th he Avas sent to Mount Pleasant Hospital, Washington, and on May 30th to Cuyler Hospital, Philadelphia. On admission to the latter hospital he was much exhausted and depressed, becoming toAvards evening feverish, with pain in head. A portion of the ball Avas removed from beneath the scalp by counter opening. For tAvo Aveeks the only prominent symptoms Avere headache, constipation, and vomiting, folloAved afterward by insomnia and great jactation. On June 18th the patient became almost completely comatose. He could be aroused only Avith difficulty and relapsed almost immediately. The left pupil became contracted, Avhile the right was Avidely dilated, both being insensible to light. He died June 18th, 1864. At the autopsy the membranes Avere found to contain a fine arterial injection, the venous trunks also being considerably engorged. The brain presented a moderate degree of interstitial congestion. A large abscess Avas found in the lower part of the anterior lobe of the right hemisphere, containing about three ounces of greenish, flocculent pus, mingled with broken-doAvn brain substance. Several spiculaj of bone were found penetrating the membranes, and a small clot of coagulable lymph shoAved at once the original seat of injury, and the point at which suppuration had begun. A point of interest in this case was the rudimentary state of the frontal sinus, an anatomical variation from the customary condition, to Avhich may probably be attributed the fatal result, since the portion of the ball which in this case pene- trated the cranium, would in an ordinary skull have lodged in the frontal sinus. The case is reported by Assistant Surgeon Henry S. Schell, U. S. A. Case.—Private Thomas Spratt, Co. G, 2d California Cavalry, was Avounded in Owens' Valley, California, April 10th, 1863, Avhile fighting Indians, by a tAvo and a quarter ounce ball, which entered the skull one inch and a quarter above the outer angle of the right eye, driving fragments of bone into the brain. The missile split, one part going beneath the scalp for one inch, and the remainder entering the brain. At the end of April, 1863, the patient Avas Avalking about, doing well. He was discharged September 27th, 1864, and his name does not appear on the pension list. The case is reported by Assistant Surgeon G. H. Horn, 2d California Cavalry. The following patients, with depressed gunshot fracture of the cranium, recovered without any disability, and were returned to duty: Case.— Private John Woods, Co. H, 63d Pennsylvania Volunteers, aged 29 years, was wounded at the battle of Bull Run, Virginia, August 29tht 1862, by^ a buckshot Avhich fractured and depressed the right frontal eminence, causing a Avound of the scalp about an inch in extent, to which cold water dressings Avere applied. The patient was sent to Philadelphia, and Avas admitted into the Broad and Cherry streets Hospital, his general condition being good. The case progressed satisfactorily until September 9th, Avhen the patient was seized with violent headache, followed by convulsions, insensibility, and stertorious breathing. At the end of tAventy-four hours consciousness returned ; his intellect, however, remained dull. Twice subsequently convulsions of a few minutes duration occurred. The wound healed rapidly, and about the end of October a hard substance Avas observed beneath the integuments near the seat of injury, which was removed, and proved to be a flattened buckshot, The patient was returned to duty December 14th, 1862. The case is reported by Acting Assistant Surgeon John Neill. Case.—Private Jasper S------, 18th Missouri Volunteers, received at the battle of Shiloh, Tennessee, April 6th, 1862, a gunshot fracture of the os frontis, a little above and back of the frontal eminence, the bone being depressed half an inch and the size of the ball. He was insensible when brought to the hospital. With expectant treatment, quiet, and Ioav diet, he became rational, and in less than three weeks recovered his usual health. Assistant Surgeon G. B. Houts 18th Missouri Volunteers, reports the case, and adds that on his return from the army he saw S------, and learned that the latter had not suffered from any cerebral trouble after his discharge from service. Case.—Sergeant Joseph Demaro, Co. E, 5th Vermont Volunteeers, aged 23 years, was wounded in an engagement near FunkstoAvn, Maryland, July 10th, 1863, by a conoidal musket ball which apparently produced a trivial wound of the scalp on the right side of the head. He Avas sent to the hospital at Point Lookout, and on the 10th of August was transferred to the Brattleboro' Hospital in Vermont. It was noAV evident that the skull Avas fractured and measurably depressed. The treatment, as far as recorded, consisted chiefly in the application of simple dressings to the wound. No unfavorable symptoms occurring' the patient Avas returned to duty October 12th, 1863. He is not on the Pension List. The following patients with depressed gunshot fracture of the cranial bones, recovered with but slight disability and were transferred to the Veteran Reserve Corps, or furloughed, or discharged on the expiration of their terms of service: Case.—Private John T. BroAvn, Co. A, 86th Illinois Volunteers, aged 18 years, was wounded near Rome, Georgia, May 17th, 1864, by a buckshot Avhich fractured the frontal bone at the superciliary ridge above the internal angle of the left orbit causing a slight depression. He was sent to the hospital of the 2d division, Fourteenth Corps, and on June 2d Avas sent to the hospital at Nashville, Tennessee. On June 4th he was transferred to the Joe Holt Hospital, Jeffersonville, Indiana; thence Avas sent to Jefferson Barracks Hospital, St. Louis. Lead-water dressings had been applied to the wound during this time. On the 9th of July he was sent to Quincy, Illinois, suffering pain in the frontal region. He Avas unable to endure the GUNSHOT FRACTURES OF BOTH TABLES OF THE SKULL. 183 beat of the sun but his appetite Avas good. His health continued fair, though he experienced occasional headache. On February 13th, 1865, he Avas transferred to the 1st battalion Veteran Reserve Corps. The case is reported by Surgeon D. G. Brinton. He is not on the Pension List. Case.—Sergeant Richard M. Cunningham, Co. D, 21st IoAva Volunteers, aged 39 years, was Avounded at the battle of Port Gibson, Mississippi, May 1st, 1863, by a conoidal ball Avhich fractured the os frontis, slightly depressing the cone. He Avas admitted to the Van Buren hospital, Miliken Bend, Louisiana, and on August llth sent to the hospital steamer C. Mc- Dougall. The case progressed favorably and by the 17th of August the wound in the scalp had nearly healed. The patient's mind Avas unimpaired and his general health good. On August 18th be was admitted to the convalescent hospital, Benton Barracks, Missouri, and thence sent to duty in the Veteran Reserve Corps, on November 28th, 1863. The case is reported by Acting Assistant Surgeon Thomas Evans. This man was discharged from service June 29th, 1865, and pensioned. On December 16th, 1867, Pension Examiner A. B. Hanna, reports him suffering from cephalalgia, vertigo, and discharge of pus from the left ear. Case.—PriA-ate James L. Adams, Co. D, llth Blinois Volunteers, received, at the battle of Jonesboro', Georgia, Sep- tember 1st, 1864, a Avound of the head from a shell fragment, Avith fracture of the right side of the frontal bone Avith slight depression. He Avas admitted into the field hospital of the 2d division, Fourteenth Army Corps, and about October 28th he Avas admitted into the Xo. 15 Hospital, Nashville. He Avas mustered out of service June 8th, 1865. On October 9th, 1869, Pensioner Examining Surgeon G. S. OAven, reported that this patient, Avhose claim for a pension was still pending, became par- tially insane if he attempted to labor aud rated his disabilities at three-fourths and permanent. Case.—Private Fielding Parsons, Co. D, llth West Virginia Volunteers, aged 26 years, was wounded at the battle of Winchester, Virginia, September 19th, 1664, by a conoidal musket ball which entered the frontal bone above the left eye and lodged, producing a fracture and depression. He was sent to a field hospital; thence was conveyed by way of Sandy Hook and Baltimore to York, Pennsylvania, Avhere he Avas admitted into the general hospital on October 4th. The patient was returned to duty on October 28th, 1864; but on November 1st he Avas again admitted to the general field hospital at Parkersburg, West Virginia, where the missile Avas extracted. Having deserted on February 24th, 1865, nothing was kno\vn of him until May 27th, when he was admitted from the Soldiers' Rest Hospital into the Sickles' Barracks Hospital at Alexandria Viiginia. He was discharged the service on July 6th, 1S65, in obedience to General Order No. 77, A. G. O., War Department and in 1666 Avas pensioned, his disability being rated at three-fourths and temporary. The case is reported by Surgeon E. Bentley, U. S. V. Case.—Private John LoveAvell, Co. A, 188th NeAV York Volunteers, aged 42 years, was Avounded at the battle of South Side Railroad, Virginia, October 27th, 1864, by a conoidal musket ball Avhich fractured and depressed a portion of the frontal bone over the right superciliary ridge. He Avas admitted into the 1st division, Fifth Corps hospital; thence was conveyed to Washington, and admitted on the 30th into Emery Hospital. The patient was furloughed in December and returned to duty April 4th, 1865. Being still unfit for duty, he Avas admitted t\vo days afterward into the Sickle's Barracks at Alexandria and was finally discharged the service June 3d, 1865, and pensioned, his disability being rated temporary. Case.—Private TF. M. Taylor, Co. K, 10th Alabama Regiment, was Avounded on July 2d, 1863, by a grape-shot which fractured and depressed a portion of the frontal bone. He was admitted into the 2d division of the Alabama Hospital at Richmond, and on July 22d he was furloughed. Case.—Private Timothy Donovan, Co. H, 29th Maine Volunteers, aged 24 years, was wounded at the battle of Cedar Creek, Virginia, October 19th, 1864, by a piece of shell Avhich fractured the external table of the frontal bone to the left of the median line. On October 22d he was admitted to the Satterlee Hospital, Philadelphia, where expectant treatment Avas used under Avhich the wound healed rapidly, and on January 18th, 1865, the patient was transferred to the Veteran Reserve Corps. He Avas discharged the service September 19th, 1865, because of general debility and headache, and was pensioned, his disabiliy being rated one-half, and its probable duration as doubtful. The following patients, with gunshot depressed fractures of the cranial bones, died from compression of the brain, following the injury, and produced by extravasation of blood within the skull. Their cases presented no marked peculiarities : Case.—Private John Ernst, Co. C, 35th IoAva Volunteers. Gunshot fracture of frontal bone. Vicksburg, Mississippi, June 8th, 1863. Conoidal musket ball. Treated at Fifteenth Corps hospital. Died June 12th, 1863. Case.—Corporal W. Johnson, Co. H, 15th Wisconsin Volunteers, aged 30 years. Gunshot fracture of frontal bone by conoidal musket ball. Resaca, Georgia, May 14th, 1864. Treated in hospital No. 1, at Nashville. Died June 16th 1864. Case.—Private Joseph Warwick, Co. A, 26th Michigan Volunteers, was Avounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal ball Avhich struck in the centre of the forehead and apparently penetrated the bone. He was sent to the hospital of the 1st division, Second Corps, thence was conveyed to Alexandria, and on December 4th Avas admitted to the 1st division hospital in a state of insensibility. Consciousness never returned, and death ensued December 6th, 1863. Case.—Private A. B.------, a Confederate soldier, was Avounded at the siege of Fort Donelson, February 16th, 1862, by a musket ball Avhich entered the skull at the right frontal eminence. He was conveyed to Nashville, and on the evening of February 16th was admitted to the Academy Hospital. He suffered no pain and Avas even cheerful. Confederate Surgeon 1st WOUNDS AND INJURIES OF THE HEAD. Madden after having anesthetized the patient explored the wound. Upon making a crucial incision a large depression was disclosed. He failed to detect any foreign substance either with the probe or fore-finger, Avhich Avas introduced in the direction of the left parietal eminence. Reaction aahs prompt, and a feAV hours after the patient Avas about the Avards. He took his supper with relish and slept Avell during the night. On aAvaking, hoAvever, he complained of pain in the head Avhich steadily increased. There Avere no symptoms of delirium. Death occurred February 22d, 1862. The case is reported by Surgeon Ehen Swift, U. S. A. Case.—Private Charles Braitlrwait, Co. F, 22d Wisconsin Volunteers, aged 20 years. Gunshot fracture and depression of frontal bone. Marietta, Georgia, June 25th, 1661. Treated at TAventieth Corps and Chattanooga hospitals. Died July 27th, 1864. Case.—Corporal H. Louth, Co. F, 27th Michigan Volunteers. Gunshot fracture of frontal hone with depression, by a shell fragment. Petersburg, Virginia, June 17th, 1864. Treated at field hospital. Died June 19th, 1864. Case..—Private T. A. Brockway, Co. G, 16th Michigan Volunteers. Gunshot depressed fracture of the frontal bone. Treated at Fifth Corps hospital. Died May 12th, 1863. Case.—Charlas Mervin, a seaman ofthe gunboat Pittsburg, Avas wounded at the siege of Fort Donelson, February 14th, 1862. by a piece of shell which struck the right frontal eminence. He Avalked from the boat to the hospital at Mound City, where he arrived February 20th. The injury being considered slight, he seemed to do well until four o'clock P. ai. on February 24th, when he was seized with nausea and vomiting, which were folloAved by delirium and death. At the post-mortem exam- ination an extensive fracture with depression of the internal table Avas revealed, and a spiculae of bone Avas found driA-en into the substance of the brain. A clot was found betAveen the calvaria and dura mater. There Avas a fissure tAvo inches long in the outer table; but the pericranium was unbroken.1 The following are examples of intra-cranial abscesses following depressed gunshot fractures of the skull: Case.—Private Thomas Bradley, Co. B, 6th New Hampshire Volunteers, aged 43 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball which fractured and depressed the frontal bone at the median line and lodged under the aponeurosis. He Avas admitted on the 7th into the 1st division hospital at Alexandria, where the missile Avas extracted on the 13th. Death resulted on June 23d, 1864. The autopsy revealed an abscess betAveen the dura mater and the brain, near the seat of fracture, and on section a considerable extravasation of fluid Avas found in the ventricles. The case is reported by Surgeon E. Bentley, U. S. V. Case.—PriA-ate John J. Griffith, Co. H, 107th. New York Volunteers, aged 24 years, received, near Atlanta, Georgia, July 28th, 1864, a gunshot fracture of the skull. The missile entered over the left eye at the superciliary ridge, fracturing the os frontis for two inches. He also received, in the same engagement, a wound of the hand. He was immediately admitted to the hospital of the 1st division, TAventieth Corps, where the forefinger Avas amputated. On August 2d, he was sent to the field hospital at Chattanooga, where he died on August 21st, 1864. At the autopsy, an abscess about the size of a hen's egg was found immediately beneath the fracture. The left arachnoid cavity was filled with cream-like pus. At the base of the brain tAvelve ounces of straw-colored fluid were discovered. The ventricles Avere distended Avith the same fluid. Case.—Lieutenant Charles L. F------, Co. K, 6th New Hampshire Volunteers, was Avounded at the battle of Bull Run, Virginia, August 29th, 1862, by a musket ball which penetrated the squamous portion of the temporal bone. He Avas conveyed to Washington, and admitted to Carver Hospital, where he died on September 14th, 1862. The autopsy revealed fragments of bone pressing upon the dura mater, and also a collection of pus in the vicinity of the wound. The pathological specimen is No. 139, Section I, A. M. M. Portions of the ball remain imbedded in the depressed fragments of the bone. Three fragments remain in situ, tAvo of which are depressed about one-fourth of an inch. The specimen Avas contributed by Sure-eon O. A. Judson CASE.-Private Charles O. Homan, Co. D, 92d New York Volunteers, aged 22 years, was wounded near Kinston, North Carolina, December 14th, 1862, by a missile, which fractured the squamous portion ofthe temporal bone driving a 7th 1864 a gunshot fracture of both tables of the frontal bone, a little to the left of the junction of the coronal with the sa.dttal suture He was admitted to the field hospital, Fifteenth Corps, and experienced only little trouble from the wound until June 4th when a convulsion occurred. From that time he remained in a semi-comatose condition until death, which took place June 19th 1-61 The autopsy revealed, a little posterior to the fracture, an abscess, which extended into the convolutions of the brain The gray substance was destroyed for a distance of one and a half inches. The case is reported by Surgeon D. J. Swarts 100th Indiana Volunteers. ' ' This case is also reported in Fka.nkuxs Science and Art of Surgery, St. Louis, 1867. Vol. 1, p. 696. CARIES AND NECROSIS AFTER DEPRESSED GUNSHOT FRACTURES. 185 Case.—Private Aaron Jones, Co. F, llth Vermont Volunteers, aged 36 years, receiA'ed at the battle of Gettysbm-g, Pennsylvania, July 3d, 1863, a gunshot fracture, Avith slight depression of the frontal bone near the median line, and equidistant from its junction Aviththe vertex and nasal bones. He Avas admitted to Camp Letterman, and on July 13th sent to Fort Wood, Ncav York Harbor. The patient stated that after the first shock of the Woav he felt no special inconvenience other than would naturally result from a simple flesh Avound. Until July 16th the patient was apparently very comfortable; he slept well, ate Avith a relish, and conversed intelligently. On the morning of that day he suddenly fell into a seini-comatose condition, characterized by hard and labored breathing, dilated pupils, and at times slight, irregular convulsive movements of the limbs. He seemed unconscious to all external impressions, and at long intervals would take a deep inspiration, open his eyes, look furtively around, and then relapse into his former condition. Counter-irritation Avas applied to the spine and extremities, but Avithout effect. Death resulted July 17th, 1863. At the autopsy, a Avide spicula of bone was found standing off from the plane of the surface of the inner table. There Avas an extensive suffusion of pus over the meningeal surfaces, immediately adjacent and around the point of fracture; but no burrowing had taken place, and the brain substance Avas perfectly healthy. The bone at seat of fracture was very thick and firm, and notAvithstanding the poAverful blow he must have received, there were no symptoms of concussion. The case is reported by Acting Assistant Surgeon 0. W. Gibson. Case.—Private M. S------, Co. F, 86th Ncav York Volunteers, aged 25 years, was Avounded at the battle of Beverly Ford, Virginia, June 9th, 1863, by a musket ball, which fractured the squamous portion of the left temporal bone. He Avas conveyed to Washington, and Avas admitted to the Lincoln Hospital on June 10th, Avhere Avater dressings were applied. Death occurred on June 28th, 1863. Autopsy: The fracture, Avhich had radiating fissures, commenced one and a half inches anteriorly to the left ear and extended one inch posteriorly, the opening being filled with disorganized brain. Upon the removal of the calvaria, the left hemisphere Avas observed to be of a dark slate color, Avhile the appearance of the right Avas natural. The dura mater Avas lined Avith a dark unhealthy fluid. Pus also Avas found in the arachnoid cavity on the left side. The pia mater Avas not affected. The inferior portion of the middle cornu Avas disorganized, and had doubtless been involved in the injury. Pus Avas found upon the superior surface of the cerebellum on both sides. The pathological specimen is No. 1344, Sect. I, A. M. M., and sIioavs the vault ofthe cranium, with the line of section through the fractured bone, of Avhich only the upper part is apparent. The specimen and history Avere contributed by Surgeon G. S. Palmer, U. S. V. Erysipelas.—Allusion has been made on pp. 77 and 101 to the comparatively small proportion of cases of erysipelas that were observed in gunshot scalp wounds and contusions of the cranial bones, and the remark is equally applicable to gunshot depressed fractures of the skull. This complication was reported in but three of three hundred and sixty- three cases of depressed gunshot fracture of the skull: Case.—Sergeant Byron XV. Worden, Co. D, 29th Indiana Volunteers, received at the battle of Chickamauga, September 19th, 1863, a gunshot depressed fracture of the left side of the head. On October 1st he was admitted to the hospital at Chattanooga. Erysipelas supervened, but the case progressed favorably, and on November 19th the patient Avas returned to duty. Not on Pension List. Case.—Private Daniel B. Harold, Co. C, 21st Virginia Regiment, Avas wounded at Gettysburg, July 2d, 1863, and died January 7th, 1664, at Point Lookout Hospital, from erysipelas following gunshot depressed fracture of right parietal. CASE.-Private Hutchinson MQler, Co. H, 29th U. S. Colored Troops, aged 40 years, was wounded in the engagement at Chapin's Farm, Virginia, October 13th, 1864, by a conoidal musket ball, which produced a depressed fracture of the parietal. On the same day, he Avas admitted to the field hospital of the Tenth Corps, and thence was sent to the general hospital at Fort Monroe, Avhere he Avas admitted on the 14th, and died on February 24th, 1865, from traumatic erysipelas. Caries and Necrosis—The following are cases of caries, or necrosis, following gunshot injuries of the cranial bones : CASE.-Private Andreas Baumgartner, Co. K, 82d Blinois Volunteers, aged 42 years, was wounded at Chancellorsville, May 2, 1863, by a round ball, which fractured the upper portion of the occipital bone. In the same engagement he received a gunshot Avound of the left orbit. On May 15th, he Avas admitted to the hospital of the 3d division, Eleventh Corps; on June 15th, he Avas sent to Lincoln Hospital, Washington, and on January 1st, 1864, was sent to the Marine Hospital, Chicago, Illinois. He was discharged on May 5th, 1864. In December, 1869, it Avas reported by Pension Examiner J. D. Howell that" there was necrosis of both tables of the skull, leaving the patient with persistent pain and vertigo, and general constitutional disturbance, which rendered him unable to earn a livelihood. Dr. Howell rated his disability at three-fourths. Case.—Sergeant William F. De Forrest, Troop M, 2d Massachusetts Cavalry, was wounded at Ashby's Gap, Virginia, July 12th, 1863, by a conoidal musket ball, which entered the right temple just above the eye, and remained in the wound for two months. No further record ofthe case is on file until December 30th, 1863, when the patient was admitted to the Ira Harris Hospital, Albany, New York. He was discharged September 4th, 1864, and pensioned on November 1st, 1864. Pension Examiner S. D. Willard reported that there was necrosis of the frontal bone, headache, mental impairment, and inability to bear exposure to the sun, which incapacitated the patient from earning a livelihood. His disability was rated three-fourths and temporary. C'ASE.-Corporal Joseph E. French, Co. E, 63d New York Volunteers, aged 30 years, was wounded at the battle of Cold Harbor, Virginia, June 5th, 1864, by a fragment of shell, which fractured the frontal bone. On the 9th, he was admitted to the Fairfax Seminary Hospital, Virginia; on the llth, was transferred to the West's Building Hospital, Baltimore and on July llth 24r ' 186 WOUNDS AND INJURIES OF THE HEAD. Avas sent to the Second Division Hospital at Annapolis. He Avas furloughed in August, and on January 27th, 1865, Avas discharged from ser\-ice on surgeon's certificate of disability and pensioned. A communication from Pension Examiner C. H. Dana, dated April 29th. 1867. stated that the wound discharged freely and Avas very offensive. There Avas ptosis ofthe right eye-lid, and the patient suffered from frequent attacks of headache and vertigo. His disability Avas rated total and permanent. Case.—Private John Mallon, Co. F, 100th Illinois A'olunteers, avus Avounded at the battle of Chickamauga, Georgia, September 20th, 1863, by a fragment of shell, Avhich lacerated the scalp and fractured the left parietal bone, causing but slight depression. He was taken prisoner, after a few days was paroled, and on October 6th Avas admitted to the hospital at Stevenson, Alabama; thence he Avas conveyed to Nashville, and on the 17th Avas admitted to hospital No. 19. In November he Avas furloughed, and afterward received into the Marine Hospital, Chicago, on November 25th, 1863. Caries of the skull ensued and still existed at the time of his discharge from service, June 9th, 1864. In a communication dated January 7th, 1868, the Commissioner of Pensions states that Mallon is a pensioner, and that his disability is rated one-half and temporary. Further information, dated Alarch 4th, 1870, and signed by three members of an examining board, shoAvs that the wound was still discharging, that the patient was losing his memory, and that his disability was rated one-half and permanent. Case—Corporal Nicholas King, Co. F, 18th Kentucky Volunteers, aged 19 years, was Avounded at the battle of Chicka- mauga, September 19th, 1863, by a fragment of shell, Avhich fractured a portion of the frontal bone at the right superciliary ridge. He Avas taken prisoner, conveyed to Richmond, exchanged about the 24th of March, 1864, was admitted to the Second Division Hospital at Annapolis, was transferred to the Chase Hospital at Columbus, Ohio, and was discharged the service May 17th, 1864. There was caries ofthe bone and purulent discharge from the nose. On August 8th, 1865, Pension Examiners Corlis and Feris reported that there was still discharge and exfoliation of bone from the wound, attended with great pain and disability, On August 14th, 1865, he Avas pensioned, his disability being rated total and permanent. Case.—Private OAven Huggins, Co. C, 10th Vermont Volunteers, aged 50 years, was wounded before Petersburg, Virginia, March 25th, 1865, by a conoidal ball, Avhich fractured the left parietal bone. He was admitted to the hospital at City Point, on the same day; on April 5th, Avas sent to the Fairfax Seminary Hospital; on April 12th, he was sent northward, and on the 15th, Avas admitted to the Sloan Hospital at Montpelier. He was discharged the service June 28th, 1865, and pensioned. The wound had not closed, and some necrosed bone remained undetached. On March 28th, 1868, Pension Examiner G. W. Vanderhull reported that the bone Avas necrosed and depressed. The patient suffered from pain in the head with loss of memory. His disability Avag rated total and permanent. Case.—Private John Thompson, Co. H, 14th North Carolina Regiment, aged 22 years, was wounded by a projectile on May 3d, 1863, which fractured a portion of the frontal bone. Necrosis ensued. On February 20th, 1885, he appeared before an examining board at Raleigh, Avhen he was retired as permanently disabled and unfit for duty in any branch of the service. Case.—Private Oavcii McDermott, Battery K, 4th U. S. Artillery, aged 28 years, was wounded at the battle of Chan- cellorsville, Virginia, May 3d, 1863, by a conoidal musket ball, Avhich struck about two inches above the left eyebroAV, and slightly fractured the frontal bone, On May 17th, he was admitted to St. Aloysius Hospital at Washington. On October 17th, he Avas sent to Harewood Hospital, and was discharged on November 17th, 1863. He re-enlisted in Co. I, 8th New Jersey A'olunteers, and, after the battle of Deep Bottom, Virginia, Avas conveyed from City Point to the Beverly Hospital, NeAV Jersey, which he entered August 21st, 1864. On April 4th, 1865, he was transferred to the Satterlee Hospital at Philadelphia, and Avas discharged from service on July 19th, 1865. From injury to periosteum, slight caries exists in the vicinity of the'wound, Avhich maintains an almost constant suppurative discharge. In October, 1868, he was a pensioner. CASE.-Private A.J. Richards, Letcher's Battery, Pegram's Battalion, aged 18 years, received, in an engagement on the Weldon Railroad, Virginia, August 16th, 1864, a gunshot fracture of the right parietal bone. He was admitted to the 3d division, Chimborazo Hospital, Richmond, on the 22d, and on March 3d, 1865, was retired by an examining board. Caries and necrosis existed, and he suffered constant pain in the head, by Avhich he Avas permanently disabled and unfitted for any duty. Case.—Private P. Smith, Co. I, 91st Ohio Volunteers, aged 22 years, was wounded at the battle of Winchester, Virginia, September 19th, 1864, by a conoidal ball, which fractured the frontal bone two inches above the left eye. On the same day he Avas admitted to the hospital of the 2d diA'ision, Army of West Virginia; thence Avas sent, on September 25th, to the Haddington Hospital at Philadelphia. Simple dressings were applied to the wound. On May 12th, 1865, he was transferred to the Satterlee Hospital, and Avas discharged the service June 6th, 1865, and received a pension, which was increased in October, 1867. At that time Pension Examiner H. Conkling reported a portion of the bone lost, the Avound discharging frequently, and the patient unable to obtain a livelihood oAving to frequent attacks of vertigo and nausea, which were aggravated by exposure to the sun. His disability is rated total and permanent. Case.—Private James W. Woodward, Co. K, 60th Illinois Volunteers, was wounded at Buzzard's Roost, Georgia, February 25th, 1864, by a piece of shell, which fractured the frontal sinus one inch above the nasal eminence. He was admitted to the regimental hospital on the same day, and on February 29th Avas sent to the hospital at Chattanooga, Tennessee. He recovered, was furloughed on April 6th, 1864, and finally \vas mustered out of service on March 14th, 1865, and pensioned. Examining Surgeon G. Brattan, in a communication dated April 20th, 1868, states that there Avas necrosis of the frontal bone, and that the wound had not entirely healed. The disability is rated as total. Case.—Private Charles Dillman, Co. H, 3d Ncav Jersey Volunteers, Avas Avounded at the battle of Chancellorsville, May 3d, 1663. The missile passed into the brain, near the junction of the parietal and occipital bones. He was admitted to the hospital of the 1st diATision, Sixth Corps. He Avas delirious, and would alloAV no clothing upon him. At times, he would not eat; at others, his appetite Avas ravenous. He passed his urine involuntarily, but retained his faeces. His memory Avas totally lost. On examination, no depression about the circumference of opening was discovered. Expectant treatment was used, and on June 1st, the patient Avas much improved. He ate regularly, slept, and his memory gradually returned; but he misplaced EXFOLIATIONS OF THE CRANIUM AFTER GUNSHOT FRACTURES. 187 words and coined new ones. On June 12th, he Avas sent to Armory Square Hospital, Washington, and on June 22d, to Citizens' Hospital, Philadalphia. The outer table of the cranium became necrosed. He was returned to duty March 9th, 1864. On June 23d, 1864, he Avas discharged the service and pensioned, his disability being rated one-half; and since, up to September 30th, 1869, he has suffered from occasional attacks of epilepsy. Case.—Private Ramsford Dunsmore, 44th NeAV York Volunteers, Avas Avounded at Hanover Court House, May 27th, 1862, by a musket ball, Avhich entered above the right zygoma, carried away part of the external ear, fractured the petrous portion of the temporal bone, and emerged at the base of the occipital bone. He was delirious for one hour after the reception of the injury. Small pieces of bone Avere discharged from the Avound, and the mind Avas impaired. On August 22d, 1862, he was admitted to the Ladies' Home Hospital, NeAV York, from Avhich he Avas discharged September 23d, 1862. AfterAvard there Avas occasional pain, and the memory was impaired. This patient is not a pensioner. Exfoliations after Depressed Gunshot Fractures of the Skull.—^Instances of the eliminations of considerable portions of the outer table, or of both tables of the cranium, were not infrequent results of necrosis following gunshot fracture. Several illustrations have been already cited,1 and others will be adduced in connection with the subjects of trephining and the removal of fragments. Hence it will be necessary to refer, in this place, to a few only: Case.—Private Dominick Barney, Co. H, 8th Minnesota Volunteers, aged 31 years, was wounded at the battle of Mur- freesboro', Tennessee, December 14th, 1864, by a conoidal ball, which caused a penetrating fracture of the petrous and squamous portion of the left temporal bone. For a few days he Avas treated in a field hospital; thence he was sent to hospital No. 4, Murfreesboro'. The case progressed favorably. On February 16th, 1865, the patient was transferred to Nashville, and thence, in March, to Jefferson Barracks near St. Louis. He Avas discharged from service on May 21st, 1865. On March 29th, 1866, Pension Examiner J. F. Scholl reported that exfoliation was still going on. The sinus, immediately above the meatus, Avas constantly discharging matter, as well as the meatus itself. The hearing Avas completely destroyed on one side. The mind was much impaired. He rated his disability total and temporary. Case.—Private Charles E. Patch, Co. C, 14th New Jersey Volunteers, aged 19 years, Avas wounded at the battle of Cold Harbor, Virginia, June 1st, 1864, by a gunshot missile, Avhich entered the face, between the inferior and superior maxillary bones, and emerged behind the ear, probably traversing the meatus in its course. He was taken prisoner and conveyed to Richmond, Avhere he AA-as admitted to Confederate Hospital No. 21. By July 31st, the temporal bone had become partially exposed, some fragments had escaped, and the sense of hearing was destroyed. With the exception of an occasional pain in the ear, the patient was doing Avell. He was afterward paroled, and on March 29th, 1865, Avas admitted to the Ward Hospital, NeAvark, New Jersey, where he Avas discharged the service June 29th, 1865, and pensioned. On August 31st, 1865, Pension Examiner J. G. Stearns reported that there was a purulent discharge fi-om the wound. On the 28th, a portion of bone came out, over an inch in length, making, in all that have come out of the jaw and ear in consequence of the Avound and gangrene, tAvelve pieces. There is total loss of external ear, which, with the paralysis, causes great deformity. Case.—Private Samuel Binns, Co. C, 88th Pennsylvania Volunteers, aged 17 years, was wounded at Bull Run, August 30th, 1862, by a projectile which entered the frontal bone one inch above the nasal eminence, a little to the right of the median line, and emerged at the external angular process. He was admitted to the Episcopal Hospital, Philadelphia, December 16th, 1832. There was a discharge of pus from the loose tissue of the superior eyelid, and the wound of entrance, from which pieces of bone had been discharged at different times before his admission, was still open. The wound of exit had closed, and the opening, formed for the escape of pus, Avas filled with a mass of granulation. The sight of the right eye Avas dim. On Decem- ber 20th, another piece of bone escaped from the wound of entrance, which afterward closed, and the patient was discharged the service March llth, 1863, and pensioned. Pension Examiner W. Carson subsequently reports that exfoliation has resulted, Avith great injury to the right eye and ear. His disability is rated three-fourths and doubtful. Case.—Private Alexander McGill, Co. I, 2d New Jersey Volunteers, aged 32 years, Avas wounded at the battle of Bull Run, Virginia, August 29th, 1862, by a fragment of shell, which fractured and depressed the external table over the coronal suture. He Avas, on September 1st, conveyed to Washington, a distance of thirty miles, and admitted into the Unitarian Church Hospital. He suffered from paralysis of the right side of the body and retention of urine. Unsuccessful efforts Avere made to elevate the depressed bone. Cold Avater dressings were applied. On September 10th, the power of motion in the arm and leg had returned, and on the 20th, the patient was so far recovered that he was able to Avalk with the help of a cane. He recovered, with the exception of a slight weakness in the right knee, and some difficulty in voiding his urine, which latter trouble was overcome by small doses of SAveet spirits of nitre. On October 5th, he Avas transferred to NeAV York City and admitted into the City Hospital. Through the Avound, which was granulating firmly, necrosed bone could be detected. An attempt Avas made to remove the latter, but failed. The patient Avas discharged from the service on January 8th, 1863. The case is reported by Surgeon A. Wynkoop, U. S. V. In January, 1863, Dr. H. C. Clark, Assistant Surgeon, 2d New Jersey Volunteers, reported that from a shell wound received on August 27 th, 1862, a portion of the skull Avas carried away, leaving a space an inch in diameter unprotected by any bony structure, and added that the man Avas unable to maintain himself, and Avas entitled to full pension. His claim for pension Avas rejected December 29th, 1865, for Avant of evidence. 1 Some of the more interesting specimens of exfoliations from the cranium, contained in the Army Medical Museum, are represented by FlGUKES 30, 31, 36, 37, 38, 39, 40, 47. 51, 53, 55, 58, 62, 99, and FlGLlUis 14 and 20, of the Catalogue of the Surgical Section of the Army Medical Museum. 188 WOUNDS AND INJURIES OF THE HEAD. Case.—Private John H. Booker, Co. L. 1st Maine HeaA-y Artillery, aged 23 years, was wounded in the engagement at Citv Point, Virginia, June 16th. 1664. The missile struck the skull at the junction ofthe coronal and sagittal sutures, lacerating the scalp, and fracturing and depressing the outer table nearly one-half inch each Avay. At the same time the patient received gunshot Avounds of the back and thigh. He Avas admitted to the hospital of the 3d division, Second Army Corps, and on July 2d Avas sent to the 3d division hospital at Alexandria, Virginia. The injuries healed kindly until July 18th, when the wound of the thigh became gangrenous, the disease extending over a surface of three inches. Lotions of chloride of zinc and afterward of creosote were applied, and tonics and anodynes given. On August 10th, a piece of exfoliated hone half an inch in diameter Avas removed from the Avound of head, and, on August 25th, t\vo more pieces of the same size Avere taken aAvaj. The slough had separated on August 1st, and the Avound had again assumed a healthy appearance, and continued to improve during the months of September and October, when, about the middle of November, the hands and feet became cedematous, the face greAV puffy, and finally the abdomen commenced to swell. By the middle of December the girth of the body at the umbilicus Avas thirty-eight inches. But little urine Avas passed, yet no symptoms of cerebral disturbance were noticed. The patient died January 9th, 1865. At the autopsy, the caA-ities of the chest and peritoneum Avere found much distended Avith serum, and the kidneys Avere completely degenerated. The case is reported by Surgeon E. Bentley, U. S. V. Case.—Private John G. Wilson, Co. F, 24th Ohio Volunteers, Avas wounded at the battle of Shiloh, Tennessee, April 7th, 1662, by a fragment of shell, Avhich struck the right parietal bone near its posterior superior angle, and carried aAvay a portion of both tables about an inch in dimension. He Avas discharged December 1st, 1862, and Avas examined for a pension November 10th, 1863, by Pension Examiner Charles Hay, who reported the dura mater exposed, the pulsations of the brain visible, and the patient obliged to use chloroform to relieve spasms, which occurred periodically. His general health had suffered greatly. There was no neAV formation of bone. On October 22d, 1867, Pension Examiner R. D. Hammond reported a consid- erable loss of bone. There Avas constant discharge of pus from the wound and small pieces of bone were occasionally thrown off. His disability is rated total and permanent by Dr. R. D. Hammond, pension examiner at Macomb, Illinois. Case.—Private William Fisher, Co. G, 98th Pennsylvania Volunteers, was Avounded near Fort Stevens, Washington, July 12th, 1864, and Avas admitted into Mount Pleasant Hospital on the folloAving day. A little above the right ear Avas a scalp wound an inch and a half long. Acting Assistant Surgeon P. C. Porter, under Avhose care the patient came, satisfied himself that a piece ofthe mastoid process was chipped off, and that a fracture extended into the petrous portion ofthe temporal. From the aspect of the wound, Dr. Porter Avas inclined to the belief that it AA-as inflicted by a conoidal musket ball. The patient did well with simple dressings, and rest,, and gentle cathartics, till the 20th of July, Avhen the wound began to slough. Applications of charcoal and yeast poultices, nitric acid, and creasote, failed to arrest the sloughing, Avhich presently gave rise to repeated haemorrhages from branches of the temporal artery. The gangrene continued to spread until August 9th, Avhen the eschars separated, leaving a space five inches in diameter on the right side of the head, denuded of integument, fascia, and muscles. During this long period, the patient complained of no inconvenience at the seat of fracture, though there Avas at times acute frontal pain. Early in September, it was evident that the exposed portions of the temporal and parietal bones were necrosed, and on September 6th, a fragment of the squamous portion of the temporal was removed. Two days subse- quently other fragments Avere detached and extracted. After this the Avound began to cicatrize rapidly, and on December 3d, 1864, the patient was reported to he entirely out of danger, and in fact nearly Avell. On February 14th, 1865, he Avas discharged from service .mri^^^&SStS ilfm °n a Certificate 0f ******* 6iSned b^ Sur&eo" H- Allen> U- S- A- He ™" pensioned. In gunshot injury. Spec. 3451, A. M. u. 1^65, he was reported as partially deaf. He was last paid at the Philadelphia Agency, September 4th, 1870, and his pension had been reduced, from which it may be inferred that the examining surgeon regarded his disabilities as comparatively slight. CASE.-Private R. W. Hamlin, Co. F, 4th Michigan Volunteers, aged 22 years, was wounded at Gettysburg, July 2d, 1863, by a conoidal ball which entered anterior to top of right ear, passed backward and downward through the external ear, injured the mastoid process, and emerged at the back of neck six inches from point of entrance. He fell senseless, and was carried to the Seminary hospital, remaining unconscious for tAvo days. On July 20th, he was sent to hospital at York, Penn- sylvania. He suffered much pain 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 Avith plastic 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 Lit to Had- dington Hospital, Philadelphia; on June llth, to Satterlee Hospital; and on August 5th, to St. Mary's Hospital, Detroit, Michigan, where he was discharged from the service September 13th, 1664. He is not a pensioner. Case.—Corporal James W. Williams, Co. G, 39th United States Colored Troop*, aged 26 years, was Avounded before Petersburg, Virginia, July 30th, 1864, by a conoidal musket ball, which fractured the frontal bone over the frontal sinus, near the parietal bone. No record of the case can be found until August 18th, when the patient was admitted to the Summit House Hospital, Philadelphia. He 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, 1865, 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 stooping or exertion. His disability is rated one-half and temporary by Examining Surgeon J. R. RoAvand. REMOTE RESULTS OF DEPRESSED GUNSHOT FRACTURES. 189 Case.—Sergeant John O'Flaherty, Co. D, 24th Wisconsin Volunteers, was Avounded by a missile at the battle of Chick- amauga, Georgia, September 19th, 1863, which fractured both tables of the frontal bone above the right eminence. He was admitted to the field hospital, 3d division, TAventieth Corps, and on October 21st, Avas sent to the hospital at Stevenson, Alabama. A day later, the patient Avas 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, 1864, and pensioned. An opening, one inch and a half long by one inch Avide, caused by exfoliation of bone, had healed and Avas covered only by the integument. The patient Avas 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. H, 45th Pennsylvania Volunteers, aged 29 years, Avas Avounded before Peters- burg, April 2d, 1865, by a conoidal musket ball, Avhich 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 imvard and upAvard, emerged at the instep; the second toe of the same foot had been carried aAvay 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, Avhen he Avas sent to the Slough Hospital at Alexandria. The metatarsal bones became necrosed. He was mustered out July 17th, 1865, and pensioned from that date. On January 17th, 1870, Pension Examiner F. B. Wagner reports that the Avound in the head often inflames and suppurates, and that dead pieces 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, Mcintosh's Battalion, Rockbridge Artillery, was wounded at Fredericksburg, December 13th, 1862, by a fragment of shell, which struck the upper portion of the left side of the frontal bone, carrying aAvay a segment of bone an inch square, and exposing the brain. He Avas admitted to hospital No. 1, at Richmond, on January 26th, and, on March 13th, 1865, he Avas 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 Avas 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, by 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 18th, 1865, Avas again discharged, and Avas pensioned. In May, 1865, there was partial paralysis of the left side of face, and deafness of the right ear, and his disability Avas rated one-half and permanent. Case.—Private Samuel Lyon, Co. E, 54th New York Volunteers, aged 25 years, was admitted, on January 14th, 1863 to Mower Hospital, Philadelphia, Avith a gunshot fracture of the left parietal bone. The wound healed readily, and on March 27th, 1863, he Avas discharged the service, being still troubled with neuralgic pains in the frontal region. He is not a pensioner. Case.—Private Robert McAllister, Co. G, 57th New York Volunteers, aged 42 years, Avas struck by a bullet at Fred- ericksburg, December 13th, 1862, Avhich caused a lacerated Avound of the scalp, and fractured a portion of the left parietal bone. He was admitted to the field hospital of the 1st division, Second Corps, on the same day, and a feAV days later Avas transferred to Washington, and on the 17th was admitted to the Campbell Hospital. On February 3d, 1863, he Avas 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, Georgia, June 15th, 1864, by a conoidal musket ball Avhich fractured the cranium. He Avas admitted to the hospital of the 2d division, TAventieth Corps, and on the 22d, Avas sent to the general hospital at Chattanooga, Tennessee. On July 7th. he was transferred to Nashville and admitted into hospital No. 19, but, three days afterward, Avas sent to Jefferson 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 Avas discharged the service December 2d, 1864. In September, 1867, he Avas a pensioner, his disability being rated total and permanent by Dr. J. Cummiskey, the pension examiner. At that date paralysis was limited to the right foot. CASE.-Private A. Perkerson, Co. A, 13th Virginia Cavalry, was Avounded at the battle of Gettysburg, July, 1863, by a piece of shell which struck the skull at the vertex. His history is unknown until March 3d, 1884, when he was admitted to an hospital at Richmond. He had been troubled with incontinence of urine ever since the reception of the injury. The wound had entirely healed, Avith slight loss of bone, showing a small furroAV. The patient complained of severe pain in the lumbar reo-ion and his speech indicated partial paralysis of the tongue. He stated that his right side had been partially paralyzed, and he°still suffered occasionally from numbness of the right hand and foot. Oil of turpentine was ordered as a counter-irritant'to the back but up to May 23d, 1864, there had been no material change in the condition of the patient. 190 WOUNDS AND INJURIES OF THE HEAD. Case..—Private Augustus J. Butler, Co. A, 7th Maine Volunteers, aged 19 years, was wounded at the battle of Cold Harbor, Virginia, June 6th, 1854, by a conoidal musket ball, which fractured the parietal bone at the eminence. He Avas conveyed by steamer to Alexandria, and admitted, on the 14th, into the 3d division hospital. Paralysis of the loAver extremities existed. Simple dressings only Avere applied. The patient recovered partial control of the muscles of the leg, and was discharged from service January 10th, 1865. Not a pensioner. Case.—PriA-ate John Shoemaker, Co. H, 100th Illinois Volunteers, aged 19 years, was wounded near Hillsboro', Tennessee, August 1st, 1863, by a musket ball, AA-hich entered the vertical portion of the frontal and escaped at the centre of the right parietal bone, grooving both tables. For tAvo weeks he was treated in the field hospital. On the 18th, he Avas sent to the Cumberland Hospital at Nashville. On the 26th of September, he Avas transferred to LouisA-ille, Kentucky; thence, on the 2d of December, to the hospital at Quincy, Blinois. Partial paralysis of the left upper and loAver extremities had ensued by this time, but the Avound was gradually healing, and his appetite was good. By the use of strychnia, some improvement in the motion of the leg Avas obtained. He Avas discharged from service April 2d, 1864, still experiencing considerable difficulty in walking. Acting Assistant Surgeon D. C. OAven reports the case. Not a pensioner. Case.—Private Frederick Abel, Troop B, 5th NeAV York Cavalry, aged 52 years, was Avounded at the battle of White Oak Swamp, Virginia, June 15th, 1864, 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 tAventy-four hours. He was then conveyed to the Chesapeake Hospital at Hampton. Paralysis agitans supervened immediately on return of consciousness. By the 4th of July, he Avas able to bear transportation to the Sixteenth and Filbert Streets hospital in Philadelphia. On March 25th, 1865, he Avas transferred to the Turner's Lane hospital; thence, on May 10th, to the McClellan Hospital, where he was discharged on July 1st, 1663. In January, 1868, 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 6th, 1864, by a conoidal musket ball, Avhich 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 Avell under ordinary treatment. On June 16th he was transferred to the Knight Hospital, Ncnv Haven, Connecticut; on October 16th to Readville, Massachusetts; and on March 22d, 1865, he was returned to duty from the Dale Hospital, 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 Avas mustered out of service June 12th, 1865. Casio.—Private Jason CoAvles, Co. E, 179th Noav York Volunteers, aged 43 years, was Avounded 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 April 3d; Avas transferred to the hospital at Fort Monroe, and on June 29th, sent to the Ira Harris Hospital, Albany, Ntnv York, where he Avas 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 great physical and mental impairment. His disability was rated three-fourths and of uncertain duration. Case.—Private Charles H. 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 Avas admitted to the regimental hospital. On December 17th he Avas sent to St. Aloysius Hospital, Washington; on January 7tb, 1863, Avas transferred to Governor Smith Hospital, Brattleboro', Vermont, and Avas discharged the service January 31st, 1863, and pensioned, his disability being rated total. Case.—Private John E. Edmonds, Battery E, 2d New York HeaA-y Artillery, aged 22 years, was Avounded at the battle of Petersburg, Virginia, June 18th, 1864, by a conoidal ball, Avhich fractured the right parietal bone. He was admitted on the same day, to the 1st division, Second Corps, hospital, and Avas transferred to the Carver Hospital, Washington, on June 22d. The functions of the brain Avere found to be, in a measure, impaired. He remained in the Carver Hospital until October 25th, Avhen he Avas transferred to the Ricord Hospital. Being regarded unfit for the Veteran Reserve Corps, he was discharged from service on March 22<1, 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.—PriA-ate George W. Gibson, Co. K, 1st Wisconsin Volunteers, aged 34 years, was wounded at the battle of Dallas, Georgia, May 31st, 1864, by a piece of shell, which fractured the right parietal 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, Wisconsin. There was hemiplegia of the left side which existed up to October 14th, 1664, the date of his discharge and pension. On February 15th, 1868, Pension Examiner J. S. Hurd reports the hemiplegia still continuing; the patient subject to epilepsy on slight exertion, and unable to remain in the open air during Avarm Aveather Avithout pain in the head. His disability is rated total and permanent. Penetrating Gunshot Fractures of the Skull.—Though 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: Case.—Private Thomas W. Dillon, Co. E, 3d New Jersey Volunteers, aged 27 years, was Avounded at the battle of Chancellorsville, May 3d, 1-63, by a musket hall. The patient remained within the enemy's lines some days after receiving the injury, and was subsequently brought to the hospital of the Sixth Corps at Potomac Creek. Upon examination, it was found PENETRATING GUNSHOT FRACTURES OF THE SKULL. 191 that the missile had entered the cranium very near the superior angle of the occipital bone, and had passed anteriorly into the substance of the brain. There Avas no comminution, fissuring, or depression of bone about the Avound of entrance, nor hernia cerebri. The Avound had not been dressed, probably because of the natural supposition that the case Avould prove speedily fatal. After shaving the head and removing a few small fragments of bone, the wound Avas dressed Avith cold water, and the patient Avas placed upon mattresses on the floor of the tent, it being impossible to retain him upon a bed Avithout force. Here he remained for a Aveek, 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 aa;is almost entirely restored; the Avound 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 Avas transferred to Philadelphia, at Avhich time he Avas able to w-alk to the station, a distance of nearly half a mile. In April, 1864, he Avas returned to his regiment in the field, perfectly well physically, but with an intellect someAvhat impaired. He remembered all that had occurred preA-ious to the reception of the injury; but from that time till an indefinite period in the autumn, he Avas totally unconscious. He is not a pensioner. The case is reported by Surgeon Lewis W. Oakley, 2d Ncav 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, Avith a gunshot fracture ofthe right parietal bone. A conoidal musket ball had entered the right side of the forehead, and had passed upward and backward. On admission the wound had healed, giving no sign of inflammation or suppuration. The patient was frequently troubled Avith a sharp pain on the top of the head, a little to the right side, Avhich sometimes caused dizziness. He recovered, and was returned to duty on September 21st, 1863. This man is not a pensioner. Case.—Corporal AndreAv Rupp, Co. C, 82d Illinois Volunteers, aged 29 years, Avas wounded in an engagement at Dallas, Georgia, May 25th, 1864, by a round musket ball which impacted itself in the left temporal bone. He was admitted to the hospital of the TAventieth Corps; on June 1st, sent to the field hospital at Chattanooga; and on June 9th, to the Sherman Hospital at Nashville, whence he Avas furloughed on July 16th. At the expiration of his leave, August 15th, 1864, he Avas admitted to the Desmarres Hospital, at Chicago, Blinois. The Avound had not healed; cold Avater 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, 1865, and pensioned. At that time he experienced but little, if any, inconvenience from the remaining portion of the impacted ball, which it was found impracticable to remove. Pension Examiner J, P. Lynn, August 10th, 1867, reports thickening, filling up, 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 Avas, on the folloAving day, admitted to the depot field hospital of the Sixth Corps, and on April 7th, was transferred to the Stanton Hospital, 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 pensioned. On March 29th, 1865, 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, 1864, by a conoidal ball, which entered at the outer edge of the left superciliary ridge of frontal bone, passed backAvard and doAvnward, involving in its course the lower surface of anterior left lobe of cerebrum. He was on the same day admitted to the hospital of the Fifteenth Corps, whence he was furloughed on August 24th. On January 15th, 1865, he was admitted to the hospital at Evansville, Indiana, and Avas discharged from service on January 27th, 1865, and pensioned. On June 21st, 1866, Pension Examiner J. J. Lesher, reported that there is a small depression from loss of bone at the wound of entrance. The patient's mind is slightly affected, and he is guilty of irregularities both mental and moral. He rates his disability at one-fourth and permanent. Case.—Private Solomon Farr, Co. F, 17th Maine Volunteers, was wounded at Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which penetrated the cranium. When admitted to the hospital of the 1st division, Third Corps, he was speechless. On July 16th, he Avas sent to McKim's Mansion Hospital at Baltimore. On September 30th Avas transferred to Patterson Park Hospital of the same city, Avhence he was returned to duty October 4th, 1883. On May 6th, 1864, he was killed in action at the battle of the Wilderness. Case.—Captain Thomas Church, Co. E, 53d Pennsylvania Volunteers, received at tho battle of Fair Oaks, Virginia, June 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 Avas discharged the service, and pensioned on May 9th, 1863. Pension Examiner S. R. Wagenseller, reported that there were several sinuses passing into the skull, communicating Avith the membranes of the brain. From these sinuses there Avas a constant discharge of pus, Avhich produced headache, vertigo, etc., when retained. He was unfit for either physical or mental exertion, and his disability Avas 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 J. McMahon, Co. D, 27th Michigan Volunteers, aged 19 years, Avas Avounded near Petersburg, July 30th, 1864, by a fragment of shell, Avhich fractured the right superior border of the frontal bone near its articulation Avith the parietal. On the same day he Avas admitted to the hospital of the 3d division, Ninth Corps, and, on August 1st, was sent to 192 WOUNDS AND INJURIES OF THE HEAD. City Point; thence he Avas conveyed by hospital steamer to Lowell Hospital, at Portsmouth Gro\-e, Rhode Island, where he Avas admitted August 7th, 1664. In November he Avas transferred to Harper's Hospital, Michigan, and Avas discharged the service December 29th, 1864, and pensioned. On January 27th, 1868, Pension Examiner XV. F. Breakey reported both tables of the bone lost from necrosis, and only a membranous formation covering the opening. There was protracted suppurative discharge, acute susceptibility to heat, vertigo, loss of memory, melancholia, symptoms of compression and general mental impairment, all of which Avere aggravated by labor or excitement. Sometimes, after stooping, he aa ould 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, Avas 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 reported healed; but it occasionally discharged pus and pieces of bone. He suffered from headache and dizziness, and his general health Avas impaired; his disability being rated total and permanent. Case.—Private Warren Mitchell, Troop D, 1st Wisconsin Cavalry, aged 21 years, Avas Avounded in an engagement near Jefferson City, Missouri, October 7th, 1864, by a conoidal musket ball, which fractured both tables of the parietal bone. On the 12th he Avas sent to the general hospital at Jefferson City, where simple dressings were applied. During the treatment several spiculae of bone Avere removed from the Avound. Complete paralysis of the right side and parietal paralysis of the left ensued. The patient was discharged the service July 10th, 1865, and pensioned, his disability being rated total and permanent. A com- munication from Pension Examiner N. Udell, states that the patient suffers from general paralysis; that he has been confined to his bed for tAventy months, and is helpless. Case.—Private Michael Murray, Troop F, 3d NeAV York Cavalry, aged 29 years, was wounded while a prisoner at Richmond, in October, 1864, by a buckshot, which fractured the left side ofthe cranium. He Avas paroled, and on March llth, 1H65, Avas 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, NeAV York City; and on May 24th to the McDougall Hospital, Fort Schuyler, NeAV York Harbor, Avhere he Avas discharged the service June 23d, 1865, and afterward pensioned. On August 20th, 1868, Pension Examiner G. S. Gale reports the process of exfoliation still in progress, and the left part of the Avhole body in a semi-paralytic state; the arm useless, and the patient rendered quite helpless from frequent convulsions. His disability is rated total and permanent. Case.—Sergeant William L. Henderson, Co. A, 123d Illinois Volunteers, aged 27 years, was Avounded 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 May 8th, when he Avas conveyed to the hospital steamer D. A. January. On May 25th, he entered the hospital at Mound City, Illinois, and on May 31st, 1865, he Avas discharged the service. The wound had entirely healed. On February 7th, 1870, Pension Examiner A. Fergusson reported that the ball remains imbedded in the bone. The patient suffered from vertigo, with loss of memory, and Avas unable to labor. He Avas 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, Battery B, 15th NeAV York Artillery, aged 25 years. Conoidal ball entered just anterior to the external meatus of left ear and lodged, probably in petrous portion of temporal bone. Bull Run, Virginia, August 29th, 1862. No treatment until May llth, 1864, Avhen he was admitted to Columbian Hospital, Washington. He was transferred as follows: May 15th, 1864, to Patterson Park, Baltimore; August 17th, to Camdeu Street, Baltimore, and on September 12th, 1864, to MoAver Hospital, Philadelphia, where an ineffectual attempt to remove the ball Avas made. Discharged from service June 16th, 1865. Not a pensioner. Case.—Private George Potter, Battery C, 3d Massachusetts Heavy Artillery, aged 26 years, received, at the battle of Mechanicsville, June llth, 1884, a penetrating fracture of the cranium by a conoidal musket ball, which entered the cavity through the parietal bone. He was sent to the hospital of the 1st division, Fifth Corps, and on June 13th, Avas transferred to the Finley Hospital at Washington. The case progressed satisfactorily under simple treatment, and on June 23d, the patient Avas furloughed. On the 22d of August, he was transferred to the Mason Hospital at Boston. Paralysis of the left side had 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 battle of Shiloh, April 7th, 1662. by a missile, Avhich penetrated the right parietal bone at its posterior superior angle. On April llth, he Avas taken on board the steamer D. A. January, and was conveyed to the City Hospital, St. Louis, Avhere he Avas admitted on April 14th. He was afterAvards 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 half an inch in depth. The sides of the opening Avere Avell covered with integument, the bottom partially so. He \vas also subject to vertigo upon slight exertion. His disability is rated three-fourths and permanent. Case.—Private George XV. Hulse, Co. G, 36th Blinois 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 upper margin, and lodged in the brain. In the same engagement, he was wounded in the chest by a conoidal ball which entered betAveen the seventh and eighth ribs. No attempt seems to have been made to extract either missile. On the 6th of October, he was conveyed to Stevenson, Alabama, for treatment, and one month later, he Avas sent to the Cumberland Hospital, Nashville, Tennessee. On December 2d, he was transferred to the hospital at Quincy, Illinois. During this time, simple dressings only had been applied to the wounds. By the 1st of March, 1664, the wounds had healed; but the patient was anaemic, and suffered more or less pain in the head. On the llth of the month, he Avas transferred to the Benton Barracks Hospital, St. Louis, Missouri, and on the BALLS LODGED WITHIN THE CRANIUM. l!>3 31st, to the Lawson Hospital. The external table Avas slightly necrosed. He Avas discharged from service July 5th, 1864, 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 ofthe urinary organs, and mental imbecility. Case.—Corporal George H. Farnum, Co. C, 16th Maine Volunteers, aged 19 years, Avas wounded at Gettysburg, July 1st. 1883, by a round ball, Avhich penetrated the cranium. He was sent to the Seminary Hospital, remaining there until the 19th of the month, when he Avas sent to the hospital at York-, Pennsylvania. The treatment, so far as recorded, was simple. He recovered and Avas transferred on the llth 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; (iettysburg, 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 lodgement 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 XV. Lilycrantz, Co. D, 103d United States Colored Troops, Avas 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 Avas vomiting freely, and about a fluid ounce of brain matter had exuded from the Avound. The vomiting being checked, but little blood, and no more brain matter, \vas discharged. A probe, five inches long, glided easily, by its own weight, its full length directly backAvard 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 Avandering, hoAvever, from the topic of conversation. He could neither taste nor smell, and his hearing 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 Ioav diet ordered. The pulse gradually declined until December 31st, when it was sixty and eighty. Until January 20th, there Avas 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 Avas discontinued. During the month of February, he had a large axillary abscess. On March 10th, he went nortliAvard on furlough, complaining only of muscular weakness and inability to look at a bright light. Occasionally pus would ooze from the wound, which was covered by a scab. He was discharged the service May llth, 1866. In November, 1867, he was examined by Dr. H. J. Bigelow, \vho found a small scar and a depression over the frontal sinus, the cause, no doubt, of the epilepsy which attacked the patient every tAvo Aveeks. These attacks were preceded by a distinct aura and by numbness in the left hand. They became less frequent, and otherwise he Avas doing Avell. The name of this patient is not upon 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 report1 of this case, in November, 1867. He records the patient's name as Libjencrantz; but in the official roster it is recorded as above.2 In the spring of 1870, Lieutenant Lilycrantz called at the Surgeon General's Office, and Avas examined by Assistant Surgeon G. A. Otis, U. S. A. There Avas a small depressed cicatrix above the inner portion, of the right eye-brow. The officer's replies to questions indicated a dull intellect. He articulated distinctly and there Avas 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 Avas immediately conveyed to Fort Scott. The ball was not extracted, but the Avound 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 Battery, aged 21 years, Avas, on May 27th, 1865, admitted to hospital at Little Rock, Arkansas, Avith a gunshot wound through the left temporal region. The missile lodged in the brain. He recovered and Avas discharged on June 20th, 1865. He is not a pensioner. i Boston Medical and Surgical Journal, Vol. LXXVII, p. 34(i. iOfficial Army Register of the Volunteer Force, Part VIII, p. 284. Washington 1867 25 191 WOUNDS AND INJURIES OF THE HEAD. Case.—Private John H. Scolder, Co. IT, 21st Wisconsin Volunteers, aged 21 years, was Avounded in the engagement at Bentonville. North Carolina, March 19th, 1665, by a conoidal ball, Avhich struck the os frontis over the right eye and passed into the brain. He Avas admitted to the hospital of the 1st division, Fourteenth Corps; on April 5th, sent to the Foster Hospital at New Heme, North Carolina; on April 12th to the Grant Hospital, Noav York Harbor, and on May 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 ball, 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, Avas sent to hospital No. 1, Nashville, thence was transferred, on June 29th, to the Totten Hospital at Louisville; and on July 12th, Avas 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, Avith 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. Casio.—Private William McCann, Co. C, 1st Maryland Regiment, received a penetrating gunshot wound ofthe bead, and was admitted to hospital No. 1, Richmond, Virginia. The missile was not extracted. He Avas discharged from the service January 27th, 1864, on recommendation of Surgeon C. B. Gibson, P. A. C. S. Case.—Private William A. AndreAvs, Co. D, 25th Massachusetts 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 Avas admitted to the Academy Hospital, NeAV Berne; was furloughed on April 20th, and was discharged the service October 16th, 1862, and pensioned. On December 12th, 1862, Pension Examiner Oramel Martin reports the Avound still discharging, and the patient complaining of stiffness in the cords of the neck, with Aveakness of the right arm, he being unable to move it for five Aveeks, except Avith 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, 1866, he says that the missile still remained in the brain, that the Avound Avas 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.—Private William F. Worley, Troop 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 Avas mustered out of service August 26th, 1865, 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. II. 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 frequent probings had failed to reach the ball, that small pieces of bone were discharged at the time of the probing, and that the Avound was a running sore, at times painful. Case.—Corporal Echvard Steible, Co. G, 43d Illinois Volunteers, Avas wounded at the battle of Shiloh, April 7th, 1862, by a musket ball, Avhich entered the frontal bone one inch above the superciliary ridge, and one inch and a half from the median line, passed through the skull backAvard and downward, and lodged. The patient was taken on board the steamer Empress on April 20th, was sent to the hospital at Keokuk, IoAva, and on July 17th to the New House of Refuge Hospital, St. Louis, Avhere he Avas discharged June 3d, 1863. The seat ofthe 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 appeared in the nasal cavity. The man Avas continually subject to vertigo. He Avas 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 Hospital, Baltimore, Avith a penetrating Avound 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 hospital at Point Lookout, Maryland; on May 1st, 1863, to West's Building Hospital, Baltimore, and on May 9th, to Portsmouth Grove, Rhode Island, where he was transferred to the Veteran Reserve Corps. He was discharged August 31st, 1866, and pensioned. The patient suffered from vertigo upon exertion. His disability Avas rated total. Case.—Corporal John W. Cook, Co. D, 52d Virginia Regiment, aged 22 years, Avas Avounded at the battle of Winchester, September 19th, 1864, by a conoidal ball, Avhich fractured the occipital bone and entered the brain. He was treated at Winchester until the 18th of December, when he Avas sent to West's Building Hospital at Baltimore. The treatment throughout was of a very simple character. The patient recovered, and Avas transferred on January 5th, 1865, to Fort McIIenry for exchange. On March 24th, 1865, he Avas examined by a Confederate retiring board. The missile Avas a source of constant irritation to the brain, and the board declared that the patient Avas unable to perform field duty, but might be employed at some post where the duties AA-ere not laborious. BALLS LODGED WITHIN THE CRANIUM. 19r, Case.—Private Jonathan Wiser. Co. E, 49th Pennsylvania Volunteers, aged 35 years, Avas Avounded at the battle of the Wilderness, May 5th, 1864, by a conoidal musket ball, Avhich fractured and slightly depressed the cranium. He Avas at first admitted to the hospital ofthe 1st division, Sixth Corps, and, on May 12th, AA-as sent to the Mount Pleasant Hospital, Washington. The records of the latter hospital state that the ball had not been extracted. On September 24th, he Avas admitted to the Frederick Hospital, Maryland, Avhere he remained under treatment until June 6th, 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 F. Leland, Troop F, 1st Illinois Cavalry, was Avounded 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 forAvard 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 Avound. The patient suffered pain in the region betAveen the entrance of the wound and the eyebrow. Active exercise, or stooping, would produce dizziness and pain. The vision and bearing of the left side were slightly impaired. He Avas discharged the service March 14th, 1862, and pensioned, his disability being rated one-half and temporary. Case.—Corporal William G. Davis, Co. A, 105th Ohio Volunteers, aged 30 years, was wounded at the battle of Chickamauga, Georgia, September 20th, 1863, by a conoidal musket ball, which fractured and penetrated the right temporal bone, and lodged AA-ithin the cranium. On September 29th, he Avas admitted to the hospital at Chattanooga, Tennessee, thence Avas transferred on October 6th to Stevenson, Alabama, and on October 12th to Nashville, where he remained under treatment until June 18th, 1864, Avhen he Avas sent to the Totten Hospital, Louisville, Kentucky. On July 15th, he was sent to the hospital at Cleveland, 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 Avounded 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 inAvard, a distance of tAvo and a half inches (as stated by the Surgeon avIio probed the Avound at the time of receipt of injury), and lodged. He was taken on board an hospital boat, where an unsuc- cessful attempt Avas made to extract the ball. On May 25th, the patient Avas admitted to the Van Buren Hospital, where he remained some Aveeks, 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 Aveeks previous to his discharge, the Avound suppurated freely, and occasionally bled, and small fragments of bone escaped. In November, he was placed to work on the levee by the Commissary Department. The Avork avus 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, Nashville, and on December 28th, sent to hospital No. 1, of the same place. On January 3d, 1864, the patient Avas 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 Avounded in an engagement at Bull Run Bridge, August 27th, 1662. by a carbine ball, which struck at a point tAvo 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 Avas not suspected, and the case Avas treated as a superficial scalp Avound. On September 3d, he Avas admitted to the Broad and Cherry Streets Hospital, Philadelphia. Healthy suppuration continued, and a fragment of bone was discharged from the wound. On November 6ch, the wound had healed, and the patient Avas returned to duty. Two days later he was admitted to the Ryland 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 suffering constant headache, which was greatly increased by exposure to cold air; he also suffered from acute darting pains across the base of brain, from the right temple to the scar of the wound. No paralysis existed and the functions of the body were generally Avell performed. The cicatrix, though tender, Avas 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 Avas becoming pale and emaciated. He Avas discharged the service January 19th, 1863. Surgeon John A. Lidell, U. S. V., Avho reports the case, states, that it Avas 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 Avas still pending, and his disability rated three-fourths and probably permanent. Case.—Sergeant Walter Rotherham, Co. D, 7th Ncav Jersey Volunteers, aged 23 years, was wounded at Gettysburg, July 2d, 1863, by a musket ball, which penetrated the skull near the right frontal eminence, passed directly inAvard and lodged someAvhere 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 Avith a probe for a considerable distance, as that mem- brane was detached from its natural connections with the skull. The patient Avas unable to say Avhetber there had been much haemorrhage or not. The parts Avere still open, and in making an exploration, the little finger could be readily inserted through the fracture, but no jagged bone pressing 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 toAvard the back of the skull Avhere it still Avas concealed. The patient further stated that, on recovering his senses, he was not in the least paralyzed, and was able to converse, and that Iris surgeon said : " you cannot possibly live." After a feAV hours, he again became insensible and remained so for tAvo days, when consciousness again returned. The patient, on admission, Avas able to sit up, stand, and Avalk, but he carried his head backAvard, resting between the shoulders, and complained of great pain and dizziness, if he attempted to change it to an erect position. There Avas no perceptible loss of poAver, motion, 196 WOUNDS AND INJURIES OF THE HEAD. or sensation on either side of bis body. He was directed to be put to bed, and quiet was enjoined. His hair was then cut short, and cold Avater dressings Avere applied. There being no arterial excitement, the treatment was chiefly expectant. His recovery was rapid, and on August 12th, he Avas furloughed for fifteen days, at the expiration of Avhich time he returned, having suffered no inconvenience from the journey. The Avound, however, had not entirely closed, and since that date several pieces of bone have exfoliated. He Avas 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 Avhich 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 boAvels were obstinately constipated, but were readily relieved by mild cathartics. Occasionally he Avas 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. Army. Case.—Private Elijah Lanning, Co. K, 79th Pennsylvania Volunteers, Avas struck by a missile at the battle of Chicka- mauga, Georgia, September 19th, 1863, which penetrated the right parietal bone. No particulars of the case can be obtained until February 17th, 1864, Avhen the patient was admitted to the field hospital at Chattanooga, Tennessee. He received a furlough 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 A\-as mustered out of service and pensioned. A month after, Pension Examiner S. Cleizer reports the ball still remaining Avithin the cranium, causing paralysis ofthe 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 AndreAV M. BroAvn, 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 Avas admitted to the hospital at Springfield. He recovered, and was returned to his regiment, then the 1st Missouri Infantry, for duty. The ball Avas successfully removed from the Avound in 1868, seven years after the reception of the injury. 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, which penetrated the left parietal bone. He was admitted to the Log Hospital, Chancellorsville, and on June 8th, Avas sent to the MoAver Hospital, Philadelphia. The ball had been extracted prior to admission, and several pieces of bone had come away. The pulsations of the brain Avere visible through the wound. During the months of June, July, August, and September, fragments of bone continued to come away, but on October 20th, the Avound had healed Avith the exception of a small point. He had been transferred to the Veteran Reserve Corps on August 20th, 1863. On September 1st, 1864, he Avas 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 Avas 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 Avas successfully performed. No ill results ensued. He was kept quiet in his quarters until the 23d of October, Avhen he Avas trans- ferred, by Avay of Chattanooga, to Nashville, Tennessee, where he was admitted into Hospital No. 1, on October 27th. On November 2d, he Avas furloughed, and on December 20th, Avas admitted to the hospital at Keokuk, IoAva. At the expiration of his term of service on the 22d of February, 1865, he was transferred to Davenport, IoAva, for muster out. He is not a pensioner. Case.— Private EdAvard Ware, Co. F, 13th Iowa Volunteers, aged 24 years, Avas wounded near Atlanta, Georgia, July 20th, 1664. by a conoidal musket ball, Avhich fractured both tables of the frontal bone at the upper border, left side, and penetrated the brain. He Avas admitted to the hospital of the 4th division, Seventeenth Corps on July 30th; on August 3d, Avas transferred to the hospital of the Seventeenth Corps, and on August 10th Avas sent north. No records of the case can be found until Decem- ber 19th, when Ware was admitted to the hospital at Keokuk, Iowa, from furlough. The ball had been removed by incision on November 6th, 1664. and simple dressings had been applied. The Avound Avas still open, but looked healthy. On January 2d, 1865, Ware Avas transferred to Davenport, IoAva. 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 Avounded at Gettysburg, July 1st, 1863, by a missile Avhich penetrated the frontal bone near the right eminence and entered the brain. He Avas admitted to the Seminary Hospital, and on July 8th, was sent to TAventy-fourth and S„uth Streets Hospital, Philadelphia, where the missile was removed by Acting Assistant Surgeon F. F. Maury. The patient recovered, and on September 17th, 1864, Avas transferred to the Yeteran Reserve Corps. He Avas discharged the service June 30th, 1865, and pensioned on June 23d, 1658. 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.—PriA-ate William Duffy, Co. F, 69th Ncav York Volunteers, aged 28 years, was Avounded at Antietam, September 17th, 1862, by a conoidal ball, Avhich entered the left parietal about its junction with the squamous portion of the temporal bone, passed doAvinvard and backward, and lodged in the substance of the brain. He aaiis insensible about an hour, at the expiration of AA'hich time the missile Avas removed. The right arm and hand Avere paralyzed. The patient was admitted to the Sixteenth and Filbert Streets Hospital, Philadelphia, September 26th, 1862, where he gradually recovered, under expectant treatment. He Avas sent to the Ladies' Home Hospital, New York City, May 26th, 1863, and Avas 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 Avas 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, AA-ith defective articulation, and rates his disability total and permanent. Case.—Private William E. Chapman, Co. E, 69th Ncav York Volunteers, Avas wounded near Petersburg, Virginia, March 25th. 1865, by a conoidal musket ball, AA'hich 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 Avas conveyed to Washington, and admitted to the Camp- bell Hospital, on March 28th, AA'here the missile Avas removed. He Avas 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, Avith a continued dull pain in the head, and the jaw Avas anchylosed. His disability is rated three-fourths and temporary. Case.—Sergeant Frank D. Hamilton, Co. E, 28th Massachusetts Volunteers, aged 22 years, Afas Avounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, Avhich apparently produced, only a scalp wound. He Avas sent to the hospital of the 1st diA-ision, Second Corps, thence Avas conveyed to Washington, and on the 7th, admitted to the HareAvood Hospital. On June 16th, he Avas transferred to the Knight Hospital at NeAV Haven, Connecticut, Avhere it Avas discovered that the frontal bone had been fractured. The treatment throughout Avas of a simple character. In November, the patient Avas sent to the Dale Hospital, Worcester, Massachusetts; 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. 1,1st Kentucky Cavalry, Avas wounded at Fair Garden, Tennessee, January 28th, 1664, by a conoidal ball, Avhich entered the forehead at the right supercdiary 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, Avas again admitted to hospital No. 1, Nashville. The Avounds of entrance and of exit had cicatrized, and the patient suffered little or no inconvenience. On February 13th, he Avas transferred to Frankfort, Kentucky, and Avas discharged December 31st, 1864, suffering from headache, neuralgia, and heaviness about the head, Avith occasional dimness of vision and almost constant discharge fi-om 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 freely, 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 Avas supposed, depressed and necrosed bone, was decided upon and performed by Dr. D. Cummins, assisted by Drs. J. A. Brady and P. Peter. A crucial incision was made directly over the point of entrance at the internal angle of the right superciliary ridge; a fungous and cartilaginous groAvth was noAV 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, Avere removed. When this Avas done, the internal table was found to be slightly depressed, Avith an opening in the depression communicating Avith the dura mater opposite the site of the fragments of lead. As the patient had never suffered from epilepsy, it Avas not deemed advisable to remove the depressed bone. The Avound Avas closed with sutures, and isinglass plaster and water dressings were applied. He improved rapidly, without any untoAvard symptoms, and in ten days left for his home. In August, 1870, the patient Avas hearty, had gained considerable flesh, and Avas free from headache, neuralgia, dimness of vision, or anything of the kind. He is a pensioner.1 CASE.-Private Jonathan U. Smith, Co. K, 20th Ohio Volunteers, aged 20, Avas Avounded at Goldsboro', North Carolina, by a missile, which struck near the centre of the left parietal bone and carried aAvay a portion. The ball avus 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 Avas unable to exert himself without severe pain in the head, and that he Avas affected by the vicissitudes of the weather. His disability Avas rated three-fourths and temporary. Case.—Private Andrew Gallagher, Co. D, llth 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 Avas gone; the eyeball wis one-third less in s.ze, and the pupil was insensible to light. Sudden shocks would give great 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. i This case is reported in the American Practitioner, A'ol. II, p. 332, Louisville, 1870. 198 WOUNDS AND INJURIES OF 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 Dickerman, Co. I, 20th Connecticut Volunteers, aged 23 years, Avas 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 inAvard and forward, and carried away a portion ofthe anterior surface ofthe greater wing of sphenoid, one-eighth of an inch in diameter. He was sent to the hospital of the TAventieth Corps, which he reached in an insensible condition. Attempts Avere made to find the ball, but without success. He remained unconscious for several days, and was, in the meantime, transferred to Awning'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 request, chloroform Avas administered, and a second search was made for the ball, Avhich Avas 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. There 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 perceptibly injured, and singu- larly enough the iris responded freely to the action of light. The patient showed 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 June 13th, 1865. But he had not recovered; working in the sun or severe mental application Avould invariably bring on vertigo and headache. In the summer of 1866, an epileptic convulsion supervened, lasting about fifteen minutes. Subsequent prostration Avas 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 Avere 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, when 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 doAvn between the hemispheres, more firmly organized lymph was found, uniting the layers of the arachnoid so firmly that they were only separated Avith difficulty. The substance of the brain presented a healthy appearance, and the ventricles contained no fluid. At the bottom of the middle lobe of the left hemisphere, an abscess was found containing tAvo or three ounces of dark-colored and offensive pus. 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 pterygoid fossa, on a line with the track of the ball and evidently caused by it. The case is reported by Surgeon J. Wadswoith Terry, 20th Connecticut Volunteers. Case.—Private C. W------, Co. E, 14th West Virginia Volunteers, aged 22 years, was admitted to the general hospital at Frederick, Maryland, September 17th, 1864, coming by rail from the hospital at Sandy Hook, having been wounded at Berry - ville, Virginia, on September 3d, by a conoidal musket ball Avhich entered the left temporal bone an inch above the auditory meatus, passed inAvard and forAvard, and a little upward. Acting Assistant Surgeon J. H. Bartholf reports that he passed a probe Avith great freedom four and a half inches into the wound. There was paralysis of the second, third, fourth, fifth, sixth and seventh cranial nerves ofthe left side, and total blindness of the left eye, with dilatation of the pupil and insensibility ofthe iris and retina, anaesthesia of the cornea and conjunctiva of the left half of the face. On one occasion a pin Avas stuck into the scalp of the forehead by an awkward nurse and the patient did not know of the accident. The facial and 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. The 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 boAvels were normal; he was perfectly conscious; his articulation thick, but improving daily. On September 18th, Acting Asistant Surgeon Bartholf succeeded in finding and extracting from an inch and a half within the skull one-third of a conical bullet. From that time onward the patient rapidly improved. The removal of the foreign body Avas immediately folloAved by a very free Aoav of pus. On September 20th there was some A-ision of the left eye. The next day the patient could count figures held near the eye. The hearing of the left ear returned sufficiently for the patient to hear loud speaking. By October 10th the patient was going about the ward in comparatively good health, except that there was ptosis, a little discbarge 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 Avound, the patient Avas transferred to the hospital at Grafton, West Virginia, whence Surgeon M. G. Sherman, U. S. V., Avrote to Assistant Surgeon R. F. Weir, U. S. A., that the Avound Avas healed when the patient came to him, but that there was some discharge from the ear; that he had learned from the attendants that the patient had drank immoderately of spirits on his way from Frederick to Grafton; one of the nurses stating that he drank at least a quart of whiskey on the day prior to his arrival at Grafton. Yet he seemed tolerably Avell on the day of his arrival and on the following day; but on November 4th BALLS LODGED WITHIN THE CRANIUM. 199 he had a severe chill in the morning, and on the 5th convulsions with strabismus of the right eye-ball. On the morning of the 6th he died, after a convulsion accompanied by opisthotonos. Twenty-eight hours after death a post mortem examination Avas made. After removing the calvaria and the brain, a portion of a conoidal musket ball, comprising nearly tAVO-thirds ofthe missile, Avas found resting against the sella Turcica, having traversed the long diameter ofthe temporal, being cut off very clean. Dr. Sherman adds that he understands that the other third of the ball Avas removed from beneath the scalp; but Dr. Bartholf s notes are conclusive as to the position of the other frag- ment. Dr. Sherman preserved the patient's skull Avith a vieAV of forwarding it with a history of the case to the Surgeon General's Office; but the specimen Avas never received at the Army Medical Museum. The notes furnished by Dr. Bartholf, and a conversation of Dr. Sherman with the editor of this Avork, have permitted mentsofball ex- the completion of this history. The fragment of the bullet, extracted by Assistant Surgeon Bartholf, is figured brain. Sp. 5555, in the adjacent Avood-cut, It Aveighs nearly half an ounce. Sect. I, A. M. M. Case.—Private 0. R. Laioless, Co. E, 28th Virginia Regiment, aged 45 years, received, near Richmond, Virginia, June 17th, 1864, a penetrating gunshot fracture of the frontal bone, the missile entering near the left eminence. On the following day he Avas admitted to Chimborazo Hospital No. 5 at Richmond, Avhere the ball Avas extracted and expectant treatment Avas used. The patient suffered some pain, but Avas in good condition, the tongue being natural, and pulse seventy-two, but intermittent. On June 20th he Avas in possession of all his faculties and doing well, and on June 22d the pulsations Avere visible through the Avound. On June 26th his pulse Avas natural, but he kept his eyes closed, only opening them when spoken to. He answered questions, but Avas 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, 1864, Avithout exhibiting any violent symptoms. Case.—Private Francis Donohue, Co. B, 83d Pennsylvania Volunteers, aged 19 years, was wounded at the South Side Railroad, Virginia, March 31st, 1865, by a conoidal projectile which penetrated the frontal bone one inch above the right frontal eminence. He Avas sent to the hospital ofthe 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 Avas extensive laceration of the integument and considerable comminution of bone. Considerable brain substance escaped through the opening in the cranium. Expectant treatment Avas resorted to, in spite of which the patient sank rapidly and died April 16th, 1865. 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, U. S. A. Case.—Private Thomas J. C------, Co. B, 28th NeAV York Volunteers, was Avounded at the battle of Antietam, September 17th, 1862, by a spherical projectile Avhich entered near the centre of the forehead, passed doAvnward 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 Avas admitted to 24th and South streets Hospital on September 26th, 1862. The right eye, which was in a sloughing condition, Avas extirpated next day and the missile removed. Death occurred October 4th, 1862. At the autopsy a large abscess was found behind the orbit pressing on the base of the brain, with extensive softening and infiltration in its vicinity. The pathological specimen is No. 216, Sect. I, A. M. M. A section of frontal bone perforated just above the inner angle ofthe 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 ofthe opening. Two square inches of the inner table have been carried away, including a portion ofthe orbital plate. A fissure extends downward through the entire thickness of the supra-orbital arch, and a second fissure traverses the plate of bone between the frontal sinuses. The specimen Avas contributed by Surgeon J. Hopkinson, IT. S. V. Case.—Sergeant J. Wilds 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 6th, 1864. The missile, which had entered the centre of the occipital bone, Avas extracted on the field. Considerable loss of brain matter ensued, and the patient died May 10th, 1864. Case.—Sergeaut Aurelius A. Robinson, Co. I, 17th Maine Volunteers, was wounded at the battle of Gettysburg, July 2d, 1863, by a conoidal ball which struck the forehead, penetrated the outer table ofthe 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,. Avith very ragged edges. These points and indentions Avere so closely matched by corresponding points and depressions on the skull, that a fine probe could not be inserted betAveen them. The ball was removed Avith forceps by Surgeon H. F. Lyster, 5th Michigan Volunteers. The case proved fatal July 6th, 1863. Case.—Private Montellion Smith, Co. H, 5th Vermont Volunteers, aged 39 years, Avas Avounded 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 Avas extracted on the field. He Avas admitted to the hospital of the 2d division, Sixth Corps, and on October 23d, Avas 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 folloAved. On the 28th, the wound Avas enlarged, when an extensive fracture of the bone was disclosed. Cold water dressings Avere applied 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 Avere found imbedded in the brain substance. The dura mater near the wound Avas disorganized and coated Avith a purulent and lymphy deposit. A large abscess extended to, but did not open into, the lateral ventricle; there Avas considerable interstitial congestion through the brain. 200 WOUNDS AND INJURIES OF THE HEAD. Case.—Corporal McD------, Troop F, 6th South Carolina Cavalry. Avas Avounded February 10th, 1864, by a conoidal ball, which perforated the skull under the superior curved line ofthe 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 Avas round and smooth, and alloAved 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 aftenvard. After diligent search, half of the missile was found under the scalp, one inch from the original injury, and was easily remov-ed. The patient died February llth, 1864. 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 Avas contributed by Surgeon S. BrillantOAVski, 41st Ncav York Volunteers. Case.—Corporal John Sponsler, Co. H, 48th Pennsylvania Volunteers, was Avounded at Campbell's Station, near Knoxville. Tennessee, on November 29th, 1863, by the plug of a shell, AA'hich passed through the skull near the coronal suture. II«' Avas 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 XV. Tolles, chief quartermaster Middle Military Division, was attacked on the llth of October, 1864, by a band of guerillas as he Avas passing through NeAvtoAvn, Virginia, on his Avay to the front. Although he surrendered Avithout 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 midAvay 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 Avas conveyed to Winchester, and placed under the care of Dr. Emanuel, Acting Staff Surgeon, U. S. A. This officer states that the Avound suppurated well, and caused no pain; the patient's mental faculties remained unimpaired, and his appetite good, so that a favorable prognosis Avas granted. On October 22d, the ball Avas extracted in small fragments. About the end of October, evacuations of the faeces and urine began to occur involuntarily; on the 31st, there Avas 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, AA'hich Avas about one-half inch deep, filled with purulent and offensive pus, and lined Avith plastic filamentous fibrin. A fragment of bone, about three-fourths of an inch in diameter, Avas extracted from a point just below. The pia mater had suffered morbid changes. A sero-purulent fluid Avas found in the inferior and posterior depressions of the lateral ventricles, and likeAvise 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 Avere of a greenish hue; the optic commissure Avas congested. The substance of the encephalon Avas sound throughout. The semi-lunar lobe of the left lateral hemisphere of the cerebellum Avas firmly adherent to the tentorium. The case is reported by Acting Assistant Surgeon W. L. Hammond. Case.—Private A. A. Watson, Co. B, 46th North Carolina Regiment, Avas, on June 7th, 1864, admitted to hospital No. 24, Richmond, Virginia, Avith a gunshot fracture of the skull. The missile entered at the right protuberance of the frontal bone, passed through and lodged. He Avas 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 folloAved, but in a feAV days the Avound 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 Reserves, aged 26 years, Avas Avounded near Old Church, Virginia, May 30th, 1864, by a conoidal ball, Avhich fractured the anterior inferior angle of the right parietal bone and lodged in the brain. He Avas 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 bone were removed. A cerebral abscess formed, and death ensued on the llth. The pathological specimen, No. 2682, Sect. I, A. M. M., is a section of cranium, from Avhich fragments have been removed for a distance of tAvo inches from before backAvard, 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 tAvo 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 Avere contributed by Assistant Surgeon G. A. Mursick, U. S. V. Case.—Sergeant George W. Burtiss, Co. G, 173d New York Volunteers, Avas accidentally wounded, on January 23d, 1864, by a pistol ball, Avhich fractured the cranium and lodged in the left side of the brain. He became unconscious and Avas taken to the regimental hospital. Ten minutes after the accident his countenance Avas livid, pulse sIoav and full, respiration labored and spasmodic. Some reaction took place noAV and he cried out to have his face Aviped. He struggled to "et up to urinate and begged his attendants to let him 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. The patient died nine hours after the reception of the injury. At the autopsy tAvo small Avounds were found, one incised, about one inch above the left eyebrow. The areolar tissue of the left eyelid and sin rounding the AA-ounded parts were infiltrated with blood. Several spiculae of bone and a small scale of lead Avere 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, Avas found in the frontal bone about one inch above the left superciliary ridge. Fig. 101 .—Two lateral views of u fragment of a conoidal ball sjilil upon the skull. Spec. 4150, Sect. 1, A. M. M. FATAL PENETRATING GUNSHOT FRACTURES OF THE SKULL. 201 Between the skull and dura mater Avere several spicula; of bone. The left hemisphere ofthe cerebrum was extensively lacerated through its longitudinal diameter. The bullet Avas found in the posterior lobe of left hemisphere near the dura mater. Large clots of blood covered the 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. Leigbton, 173d Noav York Volunteers. Case.—Private Anton Lambert, Co. E, 9th Kansas Cavalry, was wounded in a skirmish Avith guerillas near Westport, Missouri, June 17th, 1863, by 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, but died June 20th, 1863. The autopsy revealed a rupture of the lateral sinus. The ball had glanced forAvard, 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, llth 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 Avas corn-eyed to Washington, and on the 7th, Avas admitted to the Douglas Hospital. Hemiplegia of the left side existed at the time of his admission; the pupil of the right eye Avas much dilated, and brain substance Avas protruding from the wound of entrance. Simple dressings Avere applied to the wound, and expectant treatment was had recourse to; but he died on the llth of the month. At the autopsy, FiG.l02.-Round the missile Avas found lodged behind the sella Turcica. It was a bullet, with a deep groove containing a frag- the cerebrum. ment of the temporal bone, contributed, AA-ith its history, by Acting Assistant Surgeon John O. Smith. t^a^m' m60*' Case.—Private E. G------, 18th Indiana Battery, aged 25 years, was accidentally wounded on January 7th, 1865, by a pistol ball Avhich 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, Avell 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 left hemisphere. Brain sub- stance 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 occurred January 14th, 1865. The ball had traversed the AA'hole 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 Avas fruitless. The ball must have dropped out of the wound of entrance at some time when the face and head hung loAver 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. May. 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, 1863, and died July 2d, 1863, his widow receiving a pension from that date. Doctor William H. BoAven, 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 aAvay 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 pupil 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, Avas wounded at Fredericksburg, December 13th, 1862, by a piece of shell, which fractured 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 loAver extremities, involving the bladder, followed. On December 19th, the patient was transferred to Alexandria, and was admitted to the 3d division hospital. Stimulating lotions Avere 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. Case.—Private George Knapp, Co. D, 8th New Hampshire Volunteers, was accidentally wounded on October 29th, 1864, while on picket near Natchez, Mississippi, by a conoidal ball which struck 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 Avounding 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, tAvelve hours after reception of injury. The autopsy revealed an extensive depressed fracture at seat 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 AVOUNDS AND INJURIES OF THE HEAD. Case.—Corporal Gardner Gaylord, Co. B, 16th Massachusetts Volunteers, Avas Avounded at the battle of Bull Run, Virginia, August 30th, 1662. by a conoidal ball Avhich penetrated the cranium just above the right frontal eminence, causing a stellate fracture with cleanly cut edges. On September 1st he was admitted to the Judiciary Square Hospital, being perfectly conscious. All his functions remained normal; he Avas able to help himself and complained of no pain. On September 3d he became comatose, and died September 5th, 1662. At the autopsy the ball was found to have entered the anterior lobe of the right hemisphere, carrying Avith it fragments of bone and traversing the brain substance nearly the full extent of the hemisphere- At the point of entrance there Avas an abscess the size of a walnut, and the track of the ball Avas filled Avith pus. A small quantity Avas 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 AA'hich fractured the frontal bone, traversed the brain and lodged. He was con- veyed to Nashville, and on the 5th of May was admitted into hospital No. 1. Brain matter, yielding a thin, greenish, and fetid discharge, protruded from the wound, which evidently Avas of considerable extent. An examination of the Avound was made and it Avas 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 ofthe cerebral substance. The surrounding soft parts.Avere of course much inflamed and swollen. The patient was perfectly rational and would ansAver questions promptly, though he had no inclination to converse, and if left undisturbed, Avould sleep the greater part of the time. The pulse Avas alternately strong and intermittent. The digestive functions remained undisturbed. The patient did not complain of much pain, and could stand and walk. The treatment Avas expectant; but the patient gradually sunk into a comatose state, though Avhen 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 dis- placed fragment of the frontal bone Avas found to measure four and a half inches in diameter. A fissure passed doAvnward separating a part of the great ala of the sphenoid and the squamous portion of the temporal bone. The missile Avas found in the vicinity of the left great wing of the sphenoid against which it had struck, the point of contact being evident by discolora- tion as Avell as by a slight fissure of the vitreous table. The pathological specimen with history Avas contributed by Surgeon R. S. Stanford, U. S. V. It is numbered 3358 in the surgical section of the museum. Case.—Captain XV. E. Tucker, Co. B, 67th Pennsylvania Volunteers, Avas wounded at Annapolis, Maryland, October 29th, 1862, by a conoidal ball Avhich 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 sIoav. Upon probing the Avound brain matter exuded. The treatment was expectant. Full consciousness was restored on the morning of the 30th, so that when aroused he readily recog- nized his friends and answered questions correctly. He soon relapsed into the former comatose condition. On the folloAving day two small fragments of bone were discharged from the wound. On the morning of November 1st, a decided febrile action Avas 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 tAvelve hours aftenvard 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 delirium existed at any time during the progress ofthe case. At the autopsy a small, smooth perforation Avas found to the left of the median line about three-eighths of an inch in diameter. The injury to the inner table was more extensive, covering three-fourths of an inch in diameter. Fragments of the inner table were driven into the anterior lobe of the left hemisphere and softening existed in their immediate vicinity. The missile, which weighed 32 grains, was traced diagonally downward through the corpus callosum to its place of lodgment beneath the posterior lobe of the right hemisphere. 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 Avas filled with blood. The case is reported by Assistant Surgeon James W. Petinus, 67th Pennsylvania Volunteers. CASE.-Private Thomas Urch, Co. F, 211th Pennsylvania Volunteers, was wounded before Petersburg, Virginia, April 2d, 1865, by a conoidol ball Avhich entered the brain through the frontal bone one and a half inches above the right eye. On the same day he Avas admitted to the hospital of the 3d division, Ninth Corps, and thence was conveyed to Armory Square Hospital, at Washington, Avhich he entered on April 10th. An attempt was made on the folloAving 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, Avas Avounded at the battle of Coal Harbor, Virginia, June 3d, 1664, 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 knoAvn. Death took place on the 8th of June 1864. Case.—Sergeant Alexander E------, Co. B, 56th North Carolina Regiment, aged 30 years, was Avounded at Petersburg, March 26th, 1865, by a conoidal ball, Avhich 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 March 30th was admitted to Lincoln Hospital, Washington, being nearly comatose. The probe could be passed into the brain. Death occurred on April 2d, 1865, from exhaustion and congestion. The autopsy revealed the course of the ball as above stated. The pathological specimen is No. 85, Sect. I, A. M. M., and consists of nine fragments, chiefly from the malar bones, and the ball, separated into tAvo parts. The specimen, with the history, Avas contributed by Acting Assistant Surgeon T. P. Arthur. Case.—Sergeant Charles B. Hummell, Co. D, 127th Pennsylvania Volunteers, aged 22 years, was Avounded at the battle of Fredericksburg, Virginia, May 1,1663, by a spherical case-shot which penetrated the right parietal bone near the junction of the sagittal and coronal sutures. On the morning of the 6th, he Avas conveyed by steamer to Washington, and was admitted to the FATAL PENETRATING GUNSHOT FRACTURES OF THE SKULL. 203 Stanton Hospital, in a state of unconsciousness, suffering from the shock of injury; his pulse Avas one hundred and sixty and very feeble. By the afternoon of that day he had rallied considerably, though he still remained insensible. No paralysis of any part of the body could be detected. He lay upon his back, apparently sleeping, his respiration being perfectly natural. During the examination of the pupils, which Avere found someAvhat contracted, though still symmetrical, he exhibited manifestations of consciousness by offering some resistance. A probe Avas readily passed a considerable distance along the track of the missile into the brain substance. Very little hocmorrhage from the Avound occurred. The patient swallowed without difficulty and passed his urine involuntarily. After shaving the head a bag of ice Avas applied; a stimulating injection Avas then employed, Avhich acted well, and nutriment Avas given in the form of beef tea. The next morning the pulse was one hundred and fourteen and someAvhat stronger; the pupils Avere natural in size, and contracted readily under the action of light. He readily flexed and extended his legs, raised his hands to his head, rnbbed his eyes, Avhich 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 sound of his name when addressed, but took no notice of surrounding objects. The enema was repeated. On the morning of the 9th, the pulse had risen to one hundred and thirty, with further dilatation 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, Avith paralysis of the right buccinator muscle. No other face muscles Avere involved and there were no convulsions or paralysis. On the llth there Avas full dilitation of the right pupil, the left remaining natural. The respiration, still Avithout stertor, was greatly increased in frequency, the diaphragm assisting but little in the breathing. The power of deglutition Avas lost and the right arm was partially paralyzed. The enema was repeated but the patient continued to sink, and died at eight P. M. on the llth of May. At the autopsy, some fragments of bone were found at the wound of entrance. On removing the calvaria, a large quantity of serum, slightly tinged Avith blood, escaped from the cavity. The missile had passed doAvuward, backward, and to the left side, into the left cerebral hemisphere. Several small pieces of bone, a piece of scalp, and some hair, were distributed along the track, around Avhich, for the distance of half an inch, the brain Avas softened by inflammation. A large clot of blood lay along the right side of the falx cerebri. The pathological specimen, No. 1137, Sect. I, A. M. M., showing five fragments of bone, with a round bullet, removed at the autopsy, Avas contributed, with the history, by Surgeon John A. Lidell, U. S. A. Case.—Lieutenant John Harris, of Mclntyre's Command, C. S. A., aged 27 years, was wounded in action near Helena, Arkansas, about the middle of June, 1864, by a conoidal musket ball which detached the right 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 Avound soon became gangrenous, and death resulted on July 1st, 1864. No further particulars are recorded. Case.—Private Alexander Johnson, Co. A, 102d U. S. Colored Troops, received at the battle of Pocotaligo, South Carolina, December 9th, 1864, 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 Avas dressed in the usual manner. On the 14th he was 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 wounded in the head in a skirmish at West Point, Mississippi, February 22d, 1864, by a musket ball which entered the cranial cavity on the left side and lodged in the substance of the brain. He was conveyed to Memphis, Tennessee, and admitted on the 27th into the Washington Hospital. Meningitis and coma supervened, and death resulted on the llth of March, 1864. At the autopsy the ball was found, but the exact place of lodgement is not stated. Case.—Captain John R. Lamrie, Co. D, 6th Wisconsin Volunteers, aged 28 years, was wounded at Hatcher's Run, Virginia, February 6th, 1865, by a conoidal ball, Avhich penetrated the cranium. He was admitted to hospital 3d division, Fifth Corps, and on February 7th, sent to hospital of Fifth Corps at City Point. There was evidently compression of brain from extra- vasation of blood. He died February 16th, 1865. At the autopsy the greater longitudinal sinus was found perforated, and fragments of bone were lying loose upon the brain. Abscesses had formed in the superior and internal portion of each hemisphere and were in a suppurating condition. Case.—Corporal 71*. F. Lancaster, Co. F, 3d Virginia Regiment, aged 24 years, was Avounded at the battle of Gettys- burg, July 1st, 1863, by a musket ball which 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 patient was conveyed to the Seminary Hospital, where 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 wound was painful, and his sleep at night disturbed. Cold-water dressings and expectant treatment were used. On the 1st of August short periods of delirium occurred, with quick, small pulse, which was followed by obstinate diarrhoea. By the 4th, delirium had become constant, terminating five days later in a state of partial stupor. Insensibilty folloAved, on the morning of the 10th; his respiration becoming stertorous, pulse frequent and weak; and death occurred at five o'clock in the afternoon. At the autopsy, the portions of the squamous bone immediately surrounding the upper part of the perforation Avere found depressed nearly a fourth of an inch. The parietal, sphenoid, and frontal bones were also involved in the fracture. Avhich measured three and a half by two inches. In the immediate vicinity of the fragments disorganization of the brain existed, but in the other parts its structure was healthy. The pathological specimen is No. 1720, Sect. I, A. M. M., and Avas contributed, with the history, by Assistant Surgeon E. Brooks, U. S. A. CASE.-Private J. O'Brien, Co. F, 47th Pennsylvania Volunteers, Avas wounded at the battle of Pocotaligo, South Carolina, October 22, 1862, by a musket ball, AA'hich entered half an inch below the centre of the lower edge of the right orbit, passed toAvard the centre of the head and lodged deep in the brain. On the following day the man was conveyed by steamer to the general hospital at Hilton Head. He became comatose on October 25th, and died on the following day. The case is reported by Assistant Surgeon John Bell, U. S. A. 204 WOUNDS AND INJURIES OF THE HEAD. Case.—Lieutenant Colonel Melanchthon Smith, 45th Blinois Volunteers, was Avounded at the siege of Vicksburg, Mississippi, June 26th, 1663. by a buckshot, which fractured the cranium. The action of organic life seemed to be principally affected and circulation and respiration gradually failed together. He died on June 28th, 1863. The autopsy revealed a small penetrating Avound of occipital bone. The missile comminuted the external table and diploe and turned aside an oval portion of the internal table, passed through the right lobe of cerebellum and lodged in the fold of the dura mater which separates that body from the right lobe of cerebrum. There was hut little disorganization in the track of the ball and not much congestion of the meninges and cerebrum. The case is reported by Surgeon 0. B. Ormsby, 45th Blinois Volunteers. Case.—Colonel Thomas Puffin, 1st North Carolina Cavalry, aged 37 years, Avas wounded at Bristow Station, Virginia, October 14th. 1663. by a conoidal ball, which struck the skull, near the junction of the coronal and sagittal sutures, and passed along the latter a distance of four inches, fracturing both tables. He was admitted to the 2d division hospital at Alexandria on the folloAA-ing day, being perfectly conscious. No paralysis existed and the pupils were normal. On the 17th there was slight delirium occurring at intervals. The boAvels being constipated, half an ounce of castor oil Avas administered. He retained full possesion of his faculties until a minute before his death, which occurred suddenly on the 18th. On the removal of the skull-cap, it was found that the inner table was shattered for a space of one and a quarter inches in diameter; spiculae being lodged in the membranes and driven into the substance of the brain. As this organ was taken from the cavity for special examination, tAvo ounces of blood collected in the back of the skull; and tAvo clots containing someAvhat more than an ounce of fluid, with about three ounces of a sero-purulent character, were found lying upon the left anterior lobe, beneath the dura mater. A flattened piece of the missile Avas found in the right anterior lobe, on a level with the corpus callosum, directly beneath the wound of entrance. The pathological specimen is No. 1734, Sect. I, A. M. M. The fractured and depressed portion measures three-fourths by one inch. A fissure one inch in length runs doAvnward in the centre of the frontal bone. The fragments removed consist entirely of diploe and inner table. The fragments of the outer table remain in situ. The specimen and history were contributed by Acting Assistant Surgeon T. IL StillAvell. Case.—Corporal Lucian Sanderson, Independent Company, 9th Massachusetts Light Artillery, wasAVOunded at the battle of North Anna, Virginia, May 23d, 1864, by a conoidal ball, which struck the left temporal bone immediately above the meatus auditorius externus and penetrated the brain. He Avas, on the same day, admitted to the hospital of the 4th division, Fifth Corps, in a comatose condition, Avith the brain substance oozing from the wound. Simple dressing was applied, but death supervened on May 24th, 1864. CASE.-Private Butler G. S------, Co. F, 9th Kentucky Cavalry, was wounded July 12th, 1863, Morgan's Raid, by three buckshot; the first entered at the external angle of the left eye, passed through the upper lid close to the superciliary ridge, penetrated the orbital plate of the frontal bone and lodged in the cerebrum; the second entered over the zygomatic process ofthe left side, and the third over the superior maxillary bone near the origin of the zygomaticus major muscle. He was admitted to the hospital at Madison, Indiana, July 12th, 1863. He remained unconscious for three days. On July 17th, his condition had improved, but on July 23d, inflammation of brain and coma folloAved. He died July 24th, 1863. The pathological specimen is No. 4568, Sect. I, A. M. M. It was contributed by Surgeon A. M. Wilder, U. S. V. Case.—Private H. Thompson, Co. D, 16th Georgia Regiment, was wounded at the battle of Chancellorsville, May 3d, 1863, by a buckshot, AA'hich penetrated the left temple just above the zygomatic process, one inch posterior to outer portion of orbit. When admitted to the Chimborazo Hospital at Richmond, he complained of much pain in the vicinity of the wound, AAhich Avas slightly tumefied and discharged a small quantity of healthy pus. The pulse Avas natural; there Avas no fever, and the bowels Avere moved once daily. Cold applications Avere regularly kept up until May 15th, when symptoms of oppression appeared. There Avas stertorous respiration, with pulse 70, the mind much confused; mouth and tongue quite dry, but no dilata- tion of pupils Avas noticed. The orifice of wound was enlarged to permit free exit of discharge; the head was shaved and ice freely applied to the scalp. From May 18th, the patient improved, and apparently recovered, but on May 30th, he became suddenly comatose, and died May 31st, 1863. At the autopsy, a buckshot, much flattened, was found imbedded a quarter of an inch in base of an anterior portion of the middle lobe of left hemisphere. The ball had passed through the Avings ofthe sphenoid bone, and a considerable quantity of healthy looking pus flowed freely into the caA-ity of the cranium from the temporal fossa through the orifice. A complete sac had invested the ball, and also a small fragment of bone, Avhich had been carried with it. There Avas A-ery slight congestion of the pia mater and arachnoid. Case.---------------, Avas brought into the Prince Street Hospital, Alexandria, Virginia, May 14th, 1864, with a pene- trating fracture of both tables of the left parietal bone at the anterior superior angle. He was comatose, passed urine involun- tarily. He moved his arms freely; but the legs were motionless, the pupils dilated and fixed, and the right eyelid ecchymosed. A puffy sAvelling existed in the right temporal region. Convulsions supervened, and death ensued the same evening. Case.—Private E. N. York, Co. E, 9th NeAV York Heavy Artillery, aged 30 years, was Avounded at the battle of Monocacy Junction, Maryland, July 9th, 1864. by a conoidal musket ball, Avhich entered the occipital bone and lodged in the brain. He Avas sent to the Frederick Hospital on the evening of the same day. The brain exuded, but the patient could readily move about in his bed, and vdih assistance could sit up, being Avell able to converse. He continued in this state, Avith occasional severe head- ache, for five days; then stupor supervened, with strabismus, and the case terminated fatally on the 15th of July, 1664. The orifice made by the missile Avas a smooth round opening without depression of the surrounding bone. The case is reported by Acting Assistant Surgeon John H. Bartholf. In the five following curious cases, the presence of balls within the cranial cavity was unsuspected during life : Case.—Private Antoine Pascha, Co. F, 6th Vermont Volunteers, aged 21 years, received a gunshot wound in the head during the Peninsular campaign. No record of the case can be found until September 26th, 1862, when the patient was FATAL PENETRATING GUNSHOT FRACTURES OF THE SKULL. 205 Exterior view of the foregoing FIG. 103.—Conoidal ball embedded between the sphe noid and frontal bones. Spec. 1108, A. M. SI. admitted to Carver Hospital at Washington. On January 8th, 1863, he was sent to Baxter Hospital, Burlington, Vermont, and on April 7th to Fort Wood, NeAV York Harbor. He bad been treated for a AVound received in another engagement, and had nearly recovered on May 6th, 1863, when an attack of encephalitis supervened, causing death on May 8th, 1863. The autopsy revealed a bullet in the brain, behind the frontal bone, near which a small abscess had formed. Surgeon John Campbell, U. S. A., reported the case. Case.— Corporal G. XV. S----, 12th Massachusetts Volunteers, aged tAventy-nine years, Avas wounded at the battle of Fredericksburg, December 13th, 1862,and was admitted to Camden Street Hospital, Baltimore, six days subsequently. The humors of the right eye had been evacuated by a ball, Avhich had likeAvise inflicted a slight Avound of the lower lid. The left eye Avas observed to be unnaturally prominent, but its functions were undisturbed. The patient did not complain of pain or any inconvenience, except a slight headache. There were no cerebral symptoms, and no one suspected that the projectile had entered the brain. The functions of the left eye were in no way disordered, although it was observed that the globe Avas unnaturally prominent. Opiate lotions were applied to the right eye. There were no symptoms of importance except the comparatively slight local pain, and frontal headache. The Avound healed kindly, and after three weeks the man walked about the city habitually, Avith a hospital pass. He appeared to be well, except that he had an occasional pain over the left eye, until February 6th, 1863, when he had a chill, followed by a febrile reaction. The fever assumed a continued form with occasional chilliness. No marked cerebral disorder supervened, hoAvever, until February 10th, Avhen delirium Avas noticed at night. On the following day the patient was comatose, though intelligence Avas not entirely abolished. He Avould occasionally ansAver a question, or put out his tongue Avhen ordered. The pupil of his remaining eye was greatly dilated. The sphincters Avere relaxed. Cupping and blistering were employed without benefit. The patient sank rapidly, and at midnight of February 15th, he died. The autopsy revealed a conoidal musket ball wedged between the sphenoid and the left orbital plate of the frontal bone, and lying in contact Avith the dura mater. On removing the calvaria, the pia mater was found much congested, and from the confluence ofthe longitudinal and lateral sinuses, or torcular herophili, a considerable quantity of dark fluid blood escaped. The ball depressed the thin inner Avail of the left orbit, thus diminishing its capacity and forcing forward the eye. This fact explained its unnatural prominence observed during life. The missile had, after passing through the eye, entered the cranium through the third inner wall of the right orbit, at the junction of the sphenoid and ethmoid bones. The ball did not penetrate the dura mater, but remained in contact Avith and pressing against it. In consequence of this pressure, ulceration of that membrane resulted, and an abscess formed, extending from the point of contact to the left lateral ventricle, containing about tAvo drachms of pus. A few drops of pus, apparently encysted by lymph, were discovered pressing directly against the commissure of the optic nerve, which Avas the probable cause ofthe extreme dilation of the pupil. The pons Varolii and the medulla oblongata, were found bathed in pus. The autopsy was made, and the specimen, which is represented in the accompanying wood-cuts, (Fig. 103, and Fig. 104,)Avas presented to the museum by Acting Assistant Surgeon George H. Dare, who also furnished the very interesting notes of the case. Case.—Sergeant J. R. B------, Co. A, 55th Virginia Regiment, aged 26 years, was wounded at Poplar Grove Church, Virginia, October 1st, 1864, by a conoidal ball, which entered just above the inner canthus of the left eye, fractured the frontal bone, passed backward and to the right, and lodged at the posterior angle of the right orbit. He was conveyed to the hospital of the first division, Fifth Corps, and on October 8th was sent to Lincoln Hospital, Washington. The right eye was inflamed, and had a bulging appearance. No bad symptoms occurred until October 26th, when the patient vomited. He became comatose and feverish on the evening of the 28th, and died on the following morning, October 29th, 1864. At the autopsy disorganization of the anterior lobe of the left hemisphere was found extending to the left lateral ventricle; both ventricles were filled with a purulent sanguineous fluid, and the base of brain was covered with pus. The pathological specimen is No. 3373, Sect. 1, A. M. M. A section of skull, showing fracture and comminution of the intraorbital septa, and of the right orbital plate of the frontal bone. The specimen and history were contributed by Acting Assistant Surgeon H. M. Dean. Case.—Private A. Van Walker, Co. A, 7th Wisconsin Volunteers, aged 20 years, Avas Avounded at the battle of Gettys- burg, July 1st, 1863, by a conoidal musket shot which perforated the frontal bone about half an inch above the right orbit and entered the brain. He was admitted to the Camp Letterman Hospital on the same day, where he remained until the 8th, Avhen he was transferred to McKim's Mansion Hospital at Baltimore, Considerable inflammation existed in the region ofthe Avound, which readily yielded to expectant treatment, which was continued until the 3d of September, when the patient complained of pain in his head, though apparently doing Avell. On the 12th, he walked two miles to Avitness a parade, Avithout suffering any inconvenience from the exposure and exertion. On the 18th he, was seized Avith violent pain in the head, which was attended with nausea and vomiting. Tem- porary relief was in a measure afforded by the use of opiates and counter-irritants; but coma ensued next day, and death resulted at midnight of the 20th. At the autopsy, the missile and a fragment of bone Avere found lodged in the anterior lobe of the cerebrum, on the right side of the sella Turcica. The anterior lobe of the right hemisphere Avas a disorganized mass. The case is reported by Acting Assistant Surgeon William G. Small. The ball, represented in the adjacent wood-cut, was forwarded to the Museum by Surgeon L. Quick, U. S. Y. Fig. 105.—A bullet which remained eighty-two days in ihe brain. Spec. 1027, Sect. I, A. M. M. 20(5 WOUNDS AND INJURIES OF THE HEAD. Case.—J. B. I------Avas received on board the hospital steamer State of Maine from City Point, on April 5th, 1865, with a gunshot fracture of the frontal bone over the left eminence caused by a small iron canister shot. He died Avhile on the way to Alexandria. At the autopsy a portion of the depressed bone and the missile Avere found imbedded in the anterior lobe, and pus existed under the pia mater on the frontal and parietal convolutions. The substance of brain was mostly of a dark slate color and was greatly softened. There were no special bloody effusions. The pathological specimen is No. 1497, Sect. I, A. M. M. The wound of the external table is one inch by one and three-fourths from which tAvo-thirds of the substance have been removed, the remaining fragments being slightly depressed. The fracture and loss of substance of the inner table are someAvhat greater and the borders are necrosed. The specimen, Avith the history, was contributed by Surgeon E. Bentley, U. S. V. Perforating Gunshot Fractures of the Skull.—A few instances were reported in which men survived after perforations of the craniums by musket balls. The abstract of the following case furnishes an instructive example, the more interesting because the patient has been kept under observation for nearly nine years from the date of the reception of the injury: CASE.-Private Patrick Hughes, Co. K, 4th NeAV York Volunteers, aged 23 years, was wounded at the battle of Antietam, September 17th, 1862, in Sumner's attack on the right, near Dunker's Chapel. Several special reports, at variance in regard to some particulars of the case, have been received. In the note book of Surgeon J. H. Brinton, U. S. V., it is stated that "two missiles had struck the back portion of his head, the one near vertex causing injury of greatest extent," and that "he did not entirely lose his consciousness at time of injury." But the field report, and the majority of the subsequent hospital reports, state very positively that the injury was a perforation of the skull by a single conoidal musket ball entering near the inner posterior angle of the right parietal, and emerging at a higher point of the left parietal, making, after traversing a portion of the brain, a large exit Avound. Little is knoAvn of the early history of the case, except that the patient dragged himself from the field, and, after a preliminary dressing from Surgeon G. W. Lovejoy of his regiment, Avas conveyed to a field hospital in a barn near Keedys- ville, Avhere be remained until the 20th, when he was sent to HagerstoAvn. The regimental surgeon reports that the shock and depression from the injury was great, but that the patient Avas conscious and ansAvered questions rationally. There is no report from the Hagerstown hospital, except that the patient Avas sent to Washington on the 24th. On the 25th, he was received at the Mount Pleasant Hospital. The folloAving is an extract from the report of Acting Assistant Surgeon Thomas Carroll, who had immediate charge of the case, after the patient's admission to Mount Pleasant Hospital: "The ball entered half an inch posterior to the junction ofthe coronal and sagittal sutures on the median line, passed backward under the scalp and escaped one inch above the occipital protuberance, inflicting a wound four inches in length, producing a compound comminuted fracture of the skull of the same extent. At the time of his admission to the hospital, eight days after the reception of the wound, so much tumefaction of the parts existed that it could not be ascertained whether or not the brain or its membranes were injured. The general condition of the patient was good; suppuration had commenced; no febrile action existed, the pulse was regular, sleep not materially disturbed, mind clear and manifesting no signs of compression of the brain, or inflammation of its membranes. Little, if any, change Avas perceptible for several days, when the swelling of the scalp and tissues subsided, leaving a prominence nearly, if not altogether, one inch in height, and two and a half or three inches in length of brain substance, in which the pulsation of the arteries could be distinctly observed. From the closest examination that could now be made, it was supposed that the membranes of the brain were not lacerated, though this supposition was by no means certain, as there Avas reason to believe the brain itself had been penetrated. The chief, and in fact, the only unpleasant symptom complained of by the patient, was an occasional paroxysm of giddiness that occurred at intervals of from ten to fifteen days; the paroxysms continued to return, though less frequently, while he remained in the hospital. Early in December, he Avas able to sit up and walk about the ward, and was never afterwards much confined to bed. The protuberance noAV began to subside, and Avas soon reduced nearly to a level with the skull; numerous pieces of bone Avere remoA-ed as they became detached from the tissues, leaving a complete channel in the cranium from the point where the ball entered to where it emerged. At the time this man Avas discharged from the service, January 26th, 1863, the Avound was nearly healed. There was but little discharge of pus, and with the exception of an occasional recurrence of the paroxysms of giddiness, he suffered but slight inconvenience. The treatment consisted simply in cutting the hair short, and applying cold water dressing locally, paying strict attention to the diet, and administering a cathartic as often as symptoms seemed to indicate its use." Assistant Surgeon C. A. McCall, U. S. A., in charge of Mount Pleasant Hospital, furnished a report of the case, from which the following extracts are made. "The ball passed from about one inch above and to the right of occipital protuberance into the cavity of cranium and emerged at a point on the left of the median line, about one and three-fourths inches from the point of entry; probably a conoidal ball. From the posterior margin of the inferior Avound to anterior margin of superior was about four inches. At the time of his admission to hospital, eight days after the injury, so much tumefaction and hardened clot existed, that it Avas deemed inadvisable to make a very strict examination with a view to determine the extent of lesion. The hair Avas closely shaA-ed, and cold Avater dressings applied and patient placed in a sitting posture. The general condition of patient Avas promising, although all the brain functions appeared clouded, the memory impaired, speech desultory or given in fragments, yet being readily aroused and, generally at such times, ansAvering promptly and clearly. In a short time healthy suppuration was established, febrile action decreased, the pulse became regular, sleep became natural, the mind began to show clearness, and he seemed to lose all symptoms of compression or of inflammation of the brain or its membranes. The swelling and induration of the parts gradually disappeared, leaving in their place a fungus cerebri of considerable size, perhaps an inch in height by tAvo and a half or three inches in length, in which the pulsation could be distinctly seen and felt. The only unpleasant symptom now existing Avas the occurrence of a paroxysm of giddiness at intervals of ten or twelve days, which symptom continued, although at much greater iuterA-als, during the remainder of his stay at the hospital. The size and extent of the fungus deterred me from using the knife, and I had resort to compression as recommended by the surgeons of France, but Avith such serious reMilts that I Avas startled for the safety of my patient, and therefore threw aside all dressing save the simple cerate on soft lint, I 'I Sl;im-li pin.x' .I.Hi.. GUNSHOT FRACTURES OF THE CRANIUM 317 PERFORATING GUNSHOT FRACTURES OF THE SKULL. 207 and proper guard for the delicate tissues. Early in December, he Avas able to sit up and walk about the wards, and Avas never afierwards 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 26th, 1863, when it had shrunk beloAV the level of the skull, and both openings had been Avell covered by cicatricial tissue. During the progress of the case numerous spiculae of bone were removed as they became detached. The constitutional treatment consisted in paving 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 Avhatever Avith the exception of the occasional attack of giddiness, and the fact that he could not see a small object when placed in a position directly on a level and on a middle line betAveen 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 Avas made in water color, under the direction of Surgeon J. H. Brinton, 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. Stauch, whose admirable draAving 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 Avater-color draAving. I take the folloAving memorandum of the case from one of the memorandum books turned over to me by Dr. Brinton: "Gunshot wound of head: The picture of this case was taken at the Surgeon General's Office, whither the man came as an orderly, or on an errand. He was perfectly well. A small carnified cerebral hernia existed at the exit wound, which Avas healing rapidly. The ball Avent into cavity of the skull and emerged. No symptoms existed at all, Avhen the patient's portrait Avas taken. The wound was then some three or four months old. The history of this case, Avhich I took at the time, has been unfortunately mislaid." After this we have the history of the case taken up by the pension examining surgeons. The patient Avent to Newcastle, DelaAvare, and was pensioned at four dollars a month, until June, 1869, when his pension Avas increased to eight dollars a month. Dr. D. W. MauU reports, at this date, that there Avas 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. Maull regarded the disability as total. Yet the man worked afterwards in an iron foundry as puddler. On December 20th, 1870, this patient was examined by Doctors William Thomson and XV. W. Keen of Philadelphia, who have published an interesting account1 of his condition at that time, with a photograph, of which a reduced copy is given in the annexed wood-cut, (FiG. 106.) I make the following quotations from this paper: "His memory is quite good, but by no means so good as before the injury. He is rather easily 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 by a hollow two and a half by two inches, and one inch deep. No bone has closed this open- ing, but the scalp and hair dip down into the hollow. The arterial pulsations are barely perceptible. When recumbent 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 Avith his hand. When he coughs, even with moderate force, the depressed scalp instantly hedges 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 entire 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 position, to coughing, etc., as evinced by the efface- ment 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.2 l Photographic Review of Medicine and Surgery. Vol. 1, No. 3, p. 26. Philadelphia, February, 1871. J. B. Lippincott & Co. a "Wollaston, (Phil. Trans. 1824. p. 222,) 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 decussation of the optic nerves at the chiasm. Longet (Traite de Phys., 2d ed. 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 Phys. du Syst. Nerv., p. 666, he gives cases of perfect sight in both eyes, in spite of unilateral cerebral atrophy or traumatic lesion. Von Graefe (Archiv, ii, 286) assents cordially to Wollaston's view, admitting that he proposes nothing new, but that which is far too little known. Hubert Airy, (On a Distinct Form of Transient Hemiopsia, Proc. Roy. Soc, Feb. 17th, 1870, in "Nature," i, 444,) after a careful examination of preceding writers, also sup- ports it; and the experiments of Laborde and Leven, (Med. Gaz., Nov. 5th, 1870 ; from Gaz. Med. de Paris,) who found atrophy of the right optic nerve following the removal of the superficial right cerebral convolu- tions, 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 the rigid optical examination of the region between the porus opticus and the macula lutea. The semi-decussation of the nerves at the 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 toward a'; but our examination shows that it supplies less than this, viz.: only that part of the retina from c to a'; while in the right eye the fibres 6, instead of supplying the retina from the porus opticus to 6', supply more than this, viz.: that part of the retina from c' to &'. In other words the fibres a and 6 of the left optic tract supply, mathematically, the left halves of the two retinae from c to a' and c' to 6', and the right ..„...,, . . .. . , . „ ., „ . . B Fig. 107.—Diagram indicating the tract the right halves. As to the cerebral seat of the sense of vision, the amount and depth of the injury to relations of the optic commissure and the brain are too uncertain, perhaps, to warrant us in venturing on any speculations as to its locality." retinas. [After Drs. Thomson and Keen.] Fig. 106.—Cicatrix of a gunshot perforation of the skull, eight years atter the reception of the wound. [From a photograph.] as'\ 208 WOUNDS AND INJURIES OF THE HEAD. Cvsi:.—PriA-ate Abraham D. Myers, Co. K, 4th Ncav York Cavalry, aged 21 years, was Avounded in an engagement near Charlestown, Virginia, August 28t,h, 1S6L by a conoidal musket ball. Avhich penetrated the frontal bonejnst above the right eye, and passing doAvinvard through the orbit emerged near the right ear. On the following day he Avas admitted to the general hospital at Sandy Hook, Maryland. On September 4th, he Avas sent to the Jarvis Hospital at Baltimore, and on the 12th, was transferred to the MoAver Hospital, Philadelphia. The treatment seems to have been of a general character. He recovered, 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 balls, the patients survived, though totally and permanently disabled: Case.—Private Hugh Collins, Co. I, 26th NeAV York Volunteers, was wounded at Antietam, September 17th, 1862, by a conoidal ball, Avhich entered the cranium just above the right eye and lodged in the left side of the neck, four inches beloAV the ear. The ball Avas removed, and the patient was admitted to the field hospital at Smoketown, Maryland, October 8th, 186-2. On December 20th, he was discharged the service. On February 18th, 1863, he was examined for a pension by Pension Examiner H. B. Day. Partial amaurosis of both eyes existed, otherAvise 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.—Private John H. Stallman, Co. A, 4th Pennsylvania Cavalry, aged 21 years, Avas admitted to the National Hospital at Baltimore, from Sandy Hook, Maryland, September 8th, 1864, having been wounded at Winchester, 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 far as to be fit for light duty, but being subsequently seized with a spasm Avas again placed under treatment. On December 10th, 1864, he Avas transferred to Cuyler Hospital, Philadelphia. On admission, the Avounds 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 Avere equal and constantly dilated. He had no strabismus. He stated that he had purulent discharges from his right ear, attended with pain. His mental faculties were 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 transferred 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 aAvay a large fragment of the left half of the occipital bone. He became insensible and lost more than an ounce of cerebrum, leaving bare the meningeal artery. For several Aveeks he Avas treated in the hospital at Marietta, and on November 10th, was sent, via Chattanooga, to Nashville, Tennessee, Avhere he Avas admitted to Hospital No. 2, on November 12th. He was furloughed on November 16th, and afterward was admitted to the hospital at Mound City, Illinois. He was discharged on April 26th, 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 years, 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 Avas admitted to the hospital ofthe 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 Avere applied to the wound. He was discharged the service August 25th, 1865, and pensioned. On August 28th, 1865, Pension 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 Avas delirious during the night. He Avas examined on February 2d, 1865, by Pension Examiner R. K. Jones. At the Avound of entrance was a cutaneous scar, but the bone was not depressed. At the Avound of exit, eight small fragments of bone had been discharged, leaving a depression one-third to one-half inch deep. Both scars, especially 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 Avas discharged the service August 10th, 1865, and pensioned. On August 7th, 1867 Pension Examiner John Benson reported that small portions of bone had exfoliated. The patient suffered considerably from dizziness and sharp pains in the head and Avas unable to perform much labor. He had been subject to great suffering and pain ever since he was Avounded. His disability is rated total and permanent. CASE.-Private Charles C. Trot man, 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 behind the right ear. He Avas retired by an examining board on January 3d, 1865. The vision of both eyes was affected, and he was permanently disabled. Case.—Lieutenant 7T. H. Coward, Co. F, 7th Arkansas Regiment, aged 22 years, was wounded in an engagement at Jonesboro', Georgia, September 1st, 1864, by a conoidal musket ball, which entered the cranium one inch above the mastoid process aud presented itself on the opposite side, where the cerebral matter left no doubt as to the fact that the brain Avas 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 breathing. Toward evening, he became conscious and restless, complaining of loss of vision and inability to raise his head. ToAvard midnight he commenced to scream, and for three Aveeks did so incessantly, even during his moments of sleep. On September 20th, he suddenly became composed and quiet, and ansAvered questions coherently. The left side for some days seemed paralyzed, as be could not use his hand or leg. The face Avas draAvn to the right, and he seemed to have some difficulty in SAvalloAving; his secretions Avere natural, and he had constant priapism, with seminal emissions. All these symptoms, however, 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. But he rapidly improved. During the progress of healing, several spiculae of bone came aAvay. About the seventh Aveek all discharge from the Avound had ceased. The patient was transferred to Nashville on October 30th, 1864. The pupil of the left eye seemed permanently dilated and intolerant of light. On December 8th, 1864, he was sent to the Provost Marshal for exchange. The case is reported by Surgeon Edward BatAVell, 14th Michigan Volunteers. Case.—Private Eugene Phi inly, Co. L, 8th New York Heavy Artillery, aged 23 years, was wounded at Petersburg, Virginia, June 16th, 1834, by a conoidal musket ball, which entered at the inner angle of the left eye, passed through the brain substance and emerged behind the left ear. He Avas 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, Avhen he Avas transferred to the Ira Harris Hospital, Albany, New York, the wound being still open. The treatment consisted chiefly in the dressings of the Avound, which had cicatrized by the 22d of December. His general health being good at that date, he Avas discharged the service and pensioned, the vision of the left eye being obscured. On March 7th. 1837, Pension Examiner John Post reported that there was a discharge of pus from the orifice of entrance ofthe ball and through the right nostril and upper part of the posterior nasal cavity into the mouth. There was constant headache; he could not stoop AA'ithout becoming dizzy, and bis eye-sight Avas imperfect. At night, pus ran into his mouth so that he Avas 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, 1865, by a conoidal ball, which entered the left external ear and mastoid process of the temporal bone, passed obliquely through 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, 1835. 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 Avas pensioned, his disability being rated total and temporary. Case.—Private Samuel P. Starrett, Co. I, 1st Michigan Volunteers, Avas shot through the head at Gaines's Mills, Virginia, June 27th, 1832. The missile passed from temple to temple, causing the loss of both eyes. He was taken on board the Steamer Vanderbilt, and on June 24th, Avas admitted to DeCamp Hospital, New York Harbor, where he was discharged the service on September 29th, 1852, and pensioned, his disability being rated total. Case.—Private Robert Elliott, Co. E, 119th Pennsylvania Volunteers, aged 39 years, was wounded at the battle of Wilderness, Virginia, May 6th, 1834, by a conoidal ball, which entered at the occipital bone and escaped under the right eye. He Avas immediately admitted to the 1st division, Sixth Corps, hospital, and on May 27th, was conveyed to the 2d division hospital, Alexandria, Virginia. On June 20th, he Avas transferred to the hospital at Chester, Pennsylvania. Partial paralysis of the lower extremities had occurred. On March 20th, 1835, he was sent to the Turner's Lane Hospital, Philadelphia, and Avas discharged from service on August 29th, and pensioned. On September llth, 1866, Pension Examiner M. G. Emanuel reported that his disability then consisted in partial paralysis of both lower extremities, imperfect vision, disturbance of the mental faculties, and severe pain in the head. In 1887, his disability was rated total and permanent. Case.—Private Samuel CaldAVell, Co. H, 16th United States Infantry, Avas wounded at the battle of Stone River, Tennessee, 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 hospital. Inflammation extended over the entire upper part of his face, his eyes being closed and exceedingly painful; 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 Avere 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 Avas sent to Hospital No. 12, Nashville, Tennessee. He was discharged the service March 14th, 1863, by reason of total blindness, and Avas 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 classification of the Pension Bureau, implying incapacity 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 27 210 WOUNDS AND INJURIES OF THE HEAD. sufficiently detailed to permit a more minute analysis of the results of the extended lesions of the brain which co-existed with the fractures in this series of cases. The reports of a few of the fatal cases of perforating fractures embrace some partic- ulars of interest. The following nine patients were under treatment for periods varying from two hours to four months: Case—Sergeant L. O. Blanding, U. S. Signal Corps, aged 35 years, was wounded in action near Nashville, Tennessee, April 14th, 1862, by a musket ball, AA'hich entered near the centre of the left superciliary ridge and emerged just outside of the external angular process of the frontal bone. Only little haemorrhage occurred, but he immediately became insensible, and was conveyed to Hospital No. 9 at Nashville. An exploration ofthe wound revealed a comminution of the superciliary ridge and ofthe orbital plate. About a teaspoonful of cerebral matter had been scooped out by the missile. The patient never reacted; he remained in a comatose condition until his death, April 16th, 1862, forty-eight hours after the reception of the injury. The history of the case Avas contributed by Surgeon Eben SAvift, U. S. A. Case.—Private John Nulty, Co. C, 28th Massachusetts Volunteers, aged 23 years, Avas Avounded at the battle of Antietam, Maryland, September 17th, 1862, by a conoidal musket ball, AA'hich entered the right zygomatic region anterior to the meatus auditorius, passed through the internal ear and mastoid process of the temporal bone, and emerged two and a half inches directly behind the meatus. He Avas admitted to the Locust Spring Hospital, where, in the course of treatment, tAvo small pieces of bone Avere 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 B Hospital at Frederick, Maryland, December 5th, 1862, but the anterior wound was discharging someAvhat. The power of hearing in the right ear was destroyed, and the patient's vision Avas impaired. After his removal to Frederick he failed gradually, and died on January 20th, 1863. The case is reported by Surgeon T. H. Squire, 89th New York Volunteers. Case.—Private A. J. Frazicr, Co. D, 3d Arkansas Regiment, was Avounded in an engagement on the Williamsburg Road, Virginia, (htober 27th, 1864, by a conoidal musket ball, which entered one inch to the right of the occipital protuberance, passed laterally and a little doAvnward, and emerged one inch to the left of the occipital protuberance. On October 29th, he was admitted, in an insensible condition, to the Receiving and Wayside Hospital at Richmond, Avhere cold-Avater dressings Avere applied. On October 30th, the patient had someAvhat rallied; he could hear and open his eyes, but could not see; could speak, but not remember, and complained of pain. October 31st, could hear, smell, taste, and feel; urinated freely, but his bowels Avere constipated. On November 7th, he regained his eyesight. On the following day, chills folloAved by fever supervened, leaving the patient again blind. On the 10th, another chill occurred; on the llth, profuse discharge of bloody mucus from the wound took place, and death occurred on the same day. Case.—Sergeant M. V. Temples, Co. A, 2d Arkansas Regiment, aged 24 years, was wounded at Rocky Face Ridge, Georgia, May 8th, 1884, by a conoidal ball, which entered just in front ofthe left ear, passed upward and forward and emerged just above the right eye. On the next day, he Avas admitted to the Institute Hospital at Atlanta. He was perfectly rational, Avith no constitutional disturbance, could see but little Avith the right eye, and said that the vision of the left Avas lost from the time ofthe reception of the injury. On May llth, his mind was wandering, but on the 16th, he was again rational, Avith some appetite. From the 18th to the 26th, he Avas unconscious, but seemed, at times, to understand Avhen spoken to very loudly. He was feeble and emaciated and discharged faeces involuntarily; the wound suppurated freely. He died on June 8th, of asthenia. The case is reported by Surgeon D. C. O'Keefe, P. A. C. S. Case.—Private Henry E. H. P------, Troop K, 5th Iowa Cavalry, was Avounded at Wartrace, Tennessee, October 6th, 1863, by a conoidal ball, Avhich entered the centre of the os frontis and passed out at the squamous portion of the left temporal bone. Upon admission into the general hospital at Tullahoma, October 6th, lacerated brain protruded from both wounds; the patient Avas insensible and there Avas complete hemiplegia of the right side. He remained unconscious and died at four o'clock p. m., on October 9th, 1863. The pathological specimen is No. 2075, Sect. I, A. M. M. The fractured surface measures four inches in diameter, involving the anterior inferior angle of the parietal and adjoining portions of the frontal bone. The aperture of entrance is hardly larger than the point of the missile, Avhich had acted like a Avedge, splitting the bone in every direction; one of the fissures extending across the vertex; that of exit Avas, at least, an inch in diameter, and from this a fissure extended tAvo inches into the right parietal, through both tables. On removing the skull-cap, large coagulse Avere observed lining the dura mater, and the membranes of the brain and medulla were deeply congested. The specimen and history were contributed by Surgeon B. WoodAvard, 2-2d Illinois Volunteers. Case.—Private J. E. Riggins, Co. A, 43d Alabama, aged 36 years, was Avounded at Spottsylvania Court-house, May 16th, 1864, by a conoidal musket ball, which entered at the middle of the frontal bone, penetrated and emerged at the middle of the left temporal bone. He Avas conveyed to Richmond and Avas admitted to Chimborazo Hospital No. 4. For tAvo days he Avas comatose. On May 19th, his intellect became clearer, but he did not speak, and expressed himself by signs. He had the use of his limbs to a considerable extent. On May 20th, he lay in a state of semi-torpor, and from the Avound in the forehead a sero- purulent discharge was expelled at each pulsation ofthe brain. Pulse 75 and natural. There was partial paralysis of the nerves supplying the organs of speech, causing a slight defect of utterance. The right eye Avas considerably ecchymosed. On the 23d, the pulse avus 96 and weak; the patient continued to sink, and died on May 31st, 1864. The case is taken from'the Confederate Hospital Records. PERFORATING GUNSHOT FRACTURES OF THE SKULL. 211 Case.—Corporal Alexander French, Co. K, 3d Michigan Volunteers, was wounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal ball, which passed laterally from right to left through the occipital bone, traversing the substance of the brain four inches, and making its exit at a point directly opposite the wound of entrance. He was sent to the regimental hospital, and on December 4th, Avas transferred to the 2d division hospital, Alexandria, Virginia. Simple dressings were applied. The case terminated fatally on December 5th, 1863. The case was reported by Assistant Surgeon W. B. Morrison, 3d Michigan Volunteers. Case.—Lieutenant H. W. F------, Co. E, 23d North Carolina Regiment, aged 28 years, Avas Avounded at the battle of Winchester, Virginia, July 20th, 1864, by a conoidal musket ball, which entered at the middle of the inferior border of the right parietal bone and passed out just behind its posterior inferior angle, leaving a bridge of bone one inch and three- fourths wide, and lodged beneath the integuments over the occipital protuberance. On July 23d, he was admitted to the hospital at Cumberland, Maryland, where the ball was removed, and simple dressings Avere applied. A tumor appearing near the place Avhence the missile had been extracted Avas opened, and discharged about two ounces of pus. Death resulted on July 30th, 1864. At the autopsy, upon dissecting back the integuments, a large portion of the skull, already detached, fell out. Suppuration had broken down the substance of the middle and posterior lobes of the brain, and the remainder, with the meninges, were turgid and congested. The pathological specimen is No. 4257, Sect, I, A. M. M. The fractured surface measures posteriorly two by three inches, the greater portion of the fragments being in situ. There are two short fissures of the parietal and one of the occipital bone. The specimen and history were contributed by Surgeon J. B. LeAvis, U. S. V. Case.—Private E. Radcliffe, Troop E, 1st Maryland Cavalry, was Avounded by a pistol ball, which entered the centre of the parietal bone, and passing through the substance of the brain, emerged near the centre of the left lambdoid suture. Upon admission to the Receiving and Wayside Hospital at Richmond, on March 9th, cerebral matter protruded from both wounds, the pulsations of the brain were very distinct, there Avas hemiplegia of the right side of the body, and the power of speech was lost; notAvithstanding these symptoms his intellect was perfectly clear, appetite good, and bowels regular. The treatment consisted in the constant application of tepid water to the wound, a light stimulating diet, and as perfect quiet as possible. Erysipelas of the face having occurred, was speedily relieved by the local application of iodine. By May 1st, the general condition of the patient had improved, and the hemiplegia had gradually diminished. He was able to move the limbs and speak quite distinctly. The Avound of entrance had entirely healed, and the wound of exit nearly so, only a small granulating surface remaining. On May 10th, he complained of sickness, vomited a greenish matter, and symptoms of tetanus presented themselves. Brandy, quinine, and morphia were freely given, and the symptoms somewhat abated. On the following day spasms occurred and an abscess opened on the edge of the wound. The tetanic symptoms continued, and death occurred on May 12th, 1864. The case is reported by Assistant Surgeon C. W. Brock, P. A. C. S. In forty-five other cases of perforating gunshot fractures of the cranium, in which the patients survived long enough to be placed in hospitals for treatment; in which also, the positions of the entrance and exit wounds were noted, and indisputable proof that the missiles had traversed some portion of the brain tissue was adduced; in which, likewise, the dates of injury and of death were recorded, four patients survived after admission to hospital from one to twelve hours only; nine lived about twenty-four hours; six, about two days; eight lived three days; four, four days; two, five days; two, six days; three died on the seventh, eighth, and ninth days, respectively, and two on the eleventh day; one died on the thirteenth, one on the fourteenth, and two on the fifteenth days; while one survived a perforation of both parietals and both cerebral hemispheres for forty days. In one instance the ball opened the longitudinal sinus, and in another, and perhaps three others, passed through the cerebellum. It is to be regretted that in the latter cases the symptoms were not recorded more fully. The facts compiled from the hospital registers, case-books, and quarterly reports in the last three cases are as follows: CASE.-Private Zimri B. Hiatt, Co. K, 3d Iowa Cavalry, received, in an engagement at Little Rock, Arkansas, April 25th, 1864, a wound of the skull by a conoidal musket ball. One account states that the wound was accidental. The missile entered to the left and a little in advance of the occipital protuberance and passed inward and downward, penetrating the cerebellum and making its exit through the right portion of the occipital, without injuring the lateral sinus. After treatment at a field hospital, the patient was admitted, on May 1st, 1864, to the general hospital at Little Rock. He was comatose and died a few hours after his admission. The case is recorded by Surgeon E. A. Clark, 8th Missouri Cavalry. Case.—Corporal Daniel Tippin, Co. H, 57th Ohio Volunteers, received, near Kenesaw Mountain, Georgia, June 27th, 1864, a gunshot fracture of the cranium. The missile, a musket ball, penetrated from one lateral angle of the occipital bone to the other, passing through the brain. The patient was conveyed to the hospital of the Fifteenth Corps, in a comatose condition, and died July 2d, 1864. These facts are recorded by Surgeon A. Goslin, 48th Illinois Volunteers. The regimental surgeon' Dr. Asa C. Messenger, only reports the case on the corps casualty list. 212 WOUNDS AND INJURIES OF THE HEAD. Case.—Corporal William Shaddock, Co. C, 3d Massachusetts Artillery, aged 21 years, Avas wounded near Petersburg, Virginia, June 20th, 1864, by a conoidal ball, AA'hich entered the mastoid process of the temporal bone, and passed upward and baokAvard through the occipital protuberance, just above the torcular Herophili. In its course it opened the superior longitudinal sinus. The patient Avas, on the same day, admitted to the field hospital of the Fifth Corps in a comatose condition. He had lost much blood, and died eight hours after admission. In a case,1 reported by Surgeon A. M. Wilder, U. S. V., a conoidal musket ball entered at the glabella and passed through the brain substance and emerged at the occipital protuberance, a linear fissure of the vault, over seven inches in length, connecting the apertures of entrance and exit. In another case,2 reported by Surgeon G. A. Otis, 27th Massachusetts Volunteers, the patient, whose skull had been traversed by a conoidal musket ball which entered at the middle of the forehead and emerged at the junction of the inferior curved lines and crest of the occipital, survived three days, cerebral matter and grumous blood issuing freely from the exit wound. The patient was apparently conscious, and indicated his recognition of his friends by plaintive gestures. He was unable to articulate, but took food and drink without difficulty. On the second day, at intervals of one or two hours, he would throw his arms and legs about wildly, and it became necessary to secure his lower limbs to prevent injury to the amputated men who lay beside him on the floor of the field hospital. On the third day, he occasionally uttered piercing shrieks, and tossed about in great distress, and then would follow a comparatively lucid interval, when he was apparently conscious, and would recognize those about him and take nourishment, and attend decorously to the wants of nature. Later in the day, he gradually became comatose, and died sixty-two hours after the reception of the injury. It was inferred, from the direction of the track of the ball and from the disorderly movements of the limbs, that the cerebellum was injured. The exigencies of the occasion forbade an autopsy. Crash or Smash.—The depressed fractures of the skull produced by cannon balls or by the explosion of large shells, were commonly attended by frightful comminution and disjunction of the sutures, and were almost always immediately fatal, and hence had little surgical interest. Yet, in a few instances, patients survived these dreadful injuries for several days, even when the brain substance had been lacerated or torn away. It was observed also that musket balls, and even carbine and pistol balls, fired at very short range, would cause as great destruction of the walls of the cranium as was produced generally by the larger projectiles : Case.—Private OAven Owens, Co. C, 3d New York Artillery, was wounded accidentally on January 9th, 1865, by a fragment of shell, which fractured and depressed the left temporal and parietal bones. He Avas, on the same day, admitted to the Foster Hospital, New Berne, North Carolina. Simple dressings were applied, and stimulants were employed. The patient lay in a comatose state, quite unconscious of the terrible nature of his injury, or of surrounding objects, for three days. The usual symptoms of compression of the brain were present. The patient died on January 12th, 1865. Surgeon C. A. CoAVgill, U. S. V., reports the case. Some patients not only survived, for a short time, these severe injuries of the head, but were conscious and rational for a while: Case.—Private William Kay, Co. F, 7th Connecticut Volunteers, was wounded at the battle of Pocotaligo, South Carolina, October 22d, 1862, by a grapeshot, which fractured the parietal bone near its union with the frontal and temporal bones, passed doAvinvard, fractured the temporal, malar, and superior maxillary bones, and lodged. On the folloAving day he Avas admitted to the hospital at Hilton Head. Although in a stupor, he could be aroused without difficulty, and would then indicate, by the iCase of Private R. A. Fisk, Co. E, 21st Massachusetts, Knoxville, November 24th, 1863. Died November 27th, 1863. 2 Case of Private Samuel A. Dunning, Co. A. 27th Ma.-sacliusetts, New Berne, March 14th, 1862. Died March 17th, 1862. CRASH, SMASH, OR ECRASEMENT. 213 clearness of his right eye, a perception of external impressions. The left eye was closed by extensive tum°faction. BeloAV the inferior maxilla a large protuberance Avas found AA'hich contained the missile. Acting Assistant Surgeon Thomas T. Smiley made an incision and extracted the same. It proved to be an iron ball fully an inch in diameter and weighing nearly four ounces. The patient died October 24th, 1862, fifteen hours after the operation. There was diastasis of the squamous and coronal sutures, with much comminution of the left parietal and temporal. Acting Assistant .Surgeon Thomas T. Smiley reports the case. Case.—Private Clark D------, Co. G, 24th Michigan Volunteers, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a fragment of shell Avhich carried aAvay a large portion of the right temporal and frontal bones. He Avas taken to the hospital of the First Corps at Belle Plain, where he remained in a gently comatose condition, taking fluid nourishment when administered. Occasionally he had spasms or convulsions, though not of a violent nature. The wound of the scalp was huge, extending nearly to the vertex. A piece of bone about the size of a hen's egg was gone from the anterior portion of the wound. On the morning of December 19th, healthy granulations were observed rising from the Avounded cerebrum; but during the day haemorrhage took place from the middle meningeal artery, or some of its branches, and death occurred shortly afterward. At the autopsy it was found that an opening extended from the right frontal eminence to the mastoid portion of the right temporal bone, being five inches long and one and a half inches wide. From the anterior extremity of this, a fracture traversed the frontal bone to the middle of the left branch of the coronal suture, Avhile from the posterior 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 specimen is quite accu- rately figured in the accompanying wood-cut, (Fig. 108.) It Avas con- tributed, with the history of the case, by Surgeon J. H. Beach, 24th »!• !.• t i FlG- 108.—Cranium fractured by a fragment of shell. Michigan ^ olunteers. Spec, 83i, Sect. I, A. M. M. 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 conveying the wounded, abandoned by General Early, in front of Fort Stevens. According to the official reports, the Confederates retired from before Washington on the night of July 12th. The stretcher-bearers reported that this man was found nearly three miles north of Fort Stevens, unconscious and unable to articulate, with a terrible Avound over the vertex, 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 tAvo hours after his admission to hospital. On the following day an autopsy was made. Over the anterior superior angle of the left parietal bone there was an extended scalp wound. On reflecting the scalp, multiple depressed fractures of the vault of the cranium came into view. The point of greatest depression is an inch to the left of the median line, near the coronal suture. The depressed fragments measure from before backward two inches, and from right to left three inches, and involve both parietals and the os frontis. A fissure runs through the squamous portion of the left temporal, and all the sutures of this 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 Series1 of the Army Medical Museum. A yet more remarkable case is reported from Lincoln Hospital. The patient survived a fortnight: v. . .^.-Private William W. Howell, Co. G, llth Pennsylvania Reserves, was wounded at the battle of Fredericksburg ofTntr b" b t ' 86n' b7ra fBl1' ^"^ fraCtUred a"d t0re «"*"«* a» 0f the left P-^ ^one. Though in s afe of stupor he was able to swallow food and stimulants. He was treated at a field hospital for n ne days, and then was conveyed ^^lS^',T^'t,;W,1hi,,gton'",d *dmittedtoL™°- Hospital on" December 23d" at which time about 0^ hn-d of the left cerebral hemisphere had sloughed. Nearly all the brain sloughed aAvay before his death, which occurred on December 26th, 1862. Surgeon Henry Bryant, U. S. V., recorded the case. occurred on Fig. 109.—Cranium fractured by a large fragment of shell. Spec. 2871, Sect. 1,A. M. M. l Photographs of Surgical Cases and Specimens. A. Otis. Assistant Surgeon, U. S. A. Washington, 1866. Prepared, by direction of the ,Sur»-< 5 Vols., Quarto, Vol. I, Case 3. General, by Brevet Lieutenant Colonel George 214 WOUNDS AND INJURIES OF THE HEAD. Fig. 110.—Skull, exhibiting an extensive fracture by grapeshot. Spec. 1318, Sect. I, A. M. M. The specimen represented in the subjoined wood-cut, (Fig. 110,) is from a soldier ;ho survived his injury for a few hours only, and who was left on the battle field: Case.—A soldier of General Longstreet's Corps was killed in a charge upon one of the Union batteries, in the second battle of Manassas, August 29th, 186-2, by a grapeshot, at short range. The cranium Avas picked up, a year subsequently, by Surgeon F. Wolfe, 39th New York Volunteers, under an abatis near the stone bridge over Bull Run. The missile entered the left parietal near the lambdoidal suture, and made its exit through the squamous portion of the temporal. It is erroneously stated in the Catalogue of the Surgical Section of the Army Medical Museum (p. 30), that the fracture Avas inflicted, "probably, by a musket ball." The probabilities are that the missile was a grapeshot, as suggested by the collector, Avho had good reasons, apart from the appearance of the injured skull, for his opinion. It has been supposed that this skull presented an example of fracture by contre-coup, a subject to be discussed hereafter. There are, undoubtedly, fissures of the great wing of the sphenoid, and of the frontal, before and behind the right external angular process ofthe frontal—fissures unconnected with the lesions on the left side of the skull; and the right orbital plate is slightly depressed and a fissure extends through the right upper maxillary bone. Unless these fractures were produced post mortem, they must be regarded as fractures by contre-coup. The next case illustrates the great extent of fractures of the cranium that may be produced by small projectiles. The Army Medical Museum possesses many examples of such multiple comminuted gunshot fractures; but they have been collected since the close of the War: Case.—Private Thomas Dikes, Co. F, 12th Missouri Cavalry, was wounded accidentally on October 20th, 1863, by a large pistol ball, which shattered and carried away a part of the frontal and nearly the entire right parietal bones, and also lacerated and dashed out nearly one-third of the entire cerebral mass. He was immediately conveyed to the hospital at St. Joseph, Missouri. He was speechless and comatose. Death resulted in nine hours and some minutes after the reception of the injury. Assistant Surgeon Wesley Jones, 12th Missouri Cavalry, reports the case. It would be easy, but of doubtful utility, to adduce other instances of obviously fatal comminution of the cranium by gunshot projectiles. One or two more examples will suffice, and the reader may be referred to the collections in the Army Medical Museum, where the subject is fully illustrated:1 Case.—Private Joseph B------, Co. D, 17th Massachusetts Volunteers, was wounded near New Berne, North Carolina, September 1st, 1862, by a fragment of shell which entered about the centre of the frontal bone, passed around the left side of the head, and emerged near the temporo-frontal suture. He was admitted to the Douglas Hospital, Washington, on September 5th, 1862, being partially conscious, with the right eye closed and greatly swollen. The skull between the two apertures felt soft. On September 10th, an abscess over the right eye opened about the middle of the upper lid, and pus and a few fragments of bone were freely discharged. On September 13th, the patient became comatose, and died on September 16th, 1862. At the autopsy, a large abscess was found in the anterior lobe of the left hemi- sphere. The pathological specimens are Nos. 236 and 514. The former shoAVs a section of the cranium with an extensive comminuted fracture of the frontal bone a little to the left ofthe median line; the latter a wet preparation of the encephalon, with perforation of the dura mater, and abscess in the upper part 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., respectively. The calvaria is represented in the wood-cut, (Fig. 111.) It is very thin. In the Confederate hospital records, an instance is found of a patient who survived a terrible depressed fracture of the skull for a fortnight, although there was the complica- tion of erysipelas of the scalp: Case.—Private J. A. Hewlett, Co. A, 1st North Carolina Volunteers, on May llth, 1863, Avas admitted to Howard Grove Hospital, Richmond, Virginia. He had received, at the battle of Chancellorsville, May 3d, a shell Avound of the left side of the head, shattering and depressing the parietal very extensively, and' badly lacerating the scalp. The patient Avas in a state of stupor, with muttering delirium, and erysipelas had invaded the scalp. The erysipelatous inflammation extended, yet the unfortunate patient lingered until May 17th, 1863. Surgeon C. D. Rice, P. A. C. S., recorded the case. 1 Sec among others, specimens 1107, 8t>0, lltili, 1319, Sect. I, A. M. M. Fio. 111.—Fracture of the frontal bone by a shell fragment. Spec. 23ti, Sect. I, A. M. M. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 215 Removal of Fragments 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 related in previous pages of this Section, in the abstracts of cases in which some other feature was more prominent. The remainder of the cases that were reported, in which operative interference, short of perforating the skull by the trephine, was resorted to, will be recorded in this Subsection. The first series of twenty-eight such cases recovered, with slight disabilities, and were returned to duty: CASE.-Private Benjamin Bird, Co. F, 16th Virginia Regiment, aged 30 years, received, on August 30th, 1862, a gunshot wound in the right temporal region, fracturing the bone and depressing the fragments. He was admitted into the Confederate hospital at Charlottesville, Virginia, and on September 6th, was operated upon, when all detached pieces of bone were removed. The wound healed in six weeks without a single unfavorable symptom. Surgeon J. L. Cabell, P. A. C. S., reported the case.1 Case.—Sergeant James Stapleton, Co. A, 82d Pennsylvania Volunteers, aged 20 years, was wounded Avhile 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 avus taken to the field hospital of the 1st division, Sixth Corps, thence conveyed to Washington, D. C, and on the 10th, admitted into Emory Hospital, AA'here the ball was extracted. On June 14th, he was transferred to the general hospital, York, Pennsylvania. He became feverish and suffered great pain. On June 22d, Surgeon Henry Palmer, U. S. V., removed a portion of the bone, leaving the dura mater exposed. The parts surrounding the wound were very much inflamed, swollen, and painful. The wound healed rapidly, and on the 13th of December, 1864, the patient was returned to duty. He is not a pensioner. The case is reported by Surgeon Henry Palmer, U. S. V. Case.—Hospital Steward Bernard Blair, 169th NeAV York Volunteers, aged 23 years, 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 Avas admitted to the hospital of the Tenth Corps, and on the 15th, conveyed to Fort Monroe, Virginia. He was furloughed on the 4th of September, 1664. While on leave, a portion of the outer table of the skull was removed by Acting Assistant Surgeon C. L. Hubbell. On the 20th of October, he entered the general hospital at Troy, NeAV York. The wound healed rapidly, and on the 20th of December, 1864, the patient Avas returned to duty. Case.—Corporal William G. Cunningham, Co. A, 44th New York Volunteers, aged 21 years, was Avounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which struck the head just behind the left mastoid process, passed upAvard 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 Hospital on July 4th, and transferred to the hospital at York, Pennsylvania, on the 19th. The patient stated that he became senseless, and remained so five days, and that he could not speak for nine days. Spicule of bone and the ball were removed, and cold water dressings applied, after Avhich the patient improved rapidly. On August 24th, the wound had filled with healthy granulations. A marked depression in the bone behind the mastoid process could be felt. Appetite, assimilation, and secretion were good, but headache recurred about three hours each afternoon. During September, he suffered from erysipelas of the face, but he recovered and was returned to duty on January 15th, 1864. He is not a pensioner. The case is reported by Surgeon E. SAvift, U. S. A. CASE.-Private James Duffy, Co. A, 116th Pennsylvania Volunteers, aged. 33 years, was woun • Sect. I, A. M. M. the wound suppurated freely and looked healthy, having slightly contracted. Ihe applications ot 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, paralysis was still diminishing, but the patient still complained of headache induced by constipa- tion. July 8th, the brain pulsations were no longer visible, the patient was able to leave his bed, and on August 1st, could Avalk Avith the aid of a cane. He continued to improve rapidly, and on the 17th, had recovered sufficiently to go home on furlough. He Avas transferred to Ward Hospital, Newark, NeAV Jersey, on November 13th, 1863, and was discharged the service on December llth, 1863, and pensioned. On June 6th, 1866, Pension Examiner E. SAvift reports that a deep depression existed over the original seat of injury. There was paralysis of the left side, more marked- in the leg than in the arm. The limbs were atrophied and Aveak, 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 Avas unable to do manual labor. His disability was then rated total and permanent, A communication from the Commissioner of Pensions, dated January 3d, 1868, states that Scarborough Avas a pensioner, his disability being rated total and temporary. Case.—Sergeant William Dougherty, Co. G, 101st Pennsylvania Volunteers, aged 34 years, was wounded at Plymouth, North Carolina, April 20th, 1864, 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 Avas taken prisoner, and upon being exchanged Avas sent to Annapolis, entering the 1st division hospital on October 20th, 1854, suffering from partial hemi- plegia. He Avas furloughed on the Ith of November, and, at the expiration of his leave, November 22d, entered the hospital at Pittsburg, Pennsylvania, where he was discharged the service on February 10th, 1865. He subsequently applied for a pension, and Avas examined by Dr. G. McCook, Examining Surgeon for Pensions, Pittsburg, Pennsylvania, who reports that there Avere substantial granulations from the dura mater. In 1868, Dougherty Avas a pensioner, his disability being rated total and temporary. On July 28th, 1869, Pension Examiner P. B. Rice reports partial paralysis of the left side, and rates his disability permanent. Case.—Private Horace G. Conant, Co. D, 1st Ohio Volunteers, aged 21 years, Avas Avounded at Mission Ridge, Tennessee, November 25th, 1863, by a shell, which fractured the occipital bone. He Avas conveyed to Chattanooga, Tennessee, aud admitted to Hospital No. 5, on the 6th of December. Furloughed on the 26th of January, he was, on his return, March 25th, admitted to the hospital at Cleveland, Ohio, and discharged the service on the 24th of June, 1864. A portion of the external table of the occipital bone had been removed, but the place and date of the operation are not ascertained. On May 5th, 1865, Pension Examiner D. F. Alsdorf reported both tables of the bone absent, and the wound but recently closed. Active exercise causes severe pain over the right eye and dull pain at the seat of injury. The left arm is paralyzed. He rates his disability three- fourths and temporary. Case.—Private Josiah Reed, Co. F, 148th New York Volunteers, aged 39 years, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1864, by a conoidal ball, which fractured and depressed the posterior superior angle of the right parietal bone. He Avas admitted to the field hospital, Eighteenth Corps, on the same day; sent to St. Paul's Church Hospital, Alexandria, Virginia, on the 8th, and thence transferred to the Cuyler Hospital, Germantown, Pennsylvania, on the 13th. He suffered from headache Avithout stupor or delirium; partial paralysis of the left foot and leg existed, and the tongue was drawn toAvard the left side. These symptoms continued without any change, except a gradual diminution of the paralysis until the beginning of July, AA'hen increased dullness and hebetude and a decided icteroid tinge over the whole body, rendered the prog- nosis more serious. On July 2d, the soft parts Avere divided, the seat of fracture exposed and all sequestra removed. One spicula measured an inch in length by half an inch in width, involving both tables. Considerable fetid pus floAved from the Avound. The dura mater Avas covered AA'ith healthy granulations. The patient Avas kept in bed Avith his head elevated; cold applications were made to the Avound, and an occasional mercurial and saline cathartic was administered. By September 30th, the wound had entirely healed. No cerebral symptoms appeared during the treatment. On May 10th, 1865, he Avas sent to the Mower Hospital, Philadelphia, and on the 16th, Avas transfeiTed to the Veteran Reserve Corps. The case is reported by Assistant Surgeon H. S. Schell, U. S. A. This soldier was discharged the service July 10th, 1865, and pensioned. On February 13th, 1866, Pension Examiner R. C. BordAvell reports that the man suffered from partial hemiplegia of the left side, Avith confusion of ideas, loss of memory, etc. He rated his disability one-half and temporary. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 227 Case.—PriA'ate James H. Quimby, Battery L, 1st Maine Heavy Artillery, aged 21 years, Avas Avounded at Spottsylvania Court-house, May 19th, 1864, by a conoidal musket ball, which penetrated the outer table of the left temporal bone, passed doAviiAvard and chipped off a portion of the mastoid process. Another ball entered beneath the left clavicle, injuring the apex of the left lung, and passed out at the axilla. He remained on the battle-field three days without attendance; was then removed to Fredericksburg, Virginia; thence sent to the Columbian Hospital at Washington on May 28th, and was furloughed June 12th, 1864. He Avas treated at his home by Pension Examiner E. Russell. Simple dressings and expectant treatment Avere used. On July 23d, a piece of the outer table of the temporal bone, about three-fourths by one-half inch in size, was removed. After the operation, the patient slowly recovered. On August 4th, 1864, he Avas admitted to the Cony Hospital at Augusta, Maine; on February 18th, 1865, Avas transferred to the Veteran Reserve Corps; and on June 10th, 1865, was discharged the service and pensioned. At this date the wound had healed, but active exercise caused dyspnoea. Subsequent information from Pension Examiner J. B. Bell states that the patient suffered from deafness, headache, vertigo, and paralysis of arm. He was unable to bear exposure to heat. His disability is rated total and permanent, Case.—Sergeant Allen C. Taylor, Co. B, 7th New Hampshire Volunteers, aged 23 years, was wounded before Petersburg, Virginia, May 9th, 1864, by a conoidal musket ball, Avhich struck the left parietal bone, passed backAvard parallel Avith the sagittal suture, produced a furroAV in the scalp of four or five inches in length, and involved the bone for the same distance. He Avas admitted to the Hampton Hospital on May llth, and, in a feAV days, sent by steamer to the Central Park Hospital, New York, where he arrived on the 23d of the month. The wound Avas ragged in appearance and tumefied; the bone was bared and burroAved. There was no evidence of compression, and the pulse Avas full. On the 27th, the tumefaction had involved the right eye, and a sluggish movement of the pupils Avas observed, the patient feeling dull. The Avound all this time was painful and emitting an unhealthy discharge. Upon a thorough examination of the parts, pieces of the missile were found impacted in the outer table. Poultices Avere noAV applied to the head, and on June 17th Acting Assistant Surgeon George F. Shrady removed an irregular depressed portion of the external table, which had become detached, measuring three-fourths of an inch by one and a half inches. Three days later, a portion of the vitreous table, one-half by three-fourths of an inch, came away. On the 25th, again several fragments of the outer table were removed, and on the 5th of July another portion of the inner table, in which Avas imbedded a good-sized piece of the missile. Spiculae of bone and pieces of lead Avere afterward extracted at different periods. The patient experienced a good deal of pain in the head, and the occurrence of a fungus cerebri was apprehended, the pulsations of the brain being visible. The dura mater Avas uninjured, and the discharge from the wound Avas free and healthy. The patient recovered rapidly, and was discharged from service on November 21st, 1861, being, at the time, in the full possession of bis mental powers and a good degree of strength. The case is reported by Surgeon B. A. Clements, U. S. A. In 1869 Taylor Avas a pensioner, his disability being rated at three-fourths. Pension Examiner W. D. Buck reports that this pensioner has partial paralysis of the left arm, and vertigo, and that there is a depression half an inch deep at the upper anterior angle of the left parietal. Case.—Private M. R. Armour, Co. E, 83d Pennsylvania Volunteers, was wounded at the battle of Gaines' Mill, Virginia, June 27th, 1862, by a conoidal ball, which fractured the right parietal bone. He remained in the field hospital until July 29th, when he was sent to Chester, Pennsylvania, and thence, on September 18th, to the Sixteenth and Filbert Streets Hospital, Philadelphia. Acting Assistant Surgeon L. Fassitt removed a portion of the fractured bone about one inch long and one-third of an inch wide. Simple dressings were applied to the wound. The patient recovered, and was discharged from service on November 26th, 1862. He could not bear exposure to the sun, and his left hand was partially paralyzed. The Commissioner of Pensions states that in March, 1863, Armour's disability was rated " one-half and temporary". The case is reported by Acting Assistant Surgeon Richard J. Dunglison. Case.—Private David K. Pillsbury, Co. E, 12th NeAV Hampshire Volunteers, received, at the battle of Chancellorsville, Virginia, May 3d, 1863, a gunshot fracture of the left parietal bone at its posterior superior aspect. He Avas admitted to field hospital Third Corps; on June 14th, sent to 1st division hospital, Alexandria; and on June 19th, to Satterlee Hospital, Philadelphia. There was constant cephalalgia and dizziness. A piece of bone from the outer table, three-fourths by three-eighths of an inch, was detached. On July 28th, the patient Avas sent to Concord, New Hampshire. Bone had exfoliated; headache, nausea, and partial paralysis of arms and legs existed, and the patient Avas greatly enfeebled. He Avas discharged September 4th, 1863, and pensioned, his disability being rated three-fourths and doubtful. Case.—Private Adam W. Zimmerman, Co. B, 184th Pennsylvania Volunteers, aged 30 years, was wounded at the battle of Petersburg, Virginia, June 22d, 1864, upon the left side of the head, near the sagittal suture, by a conoidal musket ball. which passed directly backward, tearing up the scalp and fracturing the parietal bone. He Avas immediately admitted to the hospital of the Second Corps, and thence conveyed to Alexandria, and admitted on July 4th into the 2d division hospital. On July 13th, he was transferred to the Broad and Cherry Streets Hospital at Philadelphia. Soon after, a fragment of bone, measuring one and cne-fourth inches in length by three-fourths in width, Avas removed. On July 18th, he was sent to the Summit House Hospital, and thence, on August 24tb, transferred to the Satterlee Hospital, where, on October 20th, another piece of bone of nearly the same size, including a portion of the inner table three-fourths of an inch in diameter, was removed. An extensive incision of the scalp was now made to secure a ready discharge of pus. Other small scales of bone were removed as they became detached; otherwise the case progressed satisfactorily. The wound had fully cicatrized by the middle of March, 1865, and the patient Avas discharged from service on May 6th, 1865. The case is reported by Surgeon Isaac I. Hays, U. S. V. In 1869, he was a pensioner, his disability being rated permanent. The right arm and leg were partially paralyzed. Case.—Sergeant James W. Coaltrap, Co. G, 174th Ohio Volunteers, aged 29 years, Avas wounded near Murfreesboro' Tennessee, December 7th, 1864, by a shell, which lacerated the scalp over the frontal bone. He Avas admitted to hospital at Murfreesboro', and in February, 1865, sent to Harewood Hospital, Washington, Avhere he was discharged the service June 22d 228 WOUNDS AND INJURIES OF THE HEAD. 1865, and was afterward pensioned. On May 3d, 1869, Pension Examiner J. M. Todd reported this man to he suffering from constant seven1 headache, Avith a marked nervous irritation, insomnia, violent vertigo, partial paralysis, and mental ohtusencsH— all of which symptoms Avere on the increase. Casio.—Corporal Henry SAveiger, Co. I, 208th Pennsylvania Volunteers, aged 18 years, received, near Petersburg, Virginia, March 25th, 1865, a gunshot fracture of the right parietal bone. He was sent to the hospital of the 3d division, Ninth Corps; thence to AYashington, where he Avas admitted to the Lincoln Hospital on March 30th. On May, 13th, he was transfeiTed to the Mower Hospital, Philadelphia. Simple dressings were applied to the wound. On June 1st, an exfoliation of the outer table, three-fourths of an inch in length by one-half inch in width, was removed, and two days later another piece, one inch in length, was taken out. No untoward symptoms followed, and the patient Avas discharged the service on June 21st, 1865, and pensioned. On March 26th, 1868, Pension Examiner M. H. Strickler, reported this man to he suffering from partial paralysis ofthe left side, and to be unable to perform manual labor or bear exposure to the sun. He recommends an increase of pension. Case.—Private William Coneley, Co. H, 14th Blinois Volunteers, Avas wounded at the battle of Shiloh, Tennessee, April 6th, 1862, by a musket ball, which fractured the centre of the left parietal bone. The ball and several long spiculae of bone were removed from the wound. He was probably treated in a field hospital until July 10th, 1862, Avhen he Avas admitted to the hospital at Keokuk, IoAva. He was discharged on October 17th, 1862, and was subsequently pensioned. On May 19th, 1863, Pension Examiner T. S. Hening reports that the paralysis ofthe right arm, occurring immediately after the removal ofthe ball and fragments, still continues. He rates the patient's disability total and temporary. Case.—Private Hugh Finnegan, Co. A, 4th Rhode Island Volunteers, aged 35 years, was wounded near Petersburg, Virginia, July 30th, 1864, by a conoidal ball, which fractured the upper part of the left parietal bone. He Avas admitted to the hospital of the 2d division, Ninth Corps; on August 3d, sent to hospital of the Ninth Corps at City Point; and, on August 6th, to Lovell Hospital, Portsmouth, Rhode Island. He Avas discharged on June 1st, 1865, and pensioned, his disability being rated at two-thirds. There Avas headache, dizziness, and partial paralysis of right arm. A portion of the temporal bone had been removed, but at Avhat time cannot be definitely ascertained. On March llth, 1867, Pension Examiner R. W. Rims reported this man to be totally deaf in the left ear, and suffering almost constant pain, Avith vertigo. There is also paralysis of the right hand and arm. In the following curious case, paraplegia, relieved by the removal of the missile and depressed fragments from a depressed fracture of the parietal, was followed by hemiplegia, first of the right and then of the left side: CASE.-Private David C. Minium, Co. F, 49th, Pennsylvania Volunteers, aged 26 years, was wounded at the battle of Winchester, Virginia, September 19th, 1864, by a spent ball, which fractured and depressed the left parietal bone at the top of the head to the extent of one inch in diameter, and then lodged in the wound. He was conveyed to the hospital of the 1st division, Sixth Corps, and on September 25th, sent to the hospital at Sandy Hook, Maryland. On October 3d, half of the ball and several fragments of bone were removed by Acting Assistant Surgeon J. F. Bartholf, relieving immediately the paralysis of the loAver extremities, Avhich had existed before the operation. He recovered and was discharged on July 24th, 1865. At this date, Acting Assistant Surgeon Thomas H. Helsey reported that there Avas partial paralysis of the right side of the body, with frequent attacks of headache and vertigo. On May 31st, 1866, Pension Examiner T. C. Morris reported that there Avas a deep depression of the skull, " causing a partial paralysis of the entire left side." Epilepsy.—Many patients who recovered after gunshot fractures of the skull, treated by the removal of detached or depressed fragments of bone, suffered, ultimately, from epilepsy. Abstracts will be given of a few of these cases: CASE.-Private Benjamin K. Gardner, Co. B, 76th Pennsylvania Volunteers, aged 18 years, was wounded in front of Petersburg, Virginia, July 27th, 1864, by a conoidal musket ball, which slightly fractured the cranium. He was at once admitted to the hospital of the 2d division, Tenth Corps, sent to the general hospital at Fort Monroe on August 1st, and thence, on August 7th, by steamer to the De Camp Hospital in NeAV York Harbor. He Avas furloughed on August llth. On reaching home he became unconscious, and remained so for a period of five weeks. On November 19th, he was admitted into the Satterlee Hospital, at Philadelphia, Avhere, on the 22d, several spiculae of bone were removed, one of them measuring one by one-fourth of an inch. During the progress of the case several other spiculae were removed, the last being extracted in January, 1865. The wound afterward healed rapidly, but the patient continued to suffer from headache until the day of his discharge from service, May 16th, 1865. The Commissioner of Pensions states in a letter dated March, 1868, that Gardner receives a pension of eight dollars per month, his disahUity being rated total and doubtful. On January llth, 1869, Pension Exammer D. D. Mahon rates this man's disability total, of the third grade, and recommends an increase of pension, OAving to the presence of epilepsy, partial paralysis of the limbs, and threatening amaurosis. Case.—Sergeant Daniel W. Hayden, Co. H, 7th New Hampshire Volunteers, aged 23 years, was wounded at the battle of Olustee, Florida, February 20th, 1864, by a shell, AA'hich fractured and depressed the left parietal bone. He was sent to JaeksonA-ille, Florida, and transferred to Hilton Head, South Carolina, on February 25th. The depressed bone had been elevated, and blood extravasated Avithin the cranium had been removed before his admission. Simple dressings Avere applied. The patient recovered rapidly and Avas discharged from the service on the 28th of April, 1864. In March, 1868, his disability was rated at three-fourths and permanent. On January 29th, 1870, Pension Examiner J. V. Titts reported the disability as REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. ' 229 total. A square inch of the parietal Avas gone, part having been removed by operation, and the rest having exfoliated. The cicatrix Avas painful, the pain being much increased by pressure. Frequent epileptic fits recurred, brought on by even slight fatigue or excitement. The convulsions have increased rather than diminished in intensity as time has worn on. The pensioner feared to leave home unaccom: anied. Ultimate ruin of the mental powers was apprehended by the examiner. Case.—Private John P. Patterson, Co. A, 49th Pennsylvania Volunteers, aged 19 years, was wounded at Rappahannock Station, Virginia, November 7th, 1863, by a conoidal ball, Avhich fractured and depressed both tables of the left parietal bone near the vertex. He Avas conveyed to Washington, and admitted into the Stanton Hospital on the 9th. Several fragments of bone Avere removed exposing the dura mater. For two days convulsions occurred; after that the patient became tranquil, with the loss of voluntary motion in the right arm and leg. On the 20th, the paralysis disappeared. The wound suppurated moderately and filled with healthy granulations. On the 26th, and again on the 27th of December, several small spiculae of bone were removed. By January 1st, 1864, the patient had entirely recovered; was furloughed on the 7th, and admitted to Turner's Lane Hospital, Philadelphia, on May llth. Epilepsy supervened, and he was discharged from the service on July 18th, 1864. A communication from the Commissioner of Pensions, dated January 2d, 1868, states that Patterson is a pensioner, and that his disability is rated total and permanent. The case is reported by Acting Assistant Surgeon C. Campbell. Case.—Private James McEvoy, Co. F, 28th Massachusetts Volunteers, aged 32 years, was wounded at the battle of Chantilly, Virginia, September 1st, 1862, by a fragment of shell, which struck the right parietal bone about an inch above the squamous portion of the temporal bone, fracturing both tables, and denuded the parietal for a space of three and a half inches in length by one and a half inches in width. Leaving the battle-field without assistance, he was admitted into the Emory Hospital at Washington, on the following day, Avhere Surgeon William Clendenin, U. S. V., removed all loose spiculae of bone. Profuse haemorrhage from the meningeal artery Avas arrested by the application of ice. Cold water dressings Avere applied and morphia administered. On the 8th, the pupils Avere dilated, and the left arm was partially paralyzed, but the patient was perfectly rational. On the 14th, a piece of bone, one and one-fourth by three-fourths of an inch, was removed. Water dressings were discontinued, and cerate dressings were substituted. Mineral tonics, cathartics, and nourishing diet were ordered. On the 28th, the wound Avas discharging but a small amount of pus, and the patient was able, with some effort, to close his hand, but had no further use of it. By the 8th of October, the Avound Avas nearly healed; a small surface, covered by healthy granulations, covered the brain. The pupils Avere still dilated, but, with the exception of his palsied arm, the patient was doing well. On November llth, 1862, he was discharged the service and Avas pensioned. The case is reported by Surgeon W. Clendenin, U. S. V. On February 4th, 1867, Pension Exammer H. B. Hubbard reports the patient subject to frequent epileptic fits, and rates his disability total and permanent. Case.—Corporal George W. Monk, Co. A, 78th New York Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which fractured the right parietal bone near its posterior superior angle. He fell to the ground in a state of insensibility; when consciousness returned he passed his finger into the wound one or two inches. His left arm and both of his legs Avere paralyzed. He remained on the field for three days, exposed to a cold and drencliing rain Avithout shelter, and was then seized with convulsions. He was admitted to the Log Hospital on May 6th, and on June 15th, sent to the Armory Square Hospital, Washington. From time to time, fragments of bone from both tables escaped. About the end of June, haemorrhage occurred, probably from the middle meningeal artery, but was arrested by plugging. It recurred about four weeks later, but was again arrested. On August 27th he was furloughed; on October 14th, admitted to the Ladies' Home Hospital, New York, and on February 6th, 1864, discharged from service. The paralysis had disappeared entirely, except from his left arm, where it remained in a slight degree. On March 26th, 1868, Pension Examiner N. W. Leighton reports that the patient was a helpless epileptic. There Avas abscess of the brain and paralysis of the left arm, Avith morbid excitability of the whole cutaneous surface. He rates his disabiUty total and permanent. Case.—Corporal James C. McClusky, Co. D, 115th Pennsylvania Volunteers, aged 56 years, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal musket ball, which produced a comminuted fracture of both tables of the frontal bone, right side, and lodged. The missile and a portion of the os frontis, an inch in diameter, which was pressing upon the brain, were removed three days subsequently in the field hospital. He was sent to the Harewood Hospital, Washing- ton, on the 15th, where he remained until the 23d, when he Avas transferred to the Satterlee Hospital in Philadelphia. For a Avhile he improved steadily, but about the 1st of August, began to sink into a state of insensibility, in AA'hich he remained several days. He rallied, however, made a rapid recovery and Avas discharged from service on the 23d of October, 1863. In January, 1868, his disability was rated total and permanent. The case is reported by Surgeon I. I. Hayes, U. S. V. On January 27th, 1864, Pension Examiner John Lowman reports this man to be subject to epilepsy, and rates his disability total and permanent. CASE.-Private John Hurt, Co. E, 83d Indiana Volunteers, Avas Avounded near Vicksburg, Mississippi, December 28th, 1862, by a fragment of shell, which fractured the frontal bone over the right eye. Fragments of bone Avere removed by Surgeon E. Andrews, 1st Illinois Light Artillery. He was conveyed to the Hospital Steamer City of Memphis, and thence, on January 13th, 1863, transferred to Paducah, Kentucky. He was discharged the service on March 23d, 1863, and was subsequently pensioned. On August 7th, 1868, Pension Examiner J. C. Burt reports that this man, in addition to a depression of the skull and the loss of an eye, suffers from pain in the head, and alleges that he has attacks simulating epilepsy. He rates his disability permanent. CASE.-Private Columbus Custer, Co. C, 16th Iowa Volunteers, aged 33 years, was wounded at Atlanta, Georgia, July 22d, 1864, by a piece of shell, which fractured the parietal bone. He was admitted to a hospital at Chattanooga, on November 28th; sent, via Nashville, Tennessee, to the Jefferson Hospital at Jeffersonville, Indiana, where he was admitted on December 1st, 1864. The Avound had entirely healed. The patient Avas discharged on April 4th, 1865. On January 4th, 1866, Pension 230 WOUNDS AND INJURIES OF THE HEAD. Examiner R. S. Lewis reports this man to be suffering from partial paralysis of the right side, and from epileptic fits, which occur once or twice monthly. He rates his disability total and temporary. A communication from the Commissioner of Pensions, dated July, 1868, states that Custer is a pensioner at §8 per month, his disability being rated total and temporary. Case.—Private Joseph Link, 19th New York Independent Battery, aged 24 years, Avas wounded at Spottsylvania Court- house, A'irginia, May 12th, 1864, by a shell, Avhich fractured the frontal bone, right side, half an inch above the superciliary ridge; fragments of inner table were imbedded in the membranes above the frontal sinus. Inflammation and compression folloAved and fragments of both tables were removed by forceps and elevator. He was discharged May 2d, 1865, and Avas subsequently pensioned. On October 17th, 1866, Pension Examiner J. H. Helmers reports a small piece of bone to be still denuded. There Avas a slight discharge from the Avound, and the patient was subject to frequent attacks of epilepsy. He rates his disability total. Case.—Private James W. Hotchkiss, 19th New York Battery, was wounded in the engagement before Petersburg, Virginia, November 9th, 1864, by a musket ball, Avhich fractured the cranium. He \vas admitted to the hospital of the 1st division, Ninth Corps; on November 13th, sent to the depot field hospital at City Point, and on November 29th, transferred to 3d division hospital at Alexandria. He was discharged from the service on April 3d, 1865, on account of fracture of skull and partial paralysis, and \vas afterward pensioned. On January 25th, 1868, Pension Examiner J. H. Helmers reported this man to be suffering from partial paralysis of the left side, with loss of memory. He also credits the patient's statement of being subject to frequent and severe epileptic fits. He rated his disability equivalent to the loss of a foot or hand and permanent. Defective Vision.—In those patients who recovered after gunshot fractures of the skull, treated by removal of fragments, partial or complete loss of vision was one of the most frequent of the remote results. Case.—Private Adam Cornwall, Co. B, 91st Pennsylvania Volunteers, aged 21 years, Avas wounded at the battle of Cold Harbor, Virginia, June 21st, 1864, by a piece of shell, which struck the outer angle of the orbital ridge, fractured the orbital plate, and partially destroyed the sight of the right eye. He was at once admitted to the hospital of the Fifth Corps; on the 10th, sent to Sickle branch of the 2d division hospital at Alexandria, Virginia; and on the 20th transferred to Philadelphia, entering Satterlee Hospital on the 25th. On June 28th, Acting Assistant Surgeon Ezra Dyer removed two pieces of the orbital ridge. The patient's constitutional condition at this time was excellent, but there was some cerebral irritation. On July 1st, an incision in the scalp was made, and tAvo pieces of bone were removed; one the size of a filbert, the other as large as a pea. Simple antiphlogistic treatment was employed, and the patient progressed finely. On April 13th, 1865, he was discharged from the service by reason of loss of sight ofthe right eye. A communication from the Commissioner of Pensions, dated March 26th, 1868, states that Adam Cornwall is a pensioner, and that his disability is rated at one-half and permanent. Examining Surgeon J. Cumminskey reports that the vision of the right eye is totally destroyed, but that the left eye is unaffected. Case.—Private Louis Dubar, Co. K, 12th Maine Volunteers, aged 21 years, was Avounded at the battle of Cedar Creek, Virginia, October 19th, 1864, by a conoidal ball, Avhich fractured and depressed the middle of the frontal bone. The fracture extended backward a distance of four inches. He Avas taken to a field hospital, and thence sent to Philadelphia, where he was admitted into Satterlee Hospital on the 23d, suffering much pain. Simple dressings Avere applied, and Ioav diet ordered. On November 10th, coma supervened, and the right upper extremity became paralyzed. An examination revealed the edges of the bone depressed, and several small pieces lying loose betAveen them. The fragments were removed, and the depressed portions elevated, revealing the dura mater intact. He improved at once, and in five days was able to walk about the ward free from any symptoms of nervous disorder. On May 20th, 1865, he was discharged from the service by reason of impaired vision. The case is reported by Surgeon I. I. Hayes, U. S. V. Pension Examining Surgeon H. Lenox Hodge reports that this pensioner is suffering from giddiness and faintness, and that the vision of the left eye is much impaired. CASE.-Private Jerome Dickerson, Co. B, 179th NeAV York Volunteers, was wounded in the engagement near the Weldon Railroad, Virginia, June 17th, 1864, by a conoidal ball. He was at once admitted to the hospital of the 1st division, Ninth Corps, and on July 1st Avas sent to the Mount Pleasant Hospital, Washington. The injury was treated as a slight scalp wound, and on July 20th the patient Avas sent to MoAver Hospital, Philadelphia, where it Avas discovered that the frontal bone was fractured near its eminence. Small pieces of bone were removed at various times. He recovered, was returned to duty on December 5th, 1864, and discharged the service June 8th, 1865, and pensioned. On April 2d, 1866, Pension Examiner H. W. Nye stated that the patient suffers from pain, giddiness, and partial loss of sight of right eye. The patient also deposed that he Avas unable to labor in the summer, on account of dizziness and frequent pain in the head. Case.—Private James W. Duncan, Co. B, 10th West Virginia Infantry, aged 19 years, was wounded at Ashhy's Gap, Virginia, July 18th, 1864, by the explosion of a caisson, causing depressed fracture of both tables of the superior portion of the frontal bone, a little to the right of the median line. He Avas admitted to the general hospital at Sandy Hook, Maryland, on the 22d, and was transferred to the hospital at Frederick on the 27th, suffering from headache and pain in the chest. Assistant Surgeon R. F. Wier. U. S. A., removed the depressed fragments to the extent of two and a half inches Avith bone-cutting forceps. No cerebral symptoms existed at the time. The injury to the head healed Avell, but the patient suffered for some time from empyema and pneumothorax. He recovered, was transferred to the hospital at Grafton, West Virginia, on January 31st, 1865, and discharged the seiwice on June 5th, 1865. A communication from the Commissioner of Pensions, of March 26th, 1868, states that Private Duncan is a pensioner, his disability being rated as total and permanent. The other facts in the case were reported by Surgeon S. N. Sherman, U. S. V. On March 12th, 1869, Pension Examiner Thomas Kenney states that this man is totally blind in the left eye. Exercise or stooping produced total blindness. He rates his disability total and permanent. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 231 CASE.-Private George W. Eastlick, Co. O, 29th Ohio Volunteers, aged 30 years, was wounded at the battle of Port Republic, A'irginia, June 9th, 1862, by a conoidal ball, Avhich fractured and depressed the cranium at the left parietal eminence. He Avas rendered insensible by the bloAV, and remained in that state for about four hours, Avhen he recovered sufficiently to leave the field. The ball, which had fractured both tables of the skull and split upon the sharp edge of the outer table for tAvo-thirds 'of its length, was readily removed on the field. On June 15th, he Avas admitted into Cliff burne Hospital, Washington. His general condition Avas good, but there was considerable mental confusion, loss of memory, marked deficiency in the strength and sensibility of the right arm, slight but persistent and daily increasing contraction of the fingers. The wound looked healthy and was granulating. Absolute quiet was enjoined, and laxation and light diet ordered; but the unfavorable symptoms evidently increased. On June 23d, ether was administered, and Assistant Surgeon John S. Billings, U. S. A., made a crucial incision over the seat of injury, cut away a small portion of the sound bone Avith 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 operation 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 untoAvard symptoms supervened, and the Avound, Avhich Avas kept open for tAvo Aveeks to permit the free escape of pus, healed rapidly. On July 9th, while holding a candle and assisting in dressing a patient, he Avas suddenly seized with vertigo, and Avas immediately compelled to lie down. A full saline cathartic Avas given, and low diet ordered. No further cerebral symptoms occurred, and by the 20th he was perfectly convalescent. He was discharged August 5th, 1862. The case is reported by Assistant Surgeon J. S. Billings, U. S. A. In September, 1867, Pension Examiner John F. Ray reports that the vision in the left eye is impaired and intolerant of light. His disability is rated two-thirds and permanent. Case.—Lieutenant William Finn, Co. C, 14th Michigan Volunteers, aged 22 years, Avas wounded at the battle of Jonesboro', Georgia, September 1st, 1864, by a conoidal ball, which fractured the right parietal bone. He was on the same day admitted to the hospital of the 2d division, Fourteenth Corps, and on October 25th sent to the Officers' Hospital at Lookout Mountain, Tennessee. During the treatment several spiculae of bone were removed. On November 5th, 1864, the wound had healed, and Finn received a leaA'e of absence. He was mustered out on December 15th, 1864, on account of expiration of term of service, and Avas afterward pensioned on account of partial loss of sight in both eyes, with cephalalgia and dizziness. On March 26th, 1865, Pension Exammer J. N. BroAvn rated his disability one-half and permanent. Case.—Sergeant Robert Hays, 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 a field hospital until May 17th, 1865, when he was admitted to the Asylum Hospital, Knoxville, Tennessee. He was discharged on May 24th, 1865, and Avas pensioned. On October 12th, 1867, Pension Examiner C. Wheeler reports that the Avound was succeeded by 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, Avith 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 Heiman, 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 upper edge of the right parietal bone. He Avas conveyed to Philadelphia, entering Broad and Cherry Streets Hospital on the 7th. On the 28th, he was transferred to the Satterlee Hospital. The wound Avas kept open to facilitate the discharge of pus, and the bowels Avere kept 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, Avas removed on the 8th of December, and on the 13th, 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 Avere removed. By the 31st, the scalp Avound had almost entirely healed, but the patient complained of pain at the seat of injury and great 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 trans- ferred to the hospital guard for duty; but Avas 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 ofthe heart, and a constant headache. On July 25th, 1864, he applied for a pension and was examined by Dr. Charles Rowland, examining surgeon for pensions, Brooklyn, New York. The Avound had healed, leaving a large indentation one inch in diameter, the scalp and membranes alone protecting the brain. The applicant's memory and vision in the right eye Avere impaired. The case is reported by Surgeon Isaac I Hayes, U. S. V. CASE.-Private Alexander Kreiger, Co. D, 7th IoAva Volunteers, aged 19 years, was Avounded December llth, 1864, while on picket near Anderson's Farm, Georgia, by a conoidal ball, which fractured the outer table of the left parietal bone near its superior posterior angle. He Avas immediately admitted to the regimental hospital, and thence sent to the corps hospital, where fragments of bone were removed. On the 19th, he Avas transferred to Beaufort, South Carolina, and January 23d, 1865, taken on the hospital steamer Ben Deford to the McDougall Hospital, NeAV York, Avhere he remained until March 14th, Avhen he was transferred to the hospital at Keokuk, Iowa. On May 24th, 1865, he was transferred to Davenport, to be mustered out of service. He was discharged May 27th, 1865, and pensioned. Pension Examiner R. H. Wyman reported, on April 2d, 1867, that there was almost constant discharge from the wound, with defective eyesight and memory. He rated his disability two- thirds and permanent, unless removed by an operation. Case.—Private John Lanyon, Co. E, 140th New York Volunteers, aged 35 years, Avas wounded at the battle of Spott sylvania, Virginia, May 13th, 1864, by a conoidal musket ball, which entered the frontal bone to the ricmt of the median line near the coronal suture, and lodged beneath the scalp near the place of entrance, apparently without producing any fracture of 232 WOUNDS AND INJURIES OF THE HEAD. the skull. He Avas rendered unconscious from the shock, and lay in a state of insensibility until the missile was extracted by the regimental surgeon, Henry C. Dean, five hours after the reception of the injury. The ball Avas much flattened and Aveighed an ounce. The patient was at once conveyed to the division hospital, suffering at the time great pain in the head and constant dizziness. Forty-eight hours later, to avoid capture by the advancing enemy, he started on foot for Fredericksburg, some eighteen miles distant, which he reached in tAventy hours, greatly exhausted. He was obliged to lay for ten hours after his arrival exposed to the rain before he could be admitted into a temporary hospital. He remained there four days and was then sent to Washington, and admitted into the Campbell Hospital on May 24th, 1864. About June 1st, he received a furlough and visited Buffalo, New York, Avhere he came, on June 6th, under the care of Acting Assistant Surgeon S. W. Wetmore, who discovered that the frontal bone was fractured. The Avound at this time was discharging freely; but there being no cessation of the headache and dizziness, Dr. Wetmore, on the 4th of July, removed the fractured portion of the external as well as some pieces from the internal table. On July 20th, Lanyon returned to Washington; was sent to the Lovell Hospital, Portsmouth Grove, Rhode Island, on July 30th, and thence sent, on August 24th, to the hospital at Rochester, NeAV York, where he was discharged from service on the 26th of December, 1864. He was able to folloAv his trade as a carpenter, but as late as June, 1866, he had not become entirely free from attacks of dizziness and neuralgic pain. A communication from the Commissioner of Pensions, dated July, 1868, states that Lanyon is a pensioner at $6 per month, his disability being rated at three-fourths and permanent. On May 21st, 1869, Pension Examining Surgeon Horatio N. Loomis reported that this pensioner complained of headache and dizziness and dimness of vision and occasional faintness; but that he was able to work moderately a great part of the time. Case.—Private John Lahey, Co. E, 38th New York Volunteers, was wounded at Fredericksburg, Virginia, December 13th, 1862, by a conoidal ball, which fractured the right temporal bone above the zygomatic arch, and lodged in the diploe. He Avas sent to Harewood Hospital, Washington, where the ball Avas removed at the first dressing. On December 25th, a triangular piece of the external table Avas removed through incision, and the inner table was found to be fissured. The wound healed rapidly by granulation, and on April 20th, 1863, the man was discharged the service. In June, 1864, Pension Examiner James Neil reports that there is incipient amaurosis, and that the mental powers seem to be somewhat obtuse. Case.—Lieutenant Isaac N. Morgan, Co. B, 1st Maine Artillery, aged 23 years, was wounded at the battle of Spottsylvania, May 19th, 1864, by a conoidal ball, which entered above the inner angle of the right eye, fractured the supra-orbital ridge, and lodged in front of the right ear. The ball and a portion of the supra-orbital ridge Avere removed. The patient Avas admitted to the Seminary Hospital, Georgetown, on May 25th, 1864. He Avas transferred to the Officers' Hospital at Annapolis August 8th, 1864, and discharged August 15th, 1864. Lieutenant Morgan Avas afterward pensioned. On September 15th, 1865, Pension Examiner R. K. Jones reports that he has much pain in the forehead, and that any exposure to the heat of the sun, or exercise, causes giddiness, Avith severe pain in the other eye, and dimness of vision. He rates his disability total. Case.—Private Daniel D. O'Donovan, Co. K, 59th Massachusetts Volunteers, aged 23 years, was wounded at the battle of the Wilderness, Virginia, May 6th, 1864, by a conoidal musket ball, which injured the orbital ridge of the frontal bone. He was, on May llth, admitted to the Lincoln Hospital, Washington, D. C.; on May 16th, sent to the Patterson Park Hospital, Baltimore, Maryland; on June 17th, to the Knight Hospital, New Haven, Connecticut; on October 16th, to Readville; and thence, on October 24th, to the Dale Hospital, Worcester, Massachusetts, where he Avas discharged from service on March 2d, 1865, and pensioned. The vision of the left eye Avas totally destroyed, and the man suffered from morbid sensibility. On April 9th, 1867, Pension Examiner G. S. Jones reported this man to be suffering from a sympathetic affection of the right eye, with pain in the head and vertigo. He rates his disability total and probably permanent. Case.—Private Joseph G. Robinson, Co. I, 14th Connecticut Volunteers, aged 54 years, was wounded at the Weldon Railroad, Virginia, August 19th, 1864, by a fragment of shell, which struck the right parietal bone at a point midway between the coronal and lambdoidal sutures, producing a compound comminuted fracture of both tables of the right parietal bone. He was admitted to the hospital ofthe Second Corps, and thence conveyed to Washington, D. C, and admitted into Carver Hospital on August 30th. The patient Avas someAA'hat emaciated, and there was slight constitutional disturbance. On September llth, Acting Assistant Surgeon J. 0. French made a crucial incision through the scalp, elevated the depressed edges of the fractured bone, and removed the detached sequestra of both tables. Anodyne poultices were applied, and afterward simple dressings. On the 15th, the patient was doing well, his constitutional condition having improved. On February 20th, 1865, he was discharged from the service by reason of impaired vision. He is a pensioner, and his disability is rated total and permanent. Case.—Sergeant Thomas XV. Scott, Co. A, 5th Ohio Volunteers, received, at Cedar Mountain, Virginia, August 9th, 1862, a gunshot fracture of the skull. He was, on August 6th, admitted to 2d division hospital at Alexandria, and discharged October 22d, 1862. Pension Examiner William Devens reports, October 26th, 1868, that a portion of the left parietal bone, one inch by three-fourths of an inch, comprising both tables, with the intervening diploe, have been removed, and that the patient, six years after the reception of the injury, was seriously affected by loss of eyesight, frequent headache, dizziness, and loss of memory. Case.—Private Christian Strucoe, Co. K, 5th Michigan Volunteers, aged 32 years, was wounded at the battle of the Wilderness, Virginia, May 5th, 1864, by a conoidal ball, which fractured the frontal bone, imbedding itself in the outer angle of the left orbital ridge. He was, on May 12th, admitted to Douglas Hospital, AVashington, and on May 26th, to Satterlee Hospital, Philadelphia. On August 9th, tAvo small pieces of bone were removed from the Avound. The case progressed favorably, and on August 25th, the patient Avas transferred to St. Mary's Hospital, Detroit, Michigan, aud discharged from the service on June 17th, 18G5, on account of gunshot wound causing loss of sight of the left eye. He had also received an injury to his back by a fall from a wagon. In March, 1868, he Avas a pensioner at $4 per month, his disability being rated total and permanent. The certificate is signed by Acting Assistant Surgeon H. C. Kibbie. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 233 In two instances of gunshot fractures of the occipital bone, blindness ensued after the removal of fragments of bone, in consequence, no doubt, of some lesion of the optic centres, the nature of which could only be conjectured. CASE.-Private John XV. Snyder, Co. B, 49th Pennsylvania Volunteers, aged 22 years, was wounded in the trenches of Petersburg, A'irginia, April 1st. 1865, by a conoidal ball, which fractured the skull at the apex of the lambdoid suture, involving, probably, both parietals and the occipital. He Avas sent to the hospital of the 1st division, Sixth Corps; thence to the Judiciary Square Hospital at Washington, Avhere he arrived on the 12th. He lay in a stupor, from which he could, with difficulty, be aroused. His pupils Avere extensively dilated; the tongue was moist, and the pulse at 56; but no paralysis existed. The fractured portion of bone Avas depressed, and the brain matter was oozing out. On April 13th, Acting Assistant Surgeon F. H. Coulton removed a piece of depressed bone three-fourths of an inch square. The symptoms of compression of the brain noAV gradually subsided. During bis convalescence, it Avas noticed that his vision was impaired, especially on the left side. By the 13th of June, the wound had cicatrized, except at one point, where, probably, some slight necrosis existed. About the middle of June, Assistant Surgeon Brinton Stone, U. S. V., by Avhom the foregoing facts were communicated, brought this patient to the Army Medical Museum, Avhen a photograph of the cicatrix was made. ( Photographs of Surgical Cases and Specimens, Vol. I, No. 44). On June 19th, the patient was transferred, convalescent, to the Douglas Hospital. He Avas discharged on September 29th, 1865, and pensioned. Pension Examiner G. G. HartsAvick reports, October 11, 1869, this pensioner's disability as total, because of complete loss of vision. Case.—Captain Frank Gordon, Co. G, 121st Ncav York Volunteers, aged 30 years, Avas Avounded at the battle of Spott- sylvania Court-house, Virginia, May 8th, 1864, by a conoidal musket ball, Avhich fractured the occipital bone at the protuberance. He Avas admitted, on the same day, to the 1st division, Sixth Corps, hospital, and on the 16th, sent to the 1st division hospital at Alexandria. On examination, the fracture was found to extend one and seven-eighths inches, being one inch wide at the largest space. Fragments of bone Avere removed and ice applied. Extensive suppuration followed. On June 15th, several pieces of dead bone were removed, folloAved by haemorrhage; the orifice was kept open by sponge tents. He had so far recovered in July that a leave of absence was granted to him. On his return from furlough, he was admitted to the Officers' Hospital, Annapolis, Maryland. On October 7th, 1864, he was discharged from service and pensioned. Examiner J. A. BroAvn, M. D., reported, February 18th, 1865, that there was partial paralysis of the optic nerve of both eyes, the right being most affected. Exertion caused pain in head and vertigo. Deafness.—In the cases of this category, deafness was a less frequent complication than defective vision. It was generally associated with impairment of other special senses or of the mental faculties: Case.—Private Charles Burger, Co. G, 70th NeAV York Volunteers, was wounded at the battle of Williamsburg, Virginia, May 5th, 1862, by a musket ball which entered the left side of the head, passed through zygoma and emerged at the mastoid process of the temporal bone. He Avas conveyed to Baltimore, Maryland, and admitted into McKim's Mansion Hospital on May 10th. Four fragments of bone were removed from the squamous portion of the left temporal bone; the largest measuring one-fourth by one inch. He improved rapidly, and on August 6th, 1862, Avas discharged from service, having recovered, with paralysis of the seventh pair of nerves. The pathological specimen, contributed by Surgeon L. Quick, U. S. V., is figured in the adjacent wood-cut, (Fni. 114). In August, 1869, Burger was a pensioner at $4 per month, his disability being rated one-half. The certificate of Pension Examiner D. A. Otis, dated April 25th, 1864, states that the sight of the left eye and the hearing of the left ear are destroyed, and that twenty- eight necrosed pieces of bone had been discharged from the wound. Case.—Private George Schroeder, Co. A, 82d Illinois Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, Avhich fractured the mastoid portion of the right temporal bone. On May 5th, he was admitted to the hospital of the 3d division, Eleventh Corps, where fragments of bone Avere removed by Surgeon C. S. Wood, 66th New York Volunteers. On May 26th, the patient was sent to 2d division hospital at Alexandria, and on September 16th, 1863, returned to duty. He was discharged, August 26th, 1864, and pensioned. His pension was increased in September, 1867, reduced in September, 1869, and in March, 1870, he applied for an increase of pension, claiming that his disabilities had increased. Pension Examiner J. W. Thompson certifies that there was a depression in the mastoid portion of the temporal, and that the patient complained of neuralgic pains on the right side of the head, and of deafness of the right ear; but after several weeks of observation of this pensioner, he did not recommend any increase over his present rate for three-fourths disability. Case.—Private H. Elkin, Co. I, 35th Ohio Volunteers, aged 23 years, Avas wounded at the battle of Chickamauga, September 19th, 1863, by a conoidal ball, which entered at a point one-fourth of an inch posterior to the left ear, and immediately anterior to the lower portion of the mastoid process, opening the meatus, and emerged from the forehead at a point two inches above the outer canthus, and one inch above the superciliary ridge of the left eye. He was admitted to the hospital of the 1st division, Fourteenth Corps, and on September 29th, was sent to Hospital No. 1, at Chattanooga. There were no cerebral symp- toms. Some small spiculae of bone Avere removed from the upper opening. No unfavorable symptoms presented themselves. The patient Avas, on November 13th, sent to the field hospital at Bridgeport, Alabama; on November 14th, to Cumberland; Decern her 6th, to Taylor Hospital, Louisville, Kentucky; and February 23d, 1864, to Jeffersonville, Indiana, whence he was 30 Fig. 114.—Fragments of tem- poral removed after gunshot fracture. Spec 411, Sect. I, A. M. M. 2:U WOUNDS AND INJURIES OF THE HEAD. returned to dutv February 29th, 1864. He Avas discharged August 31st, 1865. and pensioned. Pension Examiner J. S. McNeelev reported, in October, 1867, that there Avas total loss of hearing in the left ear, and of sight in the left eye, and mental imbecility, unfitting this pensioner for business pursuits or for manual labor. Cask.—Private Richard S. McLaury, Co. G, 101st Noav York Volunteers.received, in the engagement near Chantilly, Virginia. September 1st, 1862, a fracture of the right parietal, and a slight Avound of the scrotum. He Avas coin-eyed to Wash- ington and admitted to Douglas Hospital. On October 25th, a piece of bone was removed from the skull; otherwise the wound did Avell, and the patient Avas sent to Jarvis Hospital, Baltimore, Avhere he Avas discharged from the service on December 27th, 1862, and pensioned. In September, 1863, Examiners 0. S. Bundy and J. G. Orton reported that this pensioner had defective hearing and vision, and that his intellect Avas impaired and general health seriously undeimined. They rated his disability as total. No improvement is noted in the reports since that date. Case.—Private Oliver M. Phillips, Co. B, 58th Massachusetts Volunteers, aged 29 years, was wounded at the battle ot Cold Harbor, Virginia, June 3d, 1864, by a conoidal musket ball, Avhich entered near the superior angle of the occipital bone and emerged about one inch above. He Avas admitted to the hospital of the 2d division, Ninth Corps, and on June 7th, sent to the 1st division hospital at Alexandria, where several pieces of bone Avere removed. Here he remained until February 25th, 1865, when he was sent to the Faiifax Seminary Hospital. He recovered, and Avas discharged from the service on May 29th, 1865. The Pension Examiner reported, September 21st, 1865, that there Avas a depressed cicatrix near the vertex, half an inch wide and three inches in length, and that the patient Avas totally deaf in the right ear, and that he had constant pain in the head. The following two cases were believed to be examples of recovery with balls lodged in the brain. (See p. 193, ante.) Case.—Corporal Ellroy Churchill, Co. A, 1st New York Mounted Rifles, aged 23 years, on April 8th, 1863, was admitted to Ladies' Home Hospital, New York, with a gunshot wound of the head. The missile had entered just anteriorly to the right ear, and lodged in the external auditory canal. On admission, there Avas free purulent discharge from the right meatus. In front of the corresponding tragus was the scar of a gunshot wound. Deep in the external auditory canal was a mass of florid granulations gi\ring issue to pus, and supposed to cover the seat of the rifle ball. Deafness was marked, but not complete, proving that the internal ear remained uninjured. The auditory canal was kept clear, and a solution of nitrate of silver was applied to the granulations Avith a vieAV of reducing their size and making exploration for the ball possible. On May 9th, the patient Avas placed under the influence of chloroform, and tAvo small pieces of carious bone were removed fi-om a mass blocking up the canal. The meatus Avas freely incised, and a plug of sponge introduced Avith the expectation of making another attempt to remove the remaining mass and to reach the ball, but before the latter operation could be attempted, the patient was discharged from the service on May 20th, 1863, and left the hospital. Pension Examining Surgeon W. M. Chamberlain reported, August 4th, 1863, that there Avas a ball lodged in the right temporal bone, causing necrosis and loss of hearing. The patient appears not to have been pensioned at the time. The records of the Interior Department show that the case Avas reopened for investigation March 17th, 1870, the patient having insisted on his right to pension. Case.—Private Richard N. Thorndyke, 2d Battery, 1st Maine Artillery, aged 23 years, was Avounded at the battle of Gettysburg, July 2d, 1863, by a conoidal ball, Avhich struck the left side of the head one inch and a half above and behind the ear. penetrated the skull, and lodged. He \vas admitted to the Camp Letterman Hospital on the following day, and, on the 19th, transferred to the hospital at York, Pennsylvania. The patient stated that he was insensible for an hour or more after the reception of the Avound, that a portion of the bone had been removed, and that he had suffered constant pain in the opposite side of the head. He Avas deaf in the left ear, and had confused hearing in the right. Cold-water dressings Avere applied, and by August 7th, the Avound had healed; but dizziness still occurred whenever exposed to the solar heat. He was discharged from the service on November 30th, 1863, with loss of hearing, impaired mental poAver, and imperfect vision, the missile still undiscovered. In 1866, he Avas examined by Dr. Charles N. Germaine, pension examining surgeon. The missile still remained in his brain, causing total deafness of left ear, impaired eyesight, defective memory, vertigo, weakness, and inability to Avalk, and wholly unfitting him to perform any manual labor. He is a pensioner, and his disability is rated total and permanent. The patient whose history is related in the next abstract must afford an interesting subject for physiological study—the senses of smell, vision, hearing, and taste being more or less completely destroyed on one side, in connection with facial paralysis: Case.—Private Albert XV. Bullock, Co. B, 22d Wisconsin Volunteers, aged 22 years, Avas wounded at Atlanta, Georgia, August 17th, 1864. by a conoidal musket ball, AA'hich entered the left side ofthe head two inches in front of the ear, and emerged one and a half inches behind the ear, fracturing the mastoid process of the temporal bone. He Avas admitted to the hospital of the 3d division, TAventieth Corps, and, on September 1st, sent to Hospital No. 1, Chattanooga. On October 15th, he Avas admitted to the Joe Holt Hospital, Jeffersonville, Indiana; thence sent to the Jefferson Barracks, St. Louis, Missouri; on December 16th, transferred to the Saa ift Hospital, Prairie du Chien, Wisconsin; and on February 9th to the Harvey Hospital, Madison, Wisconsin. At the latter hospital it is stated that, on August 15th, 1864, several pieces of the mastoid process Avere removed. On May 23d, 1865, Bullock Avas mustered out of service. In 1868, he Avas a pensioner at four dollars per month, his disability being rated at one-half and temporary. His pension Avas afterward increased to fifteen dollars per month, Pension Examiner H. B. Johnson, M. D., having certified as follows: " The wound leaves him with complete loss of hearing, taste, and smell of left side, AA'ith partial blindness of that eye from retinitis; also has paralysis of all the muscles of the injured side, REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 235 inability to close the eyelids, and tenderness of eyeball. The condition of the brain induces vertigo and unsteadiness of gait. He cannot stoop for many moments without complete syncope. The deformity is very considerable, causing an appearance ot imbecility Avhen seen from the injured side. So far as knoAvn, his habits are good. The disability seems to be permanent in character, and, in my opinion, is total." Erysipelas.—The comparative rarity of erysipelatous complicatons of injuries of the head, especially among the Union troops, has been adverted to several times in the preceding pages of this chapter* The observation holds good in regard to the cases of gunshot fractures of the skull in which it was necessary to remove fragments. In the histories of one hundred and twenty-six patients of this series who recovered and were discharged and pensioned, this complication is noticed in three instances only. Case.—Private Jacob Arnold, Co. E, 64th NeAV York Volunteers, aged 22 years, received, at the battle of Antietam, Maryland, September 17th, 1862, a gunshot fracture of the left parietal bone, with depression of both tables. Treated first at his regimental hospital, he was sent, on September 24th, to the general hospital at Frederick. On admission, he had complete paralysis of the right leg and arm, and several convulsions soon after occurred. A crucial incision was made, and depressed bone Avas elevated and removed by Assistant Surgeon R. F. Wier, U. S. A. The flaps Avere then replaced, and adhesive strips and cold-Avater dressings Avere applied. Erysipelas of the forehead supervened, but this was successfully treated by the usual remedies. By November 17th the wound had cicatrized, and by April, 1863, the paralysis had disappeared. Arnold was discharged fi-om the service May 21, 1863. He is a pensioner, and his disability is rated total. Case.—Private William Bennett, Co. B, 7th Michigan Volunteers, was AVounded at the battle of Gettysburg, July 2d, 1863, by a piece of shell, which fractured the frontal bone just above the eye. He was admitted to the hospital of the 2d division, Second Corps, and on July 7th Avas sent to Mower Hospital. On July 17th, erysipelas set in, but was readily checked. On July 20th, a piece of loose bone was removed. From that time the wound healed rapidly, and in December, 1833, the patient was doing light duty in the Avard. On August 22d, he was sent to Detroit, and discharged from the service on September 2d, 1864. He is a pensioner, suffering frequently from headache and dizziness, and his disability is rated one-half and temporary. Case.—Private Erick Ward, Co. C, 31st IoAva Volunteers, aged 29 years, was wounded in an engagement before Vicksburg, Mississippi, May 20th, 1863, by a spherical musket ball, which fractured the left parietal bone. He Avas, on May 23d, admitted to hospital steamer Nashville; on June 6th, transferred to steamer R. C. Wood; and on June 8th sent to Union Hospital at Memphis. On July 9th, he was sent to City Hospital, St. Louis, where portions of the fractured bones were removed, leaving the brain exposed. On July 26th, he was sent to Jefferson Barracks, where he Avas treated for erysipelas and acute conjunctivitis. He Avas finally discharged on May 10th, 1864, and pensioned. At that date, Pension Examiner F. G. Porter sums up the case as folloAvs: "The result is a loss of a portion of the left parietal bone and partial paralysis of the right side; epilepsy and deafness of the right ear, and impaired vision." On March 25th, 1870, this pensioner applied for an increase of pension, on the ground that his disabilities had augmented. Gangrene.—Several of the cases of this subsection were complicated with sloughing. The fatal cases will be noted farther on. The four following recovered, and were pensioned: Case.—Corporal James P. Barton, Co. C, 36th Illinois Volunteers, aged 21 years, was wounded in a skirmish at Adairsville, Georgia, May 17th, 1864, by a conoidal ball, which struck the skull about three inches above the left ear, split upon the bone, and lodged. One-half of the missile was removed at the first dressing. He Avas admitted to the field hospital at Resaca, and, during the first three weeks, he was insensible. He remained in that hospital until the 22d of June, when he was transferred to the Cumberland Hospital, Nashville. At this time there was a moderate discharge from the wound. About the latter part of August, gangrene set in, and laid the skull bare for a large space around the wound, exposing the attachments of the external ear. At this stage the remaining portion of the ball, battered and misshapen, was discovered and removed. At the same time several pieces of bone were taken out, one nearly one inch square, from the squamous portion of the temporal bone, and another nearly as large from the parietal. The patient stated that some of the brain substance Avas removed at several of the dressings, but he did not know whether there Avas hernia cerebri or not. He Avent home on furlough on September 15th, and returned on December 1st. On January 26th, 1865, he was returned to duty, and served with his regiment until mustered out of service on October 8th, 1865. During this time he Avas troubled very much with headache and pains in the region of the Avound. On Alay 8th, he was examined for a pension by Dr. John Young, examining surgeon for pensions at Monmouth, Illinois. The headache and pains in the region of the wound still continued, but were not so severe or frequent. There was a depression at the place of injury about tAvo inches in length and three-fourths of an inch in width, of a crescentic form, apparently closed by firm fibrous tissue. There was also a groove running from the lower posterior corner of the depression downAvard and backward a distance of one and a half or two inches, and another, about an inch long, running directly dowmvard tOAvard the ear. With the exception of the occasional headache before mentioned, he felt no inconvenience from the injury. CASE.-Private Edwin S. Edgerly, Co. E, 12th New Hampshire Volunteers, aged 20 years, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which fractured and depressed the cranium. He Avas admitted * See pp. 77, 101, and 185, ante. 236 WOUNDS AND INJURIES OF THE HEAD. to the Third Corps field hospital on the next day; sent to Alount Pleasant, AA'ashington, on Alay 8th; transferred to the McClellan Hospital, Philadelphia, June 19th; to the Knight Hospital, New Haven, Connecticut, August 9th; and thence t<> Brattleboro', A'ermont, August 10th, 1863. Fragments of bone had been removed at different times. Gangrene of the wound appearing, bromine was applied to it, and subsequently simple dressings. On February 5th, 1864, the patient had sufficiently recovered to be discharged from the service. On August 7th, 1866, Pension Examiner Ira S. Chase reported that the patient is Avholly unable to do any manual or mental labor. His disability is rated total and permanent. Case.—Private Israel AI. Ruff, Co. B, 142d Pennsylvania ATolunteers, aged 21 years, was Avounded at the battle of (iettysburg, Pennsylvania, July 1st, 1863, by a fragment of a shell, which comminuted both tables of the skull at the right parietal eminence, and rendered him insensible for a short time. He Avas conveyed to a field hospital, where the wound Avas enlarged, and spiculas of both tables were removed, while the patient was under the influence of chloroform. On July 23d, he Avas admitted into the Broad and Cherry Streets Hospital, Philadelphia, Pennsylvania. No constitutional derangement existed at that time. A granulating surface one inch in diameter, over Avhich the brain pulsations were distinctly visible, occupied a position corresponding to that of the parietal eminence. Plain nutritious diet was ordered, and the wound dressed with a weak solution ot sulphate of copper. Under this treatment he continued to improve until August 5th, Avhen he Avas taken Avith fever, and his wound began to slough. The sloughing continued for several days, until it occupied a space tAvo inches in diameter, hut of slight depth. A Aveak solution of chlorinated soda Avas applied, and healthy granulations again sprung up. By October 1st the Avound had almost cicatrized, though the brain pulsations were still visible. He Avas discharged from the service on December 16th, 1863. Pension Examiner J. AV. Blackburn reported, January 6th, 1864, that there Avas persistent pain in the forehead, and Aveakness of sight and of intellect. A communication from the Commissioner of Pensions, January 2d, 1868, states that Ruff is a pensioner, and that his disability is rated at three-fourths and permanent. Acting Assistant Surgeon John Neill reports the earlier facts of the case. Case.—Private Asbell A. AVebster, Co. I, 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. He Avas taken to the hospital ofthe 3d division, TAventieth 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, Avere 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 aAvay. On June 27th, the wound had healed, but sores would break out occasionally, especially in hot Aveather. On October 25th, he was sent to St. Mary's Hospital, and on December 10th, transferred to Harper Hospital, Detroit, Michigan, Avhere he Avas discharged on January 6th, 1865. His mental faculties, especially his memory, were somewhat impaired, and the eyesight Avas, to some extent, weakened, according to the report of Pension Examiner R. 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 Avas 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 frag- ments 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, Avas 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 skull. Temporary symptoms of concussion followed, and after lying doAvn fifteen or twenty minutes, the patient Avalked 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 Avas shaved and cold water dressings were applied. At the expiration of forty-eight hours, the man started and Avalked to Frederick, a distance of tAventy miles. At the hospital there, a portion of felt from his hat and some hair were removed from the Avound. The patient Avas then sent to AVashington, and thence, on the 24th, he was again transferred and arrived at DeCamp Hospital, David's Island, NeAV York, on the 28th. A fissure of the right parietal bone, near the sagittal suture, avus discovered. At the expiration of a Aveek, an incision was made by Acting Assistant Surgeon E. B. Root, and some small portions of the external table Avere removed; the fissure Avas found to extend upAvard of tAvo 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 table, Avhich was found depressed about four lines, Avas elevated. The patient had suffered from neuralgic pain over his eyebrows, extending through the right temple to the Avound. These pains and the numbness of the extremities disappeared after the elevation of the depressed bone. The patient Avas discharged from the service on November 3d, 1 -62. The Avound had nearly healed, there being a feAV granulations at its centre. These moved Avith the pulsations of the brain. No head symptoms existed. A communication 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, I'. S. X. REA10VAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 237 Case.—Sergeant Conrad Bryan, Co. H, 75th Ohio Arolunteers, aged 25 years, Avas wounded at the battle of Chancellors- 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 MoAver Hospital, Philadelphia. The Avound at this time Avas very much inflamed and discharging freely. Flax-seed poultices and subsequently cold water dressings Avere applied. On June 30th, a small portion of bone, together with a piece of his cap, which had been driven into the wound, Avere removed. On July 24th, he Avas transferred to the Seminary Hospital at Columbus, Ohio, the Avound being nearly healed. Caries of the skull, however, ensued, followed by attacks of epilepsy. The patient was discharged from service on April 16th, 1864. He is a pensioner, his disability being rated total and doubtful. The early history of the case is reported by Surgeon George Suckley, U. S. V. Case.—Private William H. AVhitelaw, Co. D, 2d Connecticut Heavy Artillery, aged 25 years, was wounded at the battle of AVinchester, A'irginia, September 19th, 1864, by a bullet from a spherical case shot, which perforated and depressed the frontal bone in the median line. He also received a flesh Avound of the left thigh. He was at once admitted to the hospital of the 1st division, Sixth Corps, and thence conveyed, via Winchester and Martinsburg, to the hospital at Frederick, where he arrived on October 12th. The missile and fragments of bone had been remoA-ed 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. H. 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 Avell and was, on February 25th, 1865, transferred to the Knight Hos- pital, New Haven, and on May 15th, 1865, discharged from the service, by reason of surgeon's certificate of disability. On April 1st, 1868, AVhitelaw was a pensioner; his disability being rated at three-fourths and temporary. Pension Examiner H 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 NeAV York Volunteers, was Avounded by a musket ball, which fractured the frontal bone, two inches above the left eye. The missile split upon the edge of the bone, and remained fastened to it, requiring much force to remove it. He was admitted to the Satterlee Hospital, Philadelphia, on July 26th, 1862. No treatment is recorded, but he recovered, and Avas 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, 1866, Examining Sur- geon 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. Day 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 he was discharged and pensioned January 5th, 1863. Examining Surgeon F. Rubach, reports that "the ball lodged, and was extracted, with several spiculae 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." CASE.-Private Timothy Pender, Co. F, 3d Michigan Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 2d, 1863, by a round musket ball, Avhich 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 Avas 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 Hospital, Detroit, Michigan. The wound Avas in a bad condition, and on examination the probe revealed necrosed bone. A crucial incision Avas made, and a ring of necrosed bone one-fourth of an inch in width and comprising both tables Avas removed, Avhich had com- pletely 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: Branninger, 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 April 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 after be left the hospital. Germain, Henry J., Private, Co. K, 155th New York, aged 20 years. North Anna, Mav 18th, 1864. Shell fracture of left parietal. Alexandria, New York, and Buffalo hospitals. Discharged June 8th, 1865. Pension Office reports, November 8th, 1869, this pensioner partially insane, with defective sight and hearing, requiring a Avatcher. 238 WOUNDS AND INJURIES OF THE HEAD. Not'itsE, George H. Private, Co. F, 23d Alassachusetts. Kinston, December 14th, 1862. Shell fracture of left parietal near the posterior superior angle. Foster Hospital, Ncav Berne. Removal of fragments on the twenty-third day after reception ot the injury, Avith immediate relief to the stupor, cephalalgia, and convergent strabismus, which had existed from the date of the Avound. Transferred to Alason Hospital, Boston, February 14th, 1863. Discharged and pensioned April 27th, 1S63. January 16th, 1867, Examiner J. AV. Spalding, AI. D., reports his disability as total on account of mental imbecility. Wagner, Charles, Private, Co. L, 1st NeAV York Cavalry, aged 25 years. Pistol ball fracture of temporal. AVash- ington, June 26th, 1865. Armory Square Hospital. Removal of fragments by Surgeon D. AV. Bliss, U. S. X., and ligation of posterior auricular. Transferred to HareAvood Hospital August 15th; discharged October 12th, 1865. Pension Office reports, July 10th, 1868, disability total. Examiner P. S. TreadAvell, December 13th, 1869, states that insanity is said to have ensued. Libby, Samuel B., Private, Co. B, 17th Alaine, aged 23 years. Spottsylvania, May 21st, 1864. Fracture over vertex by conoidal musket ball. Emory, BlackAvell's Island, and Cony hospitals. Fragments removed; dura mater exposed; left leg partially paralyzed. Discharged December 15th, 1864. April 26th, 1865, Examiner D. O. Perry, AI. D., reports complete left hemiplegia, mental obtuseness, 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 recovering almost entirely from paralysis, had headache, temporary insanity, and epileptic fits. Simming, Henry, Private, Co. F, 74th Pennsylvania. Cross Keys, June 8th, 1862. Gunshot fracture of upper angle of right parietal. Tavo inches of bone removed. Grafton Hospital, West ATirginia. Discharged October 17th, 1864. January 3d, 1865, Examiner Cook, M. D., reported this applicant's mind deranged. In March, 1868, this man's disability was rated at three-fourths and temporary. Lewis, Lucia*., Private, Co. D, 69th New York, aged 18 years. Petersburg, September 30th, 1864. Fracture of occipital by conoidal musket ball. Corps, Judiciary Square, and Satterlee hospitals. Bone splinters removed and dura mater laid bare. Discharged Alay 16th, 1865. Pension Office reports him a pensioner, and that he suffers from cephalalgia and impaired mind. Love, John, Private, Co. C, 57th Massachusetts, aged 35 years.. Petersburg, October 8th, 1864. Depressed fracture of left parietal near vertex by conoidal ball. Corps, Beverly, and Satterlee hospitals. Removal of large fragments. Discharged May 24th, 1865. July 10th, 1868, disability rated total by Examiner Oramel Alartin, AI. D. Byers, Thomas P., Corporal, Co. F, 18th Ohio. Murfreesboro', December 31st, 1862. Shell fracture near upper portion angle of left parietal. Fragments removed, leaving an opening an inch long and half an inch Avide. Was hemiplegic for two months. Nashville, Hospital No. 14. Discharged April 29th, 1863. Examiner G. D. Hildreth rates the disability at three-fourths. Examiner J. H. BroAvn pronounces it permanent, and says that there is depression over the youthful corporal's posterior fontanelle. Campion, Edward J., Corporal, Co. K, 20th Alassachusettts, aged 31 years. Antietam, September 17th, 1862. Shell fracture of right temporal bone. Baltimore hospitals. Removal of spiculae of bone. Discharged March 10th, 1863. Examiner David Choate, AI. D., reports, November 27th, 1863, that the patient is subject to ■vertigo, palpitation, and morbid wakefulness. Cleveland, William P., Private, Co. K, 51st New York, aged 23 years. Petersburg, July 7th, 1864. Shell fracture of frontal. Bone splinters remoATed. Ninth Corps 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 Aveak, and rates the disability at three-fourths. O'Connor, John, Private, Co. F, 86th New York, aged 27 years. Gettysburg, July 3d, 1863. Fracture of right parietal by conoidal ball. Missile lodged, but Avas removed on the field. Gettysburg and Philadelphia hospitals. Removal of small fragment of bone July 9th. Symptoms of a typhoid character supervened, but were readily subdued. Discharged September 19th, 1864. Examiner S. N. Pierce, M. D., June 12th, 1867, reports that the pensioner has convulsions, followed by severe prostration. Disability total and permanent. Dug an, Patrick, Private, Co. A, 31st Massachusetts. Port Hudson, Louisiana, May, 1863. Gunshot fracture of cranium by a conoidal ball. Treated at barracks hospital, NeAV Orleans. Discharged November 13th, 186:5. August 17th, 1864. Examiner George C. LaAvrence reports that a portion of the skull has been removed, and that the patient suffers from pain in head and dizziness. Disability three-fourths and permanent. Dygert, Edwin F., Private, Co. D, 114th Blinois. Jackson, Tennessee, January 14th, 1863. Fracture of frontal by a pistol ball, near the median line. Accidental. Jefferson and St. Louis hospitals. Fragments of skull removed. Discharged June 5th, 1863. Discharge paper states that he has ''lost control OA'er his locomotion, so far as direction is concerned. He cannot Avalk in a straight line, but moves in a zig-zag." Examiner G. W. Cook subsequently reported that there Avas persistent pain at the point struck, Avith vertigo, and described the cicatrix as over the upper anterior angle of the right parietal. Cutler, Hiram, Private, Co. B, 2d NeAV Hampshire. Bull Run, August 29th, 1862. Fracture of right temporal and parietal by conoidal ball. Douglas Hospital. Removal of a fragment of squamous portion of temporal one by one and a half inches. Discharged December 14th, 1862. Pensioned. Complains of giddiness. Nichols, Hiram B., Private, Co. C, llth Alaine, aged 18 years. Deep Run, August 16th, 1864. Fracture of right parietal at eminence. NeAV York and Alanchester hospitals. Discharged June 17th, 1865. September 14th, 1867. Examiner Charhv AY. Shoav 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. REMOVAL OF FRAGAIENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 239 Allen, William H., Corporal, Co. K, lilth Illinois, aged 23 years. Fort McAllister, Savannah, December 13th, 1864. Fracture of left parietal by conoidal ball. Corps, Beaufort, and New A'ork hospitals. Removal of several fragments. Dis- charged Alay 6th, 1865. July, 1868, Pension Office reports his disability total and permanent. Gipple, Emanuel, Co. I, 93d Pennsylvania, aged 24 years. Spottsylvania, May 12th, 1864. Shell fracture of temporal bone. Corps, AYashington, Philadelphia, and Harrisburg hospitals. Discharged June 13th, 1865. June 1st, 1867, Examiner John Levergood, M. D., states that a piece of the outer table of bone has been removed. Disability one-half and permanent. Rice, Hiram E., Sergeant, Co. E, 112th New A'ork, aged 22 years. Fort Fisher, January 15th, 1865. Shell fracture of frontal bone. Mansfield, NeAV Berne, and Buffalo hospitals. Removal of fragments of bone. Discharged July 13th, 1865. Examiner G. AV. Hazelton, March 29th, 1866, reports disability one-half and permanent. Mathany, AAtilliam 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, AI. D., reports, July 27th, 1864, that the pensioner is mentally and physically disabled. Merener, George, Private, Co. K, 15th AVest Virginia, 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 blind- ness and giddiness, and that he is unable to Avork for many days together. Hollis, John E., Private, Battery I, 1st Alassachusetts Heavy Artillery, aged 20 years. Spottsylvania, May 19th, 1864. Stellate fracture of occipital bone, right side, by conoidal musket ball. Corps, Washington, Readville, and Worcester hospitals. Removal of a fragment of bone through incision. Discharged November 20th, 1864. January, 1868, Pension Office reports his disability tAvo-thirds and doubtful. Caries still existed. Jociium, John J., Private, Co. B, llth NeAV York State Militia, aged 26 years. Gettysburg, 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 pensioner 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 parietal bone by shell. Mobile, St. Louis, and Madison hospitals. About four square inches of bone were removed. Discharged October 5th, 1865. Alay 8th, 1869, Examiner AVilliam T. Galloway reports that the pensioner has the appearance of an epileptic. Disability total. Rhoades, Benjamin F., Private, Co. I, 93d Pennsylvania, aged 24 years. Wilderness, Alay 5th, 1864. Gunshot fracture of both parietal bones, near lambdoidal suture. Washington and Philadelphia hospitals. Removal of bone by Acting Assistant Surgeon Nordman. Discharged February 18th, 1865. March 4th, 1868, Exammer John Levergood reports that the pensioner is disqualified for manual labor. Flavin, Edward H., First Lieutenant, Co. A, 14th New York State Militia. Spottsylvania, May 8th, 1864. Gunshot fracture of anterior edge of occipital at crown of head. Corps, Washington, and New York hospitals. Removal of fragments of bone. Discharged June 6th, 1864. Examiner Charles Rowland, M. D., states, May 10th, 1865, that there is constant vertigo and partial loss of memory. Wook, 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. Washington and Philadelphia hospitals. January 25th, 1863, removal of fragments of bone, leaving brain pulsations visible. Discharged Alarch 24th, 1863. January 2d, 1868, Pension Office reports his disability one-half and temporary. Nichols, AValter, Private, Co. K, 7th Michigan, aged 24 years. Petersburg, June 22d, 1864. Gunshot fracture ot frontal bone. Corps and Philadelphia hospitals. Fragments of bone removed at various times. Discharged January 5th, 1865. July 7th, 1868, Examiner S. S. Cutter, M. 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. Murphy, Owen, Private, Co. A., 6th NeAV York Cavalry. Chancellorsville, May 3d, 1863. Gunshot fracture of parietal bone, near coronal suture. Washington and Baltimore hospitals. Removal of pieces of bone March 7th, 1864. Discharged July 9th, 1864. Exanuner J. T. Burdick, M. D., reports, May 18th, 1867, that there is constant vertigo. Disability one-fourth and temporary. McBride, Samuel B., Private, Co. G, 140th Pennsylvania. Chancellorsville, Alay 3d, 1863. Gunshot fracture oi frontal by conoidal ball. Point Lookout and Philadelphia hospitals. Sharp points of bone, and several fragments removed. Discharged December 18th, 1863. February 24th, 1864, Examiner J. R. Wilson reports that the pensioner has pain and heavi- ness in head and along the cervical and dorsal regions of the spine. Pollock, Alfred, Private, Co. G, 78th Blinois, aged 21 years. Jonesboro', September 1st, 1864. Shell fracture ot 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, 1865. Examiners Robbins and Bassett rate his disability from Avound of head total and permanent, on account of ATertigo and dizziness. Hannah, Joseph, Private, Co. B, llth Missouri. Corinth, October 3d, 1862. Gunshot fracture of frontal bone. St. John's Hospital, Paducah, Kentucky. Removal of several spiculae of bone. Discharged February 3, 1863. Examiner Thomas S. Hening, AI. D., reports that the pensioner has pains in the head, and that his nervous system is in a morbid and excitable condition. 240 WOUNDS AND INJURIES OF THE HEAD. Russell, Clement H., Private, Co. F, 37th Alassachusetts, aged 19 years. AVilderness, Alay 5th, 1864. Gunshot frac- ture of cranium by conoidal ball. AVashington and Philadelphia hospitals. Removal of fragments of hone, leaving a hm-v cavity in the skull. Discharged June 12th, 1865. December 6th, 1867, Examiner C. L. Fisk reported that the pensioner suffers from headache and dizziness, 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, John W., Lieutenant, Co. A, 101st Indiana. Chickamauga, September 20th, 1863. Gunshot fracture of left parietal at the posterior superior angle. Corps, Chattanooga, and Nashville hospitals. Fragments of bone removed October 22d and 26th. Resigned February 21, 1864. Examiner T. S. Butler, AI. D., November 23d, 1865, reports that the physical system of the pensioner is prostrated. Disability one-half and permanent. Morgan, Patrick, Private, Co. B, 57th NeAV York. Fredericksburg, December llth, 1862. Gunshot fracture of left parietal bone by conoidal ball. Corps and AA'ashington hospitals. Removal of a fragment of bone one and a half by tAvo and a half inches. Space partially filled with callus. Discharged April 25, 1863. Examiner Alonzo Churchill, AI. D., August llth, 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, 1862. 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, 1862. In May, 1864, Examiner R. Strickland reports the wound firmly healed, and rates the disability at one-third and temporary. AIcKatheran, Martin, Private, Co. I, 32d Alassachusetts. Fredericksburg, December 13, 1862. Gunshot fracture of skull at vertex. Corps and Washington hospitals. Removal of fragments of bone. Discharged February 21st, 1863. Exam- iner George Stevens, M. D., reports, October 15th, 1866, 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. Alay 9th, 1866, Examiner W. H. Page, M. D., states that the man suffers from dizziness and pain, especially on stooping. Van Valkenburg, Calvin, 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.1 In 1865^ Examiner AV. 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, 1862. Gunshot fracture of frontal bone by round ball. AVashington and Philadelphia hospitals. Spiculae of bone removed by crucial incision. Difficulty of micturition, and pain in temples and nape of neck. Discharged March 6th, 1863. September 30th, 1869, Examiner James E. Armstrong, M. D., reports that the missile still remains Avithin the cavity, and is supposed to be near the base of the brain.2 His memory and sight are impared, 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, Alarch 25th, 1865, by a conoidal ball, Avhich 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 ot 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 Alarch 31st, Surgeon N. R Moseley, U. S. V., enlarged the wound, removing numerous portions of the cranium, with pieces of the hall. On April 2d, pills of calomel and extract ot henbane were administered to produce slight ptyalism. On April 15th, the Fig. I15.-Seven small fragments of the left parietal £a1;ient was able to walk and speak, and had proper use of all parts of the bone. Spec. 4073, Sect. I, A. M. M. body. On June 3d, he was transferred to the Mower Hospital at Philadelphia • . ., 4 , . t , v. thenCe' °n Jul^ mh> 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 Avas discharged the service, July 22d, 1865. His claim for a pension is pending. ot_tmll Run, August 30th, 1862, by a conoidal ball, which fractured both tables of the cranium at the right frontal eminence. ' See photograph 9, Vol. Ill, of Contributed Surgical Photographs A M II '----------------------"------------- • See the series of nineteen cases on p. 193, et seq., with which this would have been grouped had the evidence been more ^factory. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 241 Apparently the ball had split on the edge of the bone, and one part of the missile had passed into the cranial cavity. The patient was insensible for several days. On September 3d, he was admitted to the Sixth and Alaster Streets Hospital, Philadelphia, where he remained under treatment for four and a half months. Thence he was transferred to the Mower Hospital. Two months subsequently, his wound was probed and pieces of dead bone from both tables were removed. The wound discharged freely, but gradually closed ; and the patient Avas discharged from the service on April 27th, 1863. Dr. G. S. Walker, of Ihon, Herkimer County, New York, writing under date of Alarch 6th, 1866, says that the scar is about an inch and a half in diameter, and gradually depressed from its outer margin toward the centre. There seems to be 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 patient's health had been good; but 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 opposite 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 AVilliam L. Copeland, Co. A, 1st Mississippi Marine Brigade, aged 21 years, was wounded, July 4th, 1864, at Coleman's Cross Roads, near Rodney, Alississippi, by a musket ball, which entered the cranium two inches directly above the outer canthus of the right eye, fractured the frontal bone and lodged in the wound. The missile and fragment of bone Avere removed on the folloAving day. He Avas conveyed to Vicksburg, and entered AlcPherson Hospital on the 6th. Anodynes Avere administered internally, and cold and emollient applications made to the wound. On the 1st of September, another piece of bone Avas removed, and on the 6th, a third fragment Avas removed by Surgeon E. Powell, 72d Illinois Volunteers. The wound continued very painful until after the removal of the last piece of detached bone, Avhen it healed rapidly. He recovered sufficiently to act as nurse, but had lost his voice. When returned to duty on December 4th, 1834, he had recovered his voice. He is not a pensioner. Case.—Private Louis Miller, Co. D, 46th NeAV York Volunteers, aged 34 years, was wounded at Petersburg, Virginia, June 30th, 1864, 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 Avere removed, and the flaps united by a slight suture. On July 3d, he was sent to Washington, and entered Harewood Hospital on the 4th, being someAvhat uneasy but not complaining of pain. The pulse was slightly accelerated, tongue clean, and appetite good. Upon removing the suture the wound was found to be full of maggots. The dura mater Avas exposed for a space about three inches in circumference, and of a greenish color; the pulsations of the brain were distinctly visible. On the 6th, the flap3 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 granulated finely. An incision was made, and a dressing of chlorinated soda was employed. The granulation of upper margin continued healthy. On July 28th, secondary haemorrhage occurred from the left temporal artery, which Avas ligated; about ten ounces of blood having been lost. From that time the wound assumed a healthy appearance. Small pieces of bone were removed as they became detached. Partial necrosis of the parietal bone supervened. The necrosed portion, consisting of both lamellae, was removed. The discharge now became less copious, and the wound healed rapidly. Aliller was furloughed on November 3d, 1884, returned on the 16th, and was discharged from the service on July 25th, 1865, 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 AVilliam Furlong, Co. G, 153d Pennsylvania Volunteers, aged 33 years, was Avounded at the battle ol Gettysburg, Pennsylvania, July 1st, 1863, by a fragment of shell, which struck the external angular process of the frontal bone and carried aAvay the left superciliary ridge. The wound was about one and a half inches in width and four inches in 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 oavh hand, the fragments of the shell Avhich inflicted the injury. He received little or no treatment until July 16th, when he was admitted to Cotton Factory Hospital, Harrisburg, Pennsylvania. Tepid water was injected into the wound, and several spiculae of bone were removed from the substance of the brain. One piece, however, was not removed and still remains, as it was feared that haemorrhage Avould follow; besides, the conscious condition of the patient did not warrant further interference. The pulse throughout remained 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 spiculae of bone which were forced to the surface by the granulations, were removed. He Avas discharged on September 14th, 1863. He is not a pensioner. The case is reported by Acting Assistant Surgeon Lewis Post. Case.—Private Thomas B. AVhite, Co. K, 94th Ohio Volunteers, was wounded at Murfreesboro', Tennessee, December 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 three 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 field hospital. Careful examination showed that the ball was not impacted in any of the structures; it was therefore removed, together Avith a feAV loose spicule of bone. During the operation some, brain substance escaped. Shortly afterAvard 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 speak. He improved very sloAvly, and at the end of April, 1863, could stand alone. He was discharged April 28th, 1863. In August, 1863, he looked well, and could walk without difficulty the 31 242 WOUNDS AND INJURIES OF THE HEAD. motion of his arm was yet imperfect, but the wound was almost healed. Small spiculae of hone, too firmly attached to be removed at the date of the first operation, had from time to time been loosened and detached by the efforts of nature. No pension granted. Case still pending. Case.—Private Patrick Finnegan, Co. I, 61st Ncav A'ork Volunteers, was Avounded at the battle of Chancellorsville, A'irginia, Alay 3d, 1863, by a round ball, Avhich struck the skull obliquely, fracturing both tables of the right parietal bone, just above the superior edge of the temporal bone. The ball split; one half escaped, the other half, flattened, lodged betAveen the tables. He was taken prisoner, and remained in the hands of the enemy until May 15th, when he Avas admitted to the hospital of the 1st division, Second Corps. The left arm and leg Avere paralyzed, and a number of pieces of bone were fixed in the substance of the brain. Tavo or three ounces of pus, mixed with portions of brain, escaped. The bone around the orifice was denuded on outer and inner surfaces. On about Alay 21st, spiculae of bone and portion of ball were removed by Surgeon ('. S. Wood, 66th Ncav York Volunteers, when the paralysis abated. On June 14th, he was admitted to the hospital at Point Lookout, 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 someAvhat debilitated, and his hearing was imperfect, but he was in excellent spirits, sleeping and eating well. He Avas discharged on June 10th, 1865. Case.—Private Henry R. Cox, Co. D, 47th NeAV A'ork Volunteers, aged 23 years, was wounded at the battle of Olustee, Florida, February 20th, 1864, by a conoidal musket ball, which fractured the right side of the frontal bone, without apparently causing a depression. He Avas admitted to the hospital 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 Alay, 1864, he Avas transferred to Noav l'ork, and on the 12th admitted to the St. Joseph Hospital, Central Park. lie recovered, and was mustered out on June 10th, 1865. He is not a pensioner. Case.—Private Peter Englehart, Co. E, 10th AVisconsin Volunteers, aged 25 years, was wounded near KenesaAV 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, causing a slight depression. He received in the same engagement a perforating flesh wound of the left leg four inches below the knee. He Avas at once admitted to the 1st diA'ision, 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 Jefferson Hospital, Jeffersonville, Indiana, and thence, per steamer R. C. Wood, sent to the Simons Hospital, Mound City, Blinois. 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, IoAva, and discharged from the service on October 13th, 1864. He is not a pensioner. CASE.-Private Charles W. Webb, Co. B, 144th New York Volunteers, aged 18 years, was wounded at Pocotaligo, South Carolina, December 6th, 1864, 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 hemiplegia on the right side. A small portion of the brain substance, which protruded, had sloughed aAA'ay, exhibiting clearly the depressed portion of bone. On December 15th, Surgeon John Trenor, U. S. Ar., removed several fragmints of the outer table and elevated the inner table. Water dressings were applied. The wound Avas kept thoroughly cleansed by syringing Avith water and solution of chlorinated soda, and the bowels were kept laxative by cathartics. He improved gradually, regained his speech, and recovered by degrees the use of the right arm and leg. He 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, NeAV York, AA'here 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 Wiesner, Co. A, 50th Pennsylvania Volunteers, aged 25 years, was wounded at Petersburg, A'irginia, June 28th, 1864, by a conoidal ball, which fractured and depressed the left parietal bone between the parietal eminence and the lambdoidal suture. He was conveyed to the field hospital of the 3d division, Ninth Corps, where the depressed portion Avas elevated by Surgeon AVells B. Fox, 8th Alichigan Volunteers. The patient was sent to City Point, and thence, by hospital steamer, to the AIcDougall Hospital, Fort Schuyler, New York 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 the medical director at Philadelphia. He entered Alower Hospital on September 20th, and was discharged from the service on July 14th, 1865. He is not a pensioner. Case.—Sergeant John AValton Hartley, Co. I, 61st New York Volunteers, was, on June 12th, 1862, admitted to Twenty- second and AA'ood Streets Hospital, Philadelphia, with a gunshot Avound of the head. The missile had removed the external table of the right parietal bone and depressed the inner table. He was furloughed, and while at his home, the depressed portion of the inner table was removed. He was discharged on January 28th, 1863. His left side was partially paralyzed. Not a pensioner. CASE.-Private John Duffy, Co. A, 28th Alassachusetts Volunteers, received, at the battle of Bull Run, ATrginia, August 31st, 1862. a gunshot fracture of the external table of the left parietal bone. He was admitted into the Carver Hospital, Wash- ington, September 7th; on December 10th, he Avas furloughed; and was discharged the service February 6th, 1863. On Alay 21st, 1863, Pension Examiner G. S. Jones reports this man to have a depression in the skull from which loose bone has been removed, and to be suffering from cephalalgia and vertigo. 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 Alassachu- setts A'olunteers; and to have done full duty from that time until the date of his report, when the man was a paroled prisoner of AA'ar, his disability being removed. REA10VAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 243 Case.—Corporal Patrick Farrell, Co. C, 140th Ncav York Volunteers, aged 26 years, was wounded at the battle of Spott- sylvania, A'irginia, Alay 9th, 1864. by a conoidal musket ball, which fractured the skull. He Avas at once admitted to the 1st division, Fifth Corps, hospital, and thence, on the 12th, sent to the 3d division hospital at Alexandria. A feAV small scales of bone were taken from the Avound by forceps, but no untoAvard symptoms manifested themselves in the progress of the case. On June 6th, the patient was furloughed. He was discharged the service September 6th, 1864, On February 25th, 1864, Pension Examiner H. T. Alontgomery reports this man to be perfectly 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, 1864. Gunshot fracture of zygomatic process of left temporal bone. Corps, Philadelphia, and New Haven hospitals. Portions of zygoma were removed. Discharged June 20th, 1864. Not a pensioner. Mosbery, Alexander, Private, Co. E, 40th New A'ork, aged 22 years. Petersburg, March 25th, 1865. Gunshot fracture of cranium one inch beloAV squamous suture, right side. Corps, Washington, and Whitehall hospitals. Removal of depressed bone by incision. Discharged July 3d, 1865. Not a pensioner. Barr, Thomas T., Co. H, 33d Ohio Volunteers, aged 24 years. Chickamauga, September 20th, 186:?. 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, 1864. and admitted to hospital at Annapolis Junction. Ten fragments of bone removed. Discharged September 20th, 1864. Not a pensioner. McCormick, William O, Private, Co. A, 80th Blinois, aged 30 years. Atlanta, August 20th, 1864. Gunshot fracture of frontal bone. Atlanta, Chattanooga, and Nashville hospitals. Removal of fragments of bone. Alustered out 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 Alarch 3d, 1864. Sight of left eye lost. Not a pensioner. Murgatroyd, George AI., Captain, Co. A, 68th Pennsylvania, aged 32 years. Jacob's Ford, November 27th, 1863. Gunshot fracture of zygoma. Alexandria hospital. Removal of spiculae. Recovered; transferred to Co. I, 186th Pennsylvania Volunteers, and mustered out August 15th, 1865. Not a pensioner. Wasstjre, Louis, Corporal, Co. B, 27th Alichigan, 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, 57th 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, 1864. 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 17th, 1865. Bartholomew, Francis T., Corporal, Co. C, 1st West Virginia Cavalry. Culpeper, November, 1863. 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. Griffest, 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 Blinois. Jackson, September, 1862. Gunshot fracture of frontal and parietal bones by conoidal musket ball. Alemphis and St. Louis hospitals. Fragments of both tables removed. Discharged February 3d, 1863. Not a pensioner. Lafitte, Charles, Sergeant, Co. A, 40th New Jersey, aged 36 years. Middletown, November 15th, 1864. Shell fracture of left parietal bone; also fracture of lower four ribs. Winchester, Frederick, and Washington hospitals. Removal of fragments of bone. Discharged Alay 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, 1864, 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 Calvin Forest, Co. G, 8th North Carolina Infantry, aged 18 years, was wounded at the battle of Cold Harbor, A'irginia, Alay 31st, 1864, by a conoidal ball, Avhich enteiefl one inch above the left zygomatic process, passed through the left orbit, destroying the eye, and emerged fi-om the inner Avail of the right orbit, carrying with it the light eye. He Avas 24 1 WOUNDS AND INJURIES OF THE HEAD. admitted into the general 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 suffered considerably. Five spiculae of bone Avere removed dailv. Simple dressings Avere used. Tonics Avere administered. The wounds gradually healed. There Avas a loss ofthe 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. Surgeon J. Cooper AIcKee, U. S. A., reports the case. Case.—Private 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 spicules of bone avoi e removed, and the injury soon assumed a healthy appearance, and on July 24th the patient was alloAved to go home for 60 days. Case.—Private 7F. 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 was the matter, and eating heartily. The probe could not be introduced to the skull, the track of the 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, except by cutting, Avhich required a division ofthe swollen and puffy integument, and the temporal muscles in the vicinity ofthe fracture. A consultation was 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 apply 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 tAventy-five cent piece, while the fragments Avere driven in and pressing upon the dura mater. With considerable difficulty, thirteen pieces of bone were removed Avith 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 ear 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 perfectly quiet. In twenty-four hours the erysipelas had disappeared, and from the third day after the operation, no unpleasant symptoms occurred, the Avound suppurating finely, and closing rapidly, and this, too, with the patient going about the hospital more or less every day, as it was found impossible to keep him in bed. The treatment, after the disappearance of the erysipelas, consisted solely in the application to the wound of wet lint tAvice a day, and keeping it clean. By the 18th of Sep- tember the Avound had healed, except at the intersection of the two incisions. A small opening the size of a probe existed at that point, through which a slight discharge was kept up. The patient Avas discharged from the service on February 3d, 1863. The case is reported by Assistant Surgeon B. AV. Allen, P. 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 folloAving day, admitted to a hospital at Petersburg, and thence sent to HoAvard Grove Hospital. Richmond, where a section of both tables, One and a half inches in diameter, was removed. There was paralysis 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. Baugston, 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 Avas admitted to the De Camp Hospital, David's Island, NeAV York Harbor, July 19th, 1863; thence transferred to Bedloe's Island, October 24th; and on January 10th, 1864, 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 improved slowly, and in March, 1864, 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 McClearyw&s shot on October 19th, 1863, while trying to escape from prison at Point Lookout, Alaryland,' 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 hospital at Point Lookout. There were no unfavorable symptoms; the wounds were filthy, but perfectly healthy; the secretions normal. It Avas stated that the patient had remained comatose for tAvo 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 performed the duties of a nurse in the hospital. CASE.-Private William B. Robertson, Co. E, 48th Alabama Regiment, aged 26 years, received, at the battle of Antietam, Alaryland, September 17th, 1862. a gunshot depressed fracture of the cranium at or near the right temporal ridge. No pai-dlysis existed. He Avas admitted into the hospital at Charlottesville, Virginia, Avhere he Avas operated upon on October REAIOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 245 10th, at which time he had become much enfeebled. The scalp was undermined, the bone denuded around the fractured portion, and large quantities of pus were discharged daily. During the operation it was found necessary to use Hey's saw to release a large fragment of depressed bone. No unpleasant symptoms folloAved, and the patient finally recovered, with a large depressed cicatrix. He Avas discharged on Alarch 23d, 1863. The case is reported by Assistant Surgeon B. AV. Allen, P. A. C. S. CASE.-Private G. H. Sanford, Co. A, 8th Georgia Regiment, aged 27 years, received, on August 28th, 1862, a gunshot depressed fracture of both tables of the superior portion of the left parietal bone. There Avas paralysis of the right side of the body, but the mind was clear. He was admitted into the Confederate hospital at Charlottesville, Virginia, and on September 23d was operated upon. All the pieces of bone were removed. Ten days after the operation, the paralysis had entirely disappeared. The patient improved 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.-Private James D. Ferris, Co. H, 18th Alrginia Regiment, aged 18 years, was wounded at Hatcher's Run, Virginia, April 1st, 1865, by a conoidal ball, Avhich fractured the parietal bones, the fracture extending from the coronal suture backAvard one and a half inches over the sagittal suture. He was taken prisoner, admitted into the hospital of the 3d division, Fifth Corps, and thence sent to the Lincoln Hospital, Washington, on the 8th. On April 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 recovered. The case is reported by the operator, Surgeon J. C. AIcKee, U. S. A. Vide Photographs of Surgical Cases, A. AI. AI. Vol. Ill, No. 17. Case.—Alajor V. M. Norris, 14th Tennessee Regiment, aged 30 years, was wounded at the second battle of Bull Run, A'irginia, August 30th, 1862, by a musket ball, which struck the left side of the cranium a little in front of and on a level Avith 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 Avas still more extensive; the membranes were lacerated, 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, with his fingers. The patient was perfectly unconscious for five days, and Avhen, 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 aAvay or discharged at intervals, the last of them about four months after he was wounded. His general health had not been good for several mouths prior to the reception of the injury, having suffered from chronic diarrhoea. By July 1st, 1863, his paralysis was slowly getting better, and he was able to walk about with the assistance of a crutch. He could speak only with great difficulty, frequently forgetting what he Avas talking about, and stated that he could not read anything from inability to connect the words 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, Avhen 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, Alay 9th, 1864, by a musket ball, which entered just over the external canthus of the left eye, passed upAvard and backward, and lodged under the scalp, near the occipital protuberance, fracturing the skull in its whole course. He Avas admitted to the Institute Hospital, Atlanta, Georgia, on May llth, being completely unconscious and unable to move his limbs; pulse feeble and 50, deglutition almost impossible, and the power of articulation almost entirely lost. There was great tumefaction and discoloration of the whole face and head. A scruple of calomel was with difficulty administered, which, on the following day, produced free purgation. On Alay 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 Avound. On the 19th wounds discharged cerebral matter freely, and a soft tumor appeared near the posterior wound. Involuntary actions of the bowels occurred, the pulse became slow and feeble, and the patient was thought to be sinking. On the 16th, the abscess near the posterior wound opened and discharged freely. From that date his condition improved. On June 1st, he was partially conscious, and could articulate a few words. There was now well-marked hemiplegia of the right side. Several loose spiculae 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 Avas rapidly gaining strength, but articulated imperfectly. The tumefaction had subsided, and revealed depressed bone to the extent of six inches in length by four in width. The wounds Avere open and suppurating. The case is reported by Surgeon D. C. O'Keefe, P. A. C. S. Case.—Private L. B. Lovegreen, Co. A. 25th South Carolina Regiment, was wounded in an engagement at Walthal Junction, Virginia, May 7th, 1864, by a conoidal ball, which struck the upper and receding portion of the frontal bone, left side, one inch from the median Une; the outer table was fractured, the edges being roughened and irregular; the inner table Avas broken into several fragments varying in size. The wound was an inch Avide 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 consciousness. The loose spiculae were removed, simple dressings applied, and on the following day he was sent to Richmond. Pieces of bone were removed as they became separated. He Avas delirious more or less for three Aveeks; the wound looking unhealthy, with a tendency to sloughing. Poultices and disinfecting lotions were substituted for simple dressings. At the end of the fourth week, the case looked more favorable, and shortly afterward the patient was returned to South Carolina, the wound being still open and spiculae of bone discharging from time to time; thirty-seven spiculae came away in all. In July, 1865, a firm cicatrix had formed over the cavity. In Alarch, 1866, the man was not equal to much physical exertion; he spoke sloAvly and Avith less fluency than before and suffered continually from liemicrauia, 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 reported by Surgeon F S Parker, P. A. C. S. ° ' ' 246 WOUNDS AND INJURIES OF THE HEAD. Case.—Private John McG------, Co. C, 1st Maryland Regiment, aged 27 years, was wounded at the battle of Gettys- burg, Pennsylvania, July 3d, 1863, by a conoidal musket ball, which fractured both tables of the left parietal bone, lie was admitted into Seminary Hospital, Gettysburg, and thence transferred to Baltimore, and admitted into AVest's Buildings Hospital on the 28th. Partial hemiplegia of the right side existed, affecting both limbs to some extent. Simple dressings were applied and stimulants administered. On August 3d, Assistant Surgeon E. Brooks, IT. 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 suffer no inconvenience except 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, Richmond, Virginia. He had entirely recovered. The pathological specimen is No. 1719, Sect. I, A. AI. M., and shows five necrosed fragments from the left parietal bone, removed by operation. The specimen and history were contributed by the operator, Assistant Surgeon E. Brooks, U. S. A. Philips, T. M., Private, Co. I, llth Alabama Regiment. Gettysburg, July 2d, 1863. Gunshot fracture of left parietal bone near vertex. Chester and Point Lookout hospitals. Removal of several fragments of bone. Exchanged Alarch 3d, 1864. Stiegel, Charles B., Co. H, 5th A7irginia Regiment. Fort Steadman, March 25th, 1865. Fracture of right parietal by conoidal ball. Corps and Washington hospitals. Removal of fragments of depressed bones. Recovered, and released on taking the oath of allegiance. Pel htm, E., Private, of Holcomb's Legion. Near Charlottesville, September, 1862. Gunshot fracture of frontal hone. Treated at Charlottesville. Removal of loose fragments of bone, including portions of the orbital plate. Furloughed October 8th, 1862. Toleman, William, Private, Co. L, 55th Virginia Regiment. Wilderness, May 6th, 1864. Gunshot fracture of external angular process of frontal bone. Field and Chimborazo Hospital. Removal of several pieces of bone. Furloughed June 23d, 1864. Dixon, H, Private, Co. D, 30th North Carolina Regiment. Gunshot fracture, with depression of both tables of left parietal bone. Chimborazo Hospital. Removal of loose pieces of bone. Furloughed August 25th, 1862. O'Rourke, Captain, 5th Louisiana. Alaryland Heights, July 6th, 1864. Gunshot fracture of frontal hone by conoidal ball. Considerable brain matter escaped. Loss of consciousness, and convulsive movement of right side. Depressed bone elevated, and fragments removed. Result unknown. Cook, M. S., Private, Co. C, 48th North Carolina, aged 23 years. Petersburg, September 16th, 1864. Fracture of right temporal by a conoidal ball. Removal of fragments. Farmville Hospital. Result unknown. Sharp, Gordon, Private, Co. G, 6th Alabama. Gunshot fracture of cranium. Petersburg, April 2, 1865. Corps and City Point hospitals. Removal of spiculae. Recovered. Willingham, S. M., Private, Co. D, 5th Alabama, aged 25 years. Gunshot fracture of frontal hone, right side. Boonsboro', Maryland, September 14th, 1862. Philadelphia and Charlottesville hospitals. Removal of fractured bone. Recovery. Cogan, Tobias, Private, Co. B, 19th Virginia Cavalry. Winchester, Virginia, August 20th, 1864. Gunshot fracture of frontal bone by conoidal ball. AVinchester and Baltimore hospitals. Removal of fragments of bone. Exchanged. Damron, I. T, Private, Co. H, 18th South Carolina Regiment. Gunshot fracture of frontal bone. Charlottesville hospital. September 6th, 1862. Removal of several pieces of bone. Furloughed 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 were all three examples of recovery: AA'ilson, T., Private, Co. D, 5th United States Cavalry, aged 28 years, was wounded at Brandy Station, Virginia, June 9th, 1863, by a musket ball, which fractured the left parietal protuberance, about four inches above the ear. He was insensible for several days, and partially paralyzed on the right side. He was taken prisoner, and conveyed to Confederate hospital at Charlottesville, Virginia, where, on June 13th, the ball and pieces of bone were removed. On July 6th 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 right arm, Avith partial loss of its motions. But this was rapidly improving, and he bade fair to recover entirely. The case is reported by Assistant Surgeon B. W. Allen, P. A. C. S. Case.—Corporal Theodore Boese, Co. K, 1st New Jersey Volunteers, was, on August 13th, 1863, admitted to Ladies' Home Hospital, NeAV York, with a Avound of the head. On examination, the bone Avas found to be depressed. Several spiculae were removed, AA'hen 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, 1863. Case.—Frederick R------, 43d Blinois A'olunteers, received, at the battle of Shiloh, April 6th, 1862, a gunshot fracture of the parietal bone, near its posterior superior angle. The loose pieces of bone Avere carefully removed, the flaps adjusted, warm water dressings applied, and opiates freely administered. In about three weeks a cartilaginous substance commenced 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 Alissouri Volunteers. REMOVAL OF FRAGMENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 217 Fatal Cases of Gunshot Fractures of the Skull treated by the Removal or Elevation of Fragments.—The following series of fatal cases of gunshot 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.—Sere-eant D. A. K- FlG. llfi.—Fragments of skull removed for depression from gunshot fracture of the right parietal. Spec. 4744, Sect. I, A. M. M. [Nat. size. J -, Co. D, 25th South Carolina Regiment, was wounded at Six Mile House, Virginia, August 21st, 1864. by a conoidal ball, which caused a depressed fracture of the frontal bone. He also received flesh wounds of the right arm, left fore-arm 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 Arolunteers. But the symptoms of compression Avere not relieved, and the patient gradually sank into a comatose state and died August 23d, 1864, from effusion of blood over the brain. Six of the removed fragments are represented in the adjacent wood-cut, and were contributed, Avith the history of the case, by the operator. Case — A soldier, supposed to be John R------, Co. D, 9th Alassachusetts Volunteers, aged 22 years, was admitted into the Stanton Hospital, AA'ashington, on Alay 18th, 1864, having been wounded five or six days previously by a conoidal ball, which entered the left side of the frontal bone, three-quarters of an inch above the frontal protuberance, and lodged in the brain. He wa« in a comatose condition; his respirations were sighing, pulse 110 and feeble, pupils dilated, and his right side was paralyzed. Assistant Surgeon George A. Alursick, U. S. V., enlarged the wound of soft parts by crucial incision, and removed four splinters of bone with an elevator, one of them being depressed about half an inch. An ice bag was applied to the head and a stimulating enema ordered, but the patient sank rapidly and died May 19th, 1854, ten 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. 2681, Sect. I, A. AI. M., and was contributed, with the history, by Assistant Surgeon George A. Alursick, U. S. V. CASE.-Private William B------, Co. G, 8th Pennsylvania Cavalry, aged 18 years, was wounded in an engagement at Deep Bottom, Virginia, August llth, 1864, 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 Avas 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 Avere applied, the head kept cool by constant application of iced water, and low diet ordered. On the morning of the 20th, there were symptoms of compression; pulse 88, slow and soft. Chloroform was administered and Surgeon N. R. Aloseley, 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, 1864. An autopsy shoAA-ed extensive disorganization of the brain; the middle lobe of 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. Aloseley, U. S. V. Case.—Corporal Henry F. M------, Co. G, 39th Alassachusetts Volunteers, aged 19 years, was wounded at the battle ot Spottsylvania Court-bouse, Virginia, Alay 12th, 1864, 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 18th, transferred to the Stanton Hospital, AVashington. His intellect was confused, but he Avould 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 pain in his head, and had purulent conjunctivitis of both eyes, with rupture of the cornea of the left eye. Deglutition was unimpaired. On Alay 19th, Assistant Surgeon George A. Alursick, U. S. V., enlarged the wound by crucial incision, and removed the depressed bone with an elevator. Ice was applied to the head, a stimulating enema, fluid extract of aconite, and an astringent lotion for the eyes, ordered. On the 20th, coma supervened and deglutition became difficult On the 22d, his breathing was stertorous, with puffing of the corners of the mouth. The comatose condition continued without interruption until the day of his death, May 25th, 1864. At the autopsy, the ball was found lodged in an abscess in the posterior lobe of the right hemisphere. Purulent deposit between the dura mater and the arachnoid extended over the whole hemisphere. The pathological specimen is No. 2680, Sect. I, FIG. 117.—Split ball and fragments of right parietal. Spec. 3131, Sect. I, A. M. II. (Nat. size.] 248 WOUNDS AND INJURIES OF THE HEAD. A. AI. AI. A segment of cranium fractured at the coronal suture. Five fragments of bone, chiefly from the inner table, are attached. The opening externally measures one-halt by one inch, the edge being beveled internally. The specimen and history were contributed by Assistant Surgeon G. A. Alursick, U. S. A'. Case.—Private T. M. J------, Co. H, 45th North Carolina Regiment, aged 38 years, was Avounded at Silver Spring, near AVashington, July 12th, 1864, by a conoidal 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 Avas taken prisoner 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 Avere 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 29th, when he became comatose. Mercurial purgatives, cold applications, friction and sinapisms to the extremities, were used without avail. The patient sank rapidly, and died on the 29th. The 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 right 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 Avood-cut. Fragments have been removed from an 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 ofthe opening are necrosed, cribriform, and crumbling. The specimen and history were contributed by Acting Assistant Surgeon T. L. Leavitt. Case.—Sergeant Joseph C------, Co. B, 3d Pennsylvania Cavalry, Avas wounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal musket ball, which entered above the right zygoma and penetrated the skull. He Avas 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 tAvelve 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 completely destroyed. The pathological specimen is No. 2641, Sect. I, A. M. AI. 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, 7th Michigan Volunteers, aged 20 years, Avas wounded at Ream's Station, Virginia, 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 two and a quarter inches in length, and nearly an inch in width. In the same engagement he received a flesh wound of thigh. He was 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 Washington, 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 Surgeon T. F. Betton made an elliptical incision through the integuments, and removed a portion of a musket ball and several depressed fragments of bone from the anterior lobe of the brain. The wound Avas 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 Avere bathed 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. AI,. and was contributed, with the history, by Acting Assistant Surgeon II. M. Dean. Case.—Sergeant Presley W. N- -, Co. C, 1st Ohio Volunteer Cavalry, aged 24 years, was wounded near Culpeper, Virginia, September 13th, 1863, by a musket ball, which comminuted both tables of the left temporal bone tAvo inches above the mastoid process. He Avas conveyed to Washington, and admitted into Armory Square Hospital on the 15th, where simple dressings were applied to the wound. The head symptoms were very slight until October 7th; from that time he gradually grew worse. On the 17th, nausea and vomiting supervened. An incision was made over the cicatrix by Surgeon D. W. Bliss, U. S. V., and several small spiculaa of bone were removed, which, hoAvever, afforded no relief, and the vomiting, Avith increased pain in head, continued. The patient sank rapidly, and died on the 20th. The post-mortem examination revealed the vessels of the membranes and of the brain in a high state of congestion. An abscess was found in the left ventricle, Aviiich communicated with the external wound, and contained an ounce of dark, greenish pus. The substance of the brain in the vicinity ofthe abscess was softened. Communication existed between the external wound and the abscess, which was filled with spiculae. The pathological specimen is represented in the adjacent wood- cut. The edges of the fracture in the cranium are somewhat rounded, exhibiting evidence of attempts at repair. The specimen and history were contributed by Surgeon D. AV. Bliss, U. S. V. Case—Private Otis G------, Co. C, 16th Alaine ATolunteers, aged 21 years, who was a very stout and vigorous person, weighing 180 pounds, was struck, at the affair on the AVeldon Railroad, August 18th, 1864, 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 he was admitted into the field hospital of the 3d division, Fifth Corps, where he remained until the 21st, when he was conveyed to AVashington, and admitted into the Lincoln Hospital. Ice-water dressings were applied to the head, and sedatives were administered. In the progress of the case, fragments of both the outer and inner tables were removed, leaving the brain exposed. Fig. 118.—Segment of left temporal bone, from which fragments have been removed. Spec. 1824, Sect. 1, A. M. M. [Two-thirds size.l REMOVAL OF FRAGA1ENTS AFTER GUNSHOT FRACTURES OF THE SKULL. 249 of the calvarium, the depressed porl bone, from the place of injury to the posterior inferior angle, ran a fissure, along which traces of an attempt at repair Avere observed. The meninges in the vicinity were congested and thickened. In the left hemisphere a cerebral abscess existed, extending from the surface ofthe brain to a level AA'ith the corpus callosum, three-fourths of an inch in diameter. The contiguous portion of brain Avas much softened, as Avas the right hemisphere Avithin the limits of the fracture. The pathological sjiecimen is No. 3150, Sect. I, A. AI. AI., and Avas contributed by Acting Assistant Surgeon H. AI. Dean. Case.—Corporal AVilliam M------, Co. E, 23d Pennsylvania Volunteers, Avas wounded at the battle of Malvern Hill, A'irginia, July 1st, 1862, by a fragment of shell, Avhich fractured and depressed the right parietal bone, about one inch from the sagittal suture. He avus conveyed to Ncav A'ork, and on the 24th admitted into the DeCamp Hospital, David's Island, Ncav York harbor. Hemiplegia ofthe right side of the body existed from the date of the injury ; but Avith this exception no unfavorable symptoms appeared until August 15th. On the following day tyyo 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 Avas delirious, greAV rapidly Avorse, and died August 17th, 186-2. The autopsy revealed an abscess about two inches in extent, seated in the left hemisphere of the brain, immediately beloAV the seat of the injury. The pathological specimen is No. 1059, Sect. I, A. AI. AI.. and consists of a portion of the cerebrum, with a small abscess in the upper 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, AA'ith disorganization of the brain substance, and the surrounding parts are discolored. The case it reported by Surgeon S. AV. Gross, U. S. V. Case.—Private James F. AV------, Co. H, 3d Alaine Volunteers, aged 24 years, Avas wounded at Raccoon Ford, Virginia, November 27th, 1863, by a musket ball, which fractured both tables of the occipital bone, just above and to the left of the protuberance. He Avas admitted to the 1st division, Third Corps, field hospital on the same day, and transferred to the 3d diA'ision hospital, Alexandria, A'irginia, on December 4th. On the folloAving 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 spiculae were lying loose in the wound. An opening was found near the middle and a little to the left of the centre of the occipital bone, through which a portion of the brain was protruding. The pathological specimen is No. 1904, Sect, I, A. AI. AI., 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. . CA8E-—Private Peter W------> Jr-> Co- F' 126th New York Volunteers, aged 19 years, was wounded at Bristow Station, Virginia, October 14th, 1863, 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 someAvhat contracted. On the 16th seven pieces of bone were removed; the largest being nearly an inch square. A large quantity of sanguinolent fluid was discharged, in which appeared portions of brain matter. The next morning a discharge of a bloody, foul-smellin" fluid followed, and the patient passed his urine involuntarily. On the 18th the discharge continued; the pulse became more frequent and feeble, and death occurred at two o'clock a. m., October 19th, 1863. The post-mortem revealed inflammation of the membranes over both hemispheres; also an abscess occupying the upper half of left hemisphere of the cerebrum, at the posterior part of Avhich was found a rifle ball. The pathological specimen is No. 1739, Sect. I, A. M. M. The depressed portion 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 con- tributed by Acting Assistant Surgeon C. P. BigeloAv. CASE.-Private Warren W------, Co. A, 159th New York Volunteers, aged 26 years, was wounded in the action at Irish Bend Louisiana, April 14th 1863, by a conoidal musket ball, which cut the scalp upon the right side ofthe head, one inch and a halt m extent so that the belief was entertained that the wound had been produced by a fragment of shell. Violent delirium succeeded rapidly, as reported by the field surgeon who had charge of the case previous to his admission iJt^^Z Hospital at New Orleans, April 17th, 1863. An examination of the wound was now made with a probe, which penetra eel 7Zl by its own weight to the distance of four inches. On the following day he was restless, moaneS, anu complainec1 of patAn Z h d and toward evening active delirium supervened, which subsequently alternated with periods f quiet consciousne s? Spasm whk-b h1; ""I " Ume , 2" the 6leVenth ^ ^ thC »*»* a fraS™nt of *™ ™» barged f-m the wound Z 863 At bT ^ T T deliriUm S°°n retUmed' f°ll0Wed * COma' and death "«*ed on the morningTvprfi 27^ S^rs tzz^^::nx bfonethhadfbeen Toved'iarh,e posterior inw ^iL *• ^ the expense of the inner tab e a We thr! ,ofh " ® °r " "f V^' ^ ^ °f ^ °pe"ing ^ *»*<* « table was depressed two l^/b^„S^ ^ ? < kT t,° • ^T* ^ ^ ^'^ rf^ *»« extensive disease. The cer braTsXance mmedi.t 1 ""^ r "t ^-^ °f ^ ^^ eXhibhed evi2 WOUNDS AND INJURIES OF THE HEAD. Case.—Private J- B- -, Co. D. 9th AA'est A'h'";inia. A'olunteers, aged 18 years, Avas wounded at the battle of AVinchester, A'irginia, July 20th, 1864, by a musket ball, which fractured and depressed the right parietal bone, near its posterior superior angle. He Avas admitted into the General Hospital at Cumberland, Maryland, on July 23d. During the night of the 26th, the patient had tAvo convulsions and gradually sank into a comatose condition until on the morning of the 27th, he Avas entirely insensible. The Avound of scalp Avas discharging healthy pus. Surgeon J. B. LeAvis, U. S. Y., 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, Avas removed. The patient did not rally from the comatose condition and died, on the 29th, from softening of the brain and extravasation of blood. Post-mortem revealed a perforation ofthe 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. The 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. Case.—Private W. AI. B- -, Co. E, 83d Pennsylvania Volunteers, FiG. 124.—Segment of frontal bone, carious about tho aperture, whence fragments have been removed. Spec. 3631, Sect. I, A.M. M. aged 20 years, Avas Avounded at Petersburg, Virginia, June 20th; 1864, by a conical ball, Avhich fractured and depressed both tables of the frontal bone just beloAV the fronto-parietal 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 Alount Pleasant Hospital, Washington, and thence, on the 27th, transferred to the Satterlee Hospital, Philadelphia. His pulse became sIoav and feeble, and on July 14th, his condition Avas very low. A disk of bone, one and a half inches in diameter, was removed, exposing the meninges of the brain. Pus floAved freely from the opening. The Avound subsequently became gan- grenous, and death ensued on July 26th, 1864. The post-mortem examination revealed an abscess in the left anterior lobe of the brain, with pus in the ven- tricles. The pathological specimen is figured in the wood-cut. The opening in the frontal bone is surrounded by a narroAV ring of porous and diseased bone. The fractured portion of vitreous table measures one and a half by tAvo inches. Tavo fragments remain in situ depressed one line. These fragments are covered by a thin, granular, 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, was wounded at Chantilly, Virginia, September 1st, 1862, by a round ball, which comminuted and depressed the right parietal bone, tAvo inches beloAV the sagittal suture. He became insensible and remained so for about fifteen minutes, Avhen he recovered and Avalked about. He was admitted to the Harewood Hospital, AA'ashinelon, D. C, on the 4th, having full poAver 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 Avas 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 Avas unable to move, and his voice thick and inarticulate. His left side Avas nearly insensible, but warm, and he could protrude his tongue only partially. On examining the Avound, a depression of the size of a tAventy-five cent piece was found, but evidently no ball lodged in the brain. Chloroform Avas administered, and the fragments being so pressed into each other, that neither elevator nor forceps could remove them, the trephine Avas applied by Surgeon I. Moses, U. S. A'., and the bone sawed nearly through, which loosened the pieces so that they Avere 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 Avere 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 llth, but on the folloAving morning a constant gurgling in his throat could be heard. Pus and blood were continually discharged from the Avound, Avhich 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. AI. AI., shoAVS a partially trephined segment of the right parietal bone, with five fragments, embracing one square inch. The outer table and diploe Avere 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. Aloses, U. S. V. FIG. 126.—Segment of parietal bone with frag- ments, from a case of trephining after gunshot fracture. 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, 1-64, a gunshot fracture of the skull. He Avas admitted to the regimental hospital. During the following night, hemia cerebri appeared, and on the next day, Surgeon J. H. Hutchinson, 15th Michigan A'olunteers applied the trephine, while the patient was under the influence of chloroform, (.'arson was, on June 29th, sent to General Hospital, and died on July 3d, 1861. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 263 Case.—Private P. H- , Co. E, 9th Pennsylvania Reserves, aged 28 years, was Avounded at the battle of Fredericks- burg, A'irginia, December 13th, 1862, by a conoidal ball, Avhich fractured and depressed the posterior portion of the left parietal bone. He Avas unconscious for some time after the reception of the injury. On December 15th, he was admitted into the Stanton Hospital, AA'ashington, D. C. A Avound of scalp Avas discovered through Avhich could be felt a portion of depressed bone; through another Avound, tAvo inches anteriorly, the patient stated that a portion of the ball had been extracted. No symp- toms of brain lesion were manifest, the patient being perfectly conscious and ansAvering all questions correctly and intelligently. Ice Avas applied to the head, but, tOAvard evening, convulsions ensued folloAved by others at intervals during the night. The next morning a semi-comatose condition supervened, continuing until the 17th, Avhen 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 disc of bone. The depressed portion, about an inch long and three-fourths of an inch Avide, and six fragments of bone were easily detached. One of the latter had evidently perforated the dura mater, its removal being folloAved by a discharge of disorganized brain substance. After the operation, the coma lightened someAvhat and power of deglutition and consciousness Avere restored; the loss of speech, hoAvever, continued. The improvement was of short duration, for on the next day coma and paralysis of the right side again supervened, Avith convulsive tAvitching of the right side of face. These symptoms increased in gravity continuously, the patient becoming more and more exhausted until the 23d, Avhen he died. At the post-mortem examination, a thick broAvn-colored pus, to the amount of an ounce and a half, escaped from betAveen the dura mater and the brain. Under the seat of injury Avas found red softening and disorganization of the brain extending to the depth of an inch and a half. There Avas also considerable effusion of clear serum in the ventricles, and a sero-sanguin- olent effusion at the base of the brain. The cerebrum generally, including both right and left hemispheres, was congested, the punctiform spots being unusually distinct. The dura mater, covering the convexity of the left hemisphere, showed marks of recent inflammatory action, being injected, reddened, roughened, and of a brown color in the neighborhood of the fracture. It was also lined by a thick layer of false membrane. The specimen is figured in the wood-cut. The fractured portion of the 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 Avere contributed by Surgeon J. A. Lidell, U. S. X. Fig. 126.—Segment of left parietal, from a pa- tient trephined for depressed gunshot fracture. Spec. 534, Seet. I, A. M. M. Case.—Private W- H- Co. B, 4th Alichigan Volunteers, Avas Avounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a conoidal ball, which caused a gaping ragged wound an inch and a half lon°-, 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, AA'ashington, D. C. He was rational, but his mind Avas confused; the pulse was 80 and normal; the skin moderately Avarm; pupils somewhat contracted and fixed; some dysphagia, but no paralysis existed, and he complained of a constant tinglino- in his right arm and hand. On the 19th, his memory was entirely gone. The operation of trephining Avas decided upon; the patient was etherized, and Acting Assistant Surgeon Henry W. Fisher elongated the original Avound and made another section forming a T shaped incision. Upon turning back the flaps an extensive irregular fracture Avas discovered, also a small piece of bone Avas found driven down half its thickness below the surface. At its posterior edge a small fragment of lead Avas impacted. The trephine was applied and a button removed, revealing extensive comminution of the internal table tOAvard the vertex. A tongue of bone, extending from the opening made by the trephine to a radiating fracture Avas removed by a Hays's saw, and tAvo irregular fragments of the inner table, besides numerous small spiculae, Avere removed. The dura mater Avas dis- colored but not lacerated save by a small puncture made by one of the spiculae. All extraneous substances having been removed, the Avound Avas closed and cold water dressings Avere applied. On December 20th, the patient was semi-comatose, but quite rational AA'hen spoken to. The next morning the pupils became con- tracted, 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 Avas 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 Avas found not to be sloughing, but roughened and livid. No improve- ment took place and the patient gradually sank until three o'clock p. ai., December 21st, Avhen 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 the membrane, the surface of the cerebrum was found to be in a disorganized pulpy condition for a space of an inch and a half. The convolutions were obliterated, the white and gray portions being .indistinguish- able, and the tissue a disorgamzed sanious mass, so thin that several drops ran, by their own gravity, out upon the table & The rest of the brain Avas healthy. This disorganization was found to extend down to a level with the Lateral ventricle and inward The adjacent wood-cut represents the specimen, and shows the vault of the Fig. 127.—Calvaria and fragments from a case of trephining- after gunshot fracture. Spec. 490, Sect. 1, A. M. M. almost to the outer margin of the ventricle. 2hined for Sunshot fracture. revealed a gtellate fracture and slight depression of the inner table of the Spec. 1310, Sect. I, A. M. M. , .• i. 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 by Acting Assistant Surgeon Alfred Edelin. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 267 CASE.-Private Jacob Smith. Co. D, 48th Pennsylvania 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 bone, making a vertical indsion of the scalp Iavo'inches in length. The pericranium was only slightly detached and no fracture was observable. He Avas taken to the hospital of the 2d division, Ninth Corps; on April 4th, sent to Carver Hospital, Washington, and on May 19th, transferred to Alower 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 Avas given, and the face and head dressed Avith sol. sod. sulph. On Alay 24th, the left side of the head became involved and head symptoms developed rapidly. Chloroform being administered, a crucial incision Avas made by Acting Assistant Surgeon W. P. Moon, and the bone exposed, Avhen the slightest perceptible fissure in the external table Avas discovered, from which a thin sanious discharge Avas issuing. Upon removing a portion of the tAvo tables with a trephine, it Avas 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 Alay 25th, 1865. At the autopsy, the interior lobes Avere found greatly congested, Avith 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 disorganization had taken place. The case is reported by the operator, Acting Assistant Surgeon W. P. Moon. Case.—Lieutenant AA'. V------, Co. L, 1st Alaine Heavy Artillery, aged 30 years, was wounded at the battle of Spottsylvania Court-house, Virginia, Alay 17th, 1864, by a conoidal ball, Avhich fractured and depressed both tables of the left parietal bone. He Avas admitted into the Emory Hospital, AVashington, on the 22d, in a comatose condition, with paralysis of the rio-fit side. The scalp Avas lacerated and sloughing, the pericranium torn, and spiculae of bone had been driven in upon the dura mater. The membranes of the brain Avere 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 Avere administered. Inflammation of the meninges supervened, and the patient died on the 24th of Alay, 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. AI. AI., shoAvs a disk and five small fragments of bone removed from the left parietal. The disk is split transversely. The specimen and history Avere contributed by Surgeon N. R. . tt a it ^'IG- 1^4.—Disks and fragments removed from left parietal. Aloseley, U.S. V. 2317, Sect. I, A. M. M. [Nat. size.] Spec. 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, Alaryland, December 16th, a lacerated wound of the scalp was found, of triangular shape, AA'ith 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 Avere absent. The wound was dressed with cold water, and rest and Ioav diet ordered. No change took place until the 27th, Avhen the man became droAvsy and could be aroused to answer questions only with great difficulty, relapsing immediately into a sleepy condition. The pupils were someAvhat dilated, and he complained of a feeling of numbness in the whole left side of his body; there was, hoAvever, 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 5tli of January, 1863, Avhen 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. On removing the scalp, at the autopsy, tAvo fissures were discovered diverging from the seat of the fracture; one passing from near where the trephine Avas applied backAvard 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 doAvn- Avard 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 Avith serum. The specimen, Avhich is illustrated in the annexed wood-cut was contributed, with the history, by Assistant Surgeon Clinton Wagner, U. S. A. Fig. 135.—Calvaria trephined for gunshot fracture. Spec. 924, Sect. I, A. M. M. Case.—Sergeant A- B- ■, Co. A, 5th Michigan Volunteers, aged 24 years, yvas 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 hospital, Alexandria, Virginia, in a perfectly natural condition. He continued so until the 8th, when the skull was trephined. The ball 268 WOUNDS AND INJURIES OF THE HEAD. had been removed on the field. For forty-eight hours after the operation, he Avas, at intervals slightly delirious; he recovered at the end of that time, and continued in full possession of his mental faculties until the 14th, Avhen stupor and coma supervened; he died on the same day. The pathological specimen is No. 2612, Sect. I, A. AI. 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 Assuring. The history and specimen Avere contributed by Surgeon E. Bentley, U. S. V. Case.—Private J. H. D------, Co. B, 2d New A'ork Heavy Artillery, received, at Cold Harbor, Virginia, on the 7th of June, 1864, a gunshot fracture of the right parietal bone causing slight depression. He Avas at once admitted to the 1st division, Second Corps, hospital, and transferred to the Fairfax Seminary Hospital, A'irginia, on June 9th, complaining of headache. Surgeon D. P. Smith, U. S. Ar., applied 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, 1864. The pathological specimen is No. 3305, Sect. I, A. AI. M., and was contributed by the operator. Case.—Private James A. Winn, Co. B, 13th Tennessee Cavalry, aged 22 years, was wounded at Fort PilloAV, Tennessee, April 12th, 1864, by a rifle ball Avhich passed from right to left, across the top ofthe head, fracturing the cranium. On the 14th, he Avas admitted into the general hospital at Mound City, Illinois. During the night of the 16th, he had a severe headache, but othervvise Avas doing well until tAvelve o'clock P. M. of the 19th, when he became delirious. Haemorrhage from the middle meningeal artery occurred, causing a loss of about twenty-four ounces of blood. Spasms supervened. On the folloAving 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 Avere lost during the operation. Paralysis of both extremities of the right side set in, and the convulsions continued until tAvelve o'clock m.. of the 21st, when death supervened. At the post mortem it Avas 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. AI. AI., and was contributed, Avith the history, by Surgeon H. Wardner, U. S. V. Fig. 136.—Calvaria trephined for depressed 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, 1864, by a conoidal ball, AA'hich 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, Army of the Potomac, and on the 15th, transferred to the Armory Square Hospital, Washington. On December 18th, he was placed under chloroform and his skull trephined by Surgeon D. AV. Bliss, U. S. V. The edges of the wound were brought together with straps, and the patient rallied well from the operation. During the folloAving 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 Avhich he never recovered. Complete paralysis of the left arm and partial paralysis of the left leg supervened; hernia cerebri also appeared, and death occurred on December 20th, 1864. The pathological specimen is No. 3516, Sect. I, A. AI. M., and consists of a disk of hone from the parietal one inch in diameter. The specimen and history were contributed by Surgeon D. W. Bliss, U. S. V. Case.—Private H. A------, Co. B, 36th Illinois Volunteers, aged 22 years, was wounded at Resaca, Georgia, Alay 14th, 1864, by a conoidal ball, AA'hich fractured and slightly depressed the right parietal bone at its centre. He Avas admitted on the same day to the hospital of the 2d division, Fourth Corps; transferred to Chattanooga, May 16th, and thence sent to Hospital No. 1, Nashville, Tennessee, on the 19th. He complained of a dull pain in the head, which continued until the 18th of June, when he 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, Avhich was granulating finely. The patient never fully reacted after the operation; he became lethargic, sank rapidly, and died on June 22d, 1864. At the autopsy, the mem- branes beneath the fracture Avere found dark colored and thickened. Beneath this and in the substance of the hemisphere existed a large abscess, Avhich communicated Avith the lateral ventricles, and Avas filled Avith highly offensive pus. The specimen is figured in the wood-cut, and consists of a disk and six fragments of bone, embracing about one- half square inch of the parietal bone. The specimen and history Avere Fi:. 137.-Disk and fragments removed from right parietal contributed by Acting Assistant Surgeon H. C. Alay. after gunshot fracture. Sjiec. 3302, Sect. I, A. M. M. J ° e TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 269 CASE.-Private James Addison, Co. B, 19th United States Colored Troops, received, near Petersburg, Virginia, August 19th, 1864, 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 Alaine Volunteers, aged 23 years, was wounded at the battle of Mine Run, 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, A'irginia, 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 Avas 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 effusion of coagulable lymph and serum into the cavity of the arachnoid, and the brain softened and congested. Acting Assistant Surgeon AV. G. Elliott reports the case. CASE.-Private Frederick Buck, Co. D, 52d Pennsylvania A'olunteers, was Avounded at the battle of Fair Oaks, Virginia, May 31st, 1862, by a conoidal ball, Avhich 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 NeAvport Ncavs, A'irginia, on June 4th, 1862. in a comatose condition. The skull Avas 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 XV. Burton, Co. C, 7th AVest Virginia Volunteers, aged 23 years, received, near SAvift Run, A'irginia, Alay 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 Avas performed by Surgeon H. A. Martin, U. S. A'. The patient died shortly afterward. CASE.-Private Henry S. Brandt, Co. K, 7th Connecticut A'olunteers, aged 32 years, was wounded at Bermuda Hundred, Virginia, June 2d, 1864, by a conoidal ball, which fractured and depressed the cranium over the longitudinal sinus. He Avas admitted on the 4th into the general hospital at Hampton, Virginia, and transferred on June 8th, entering DeCamp Hospital, David's Island, NeAV A'ork Harbor, on the 10th. Coma had supervened on the 19th, when Assistant Surgeon Warren AVebster, U. S. A., applied the trephine, and removed a portion of the fractured bone, revealing extensive comminution of the inner table. Simple dressings Avere 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 Avounded at Deep Bottom, Virginia, August 14th, 1864, by a shell, which severely injured the cranium. He Avas admitted to hospital 1st division, Second Corps, where the trephine Avas applied and pieces of bone were removed. He was taken on board of a transport on August 18th, 1864, but died shortly aftenvard. Case.—Captain Allen A. Burnett, Co. K, 37th Wisconsin Volunteers, aged 38 years, was wounded at Petersburg, A'irginia, July 30th, 1864, by a shell, which fractured the frontal bone, right side; he received at the same time a Avound 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 AVashington, entering Armory Square Hospital on August 1st. Haemorrhage occurred on August 14th, from one of the branches of the cerebral arteries and Avas arrested by a ligature. His strength gradually failed, and death occurred on August 16th, 18C4. The case is reported by Surgeon D. AV. Bliss, U. S. Y. Case.—Corporal Orville Bannister, Co. I, 8th NeAV York Heavy Artillery, aged 18 years, Avas wounded at the battle of Petersburg, ATrginia, June 22d, 1864, by a piece of shell, which caused a penetrating fracture of the cranium. He Avas admitted to the 2d division, Second Corps, hospital, where the trephine AA'as applied by Surgeon S. Hiram Plumb, 82d New York A'olunteers. The patient Avas transferred to the Campbell Hospital, Washington, June 28th, and died on July 1st, 1864. Case.—Corporal George C. Chase, Co. F, 8th New A'ork Heavy Artillery, aged 21 years, Avas Avounded at the battle of Cold Harbor, A'irginia, June 3d, 1864, by a fragment of shell, AA'hich fractured the cranium, driving about sixty fragments of bone through the dura mater to the depth of about half an inch 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 AIcDougall Hospital, NeAV 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 Avas performed. Death occurred on July 7th, 1864. Case.—Private Milford Clark, Co. C, 125th Ncav York Volunteers, aged 20 years, was wounded at Spottsylvania, Virginia, Alay 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 Avas admitted into the 1st division, Second Corps, hospital on the same day, and thence sent to the Armory Square Hospital, Washington, on the 23th, where the wound Avas carefully examined and a fissure of the outer table one inch in length, discovered. The operation of trephining Avas at once instituted, and the depressed portion of the inner table elevated. Death, preceded by coma, hoAvever, ensued on June 25th. Surgeon D. W. Bliss, U. S. V., reports the case. Case.—PriA-ate AVilliam Cole, Co. I, 50th Pennsylvania A'olunteers, Avas Avounded at the siege of Knoxville, Tennessee, November 19th, 1863, by a conoidal ball, Avhich penetrated the brain. He Avas conveyed to the field hospital of the Ninth Corps, where Surgeon James P. Prince, 36th Alassachusetts Volunteers, trephined the skull, and removed a piece of bone one inch in diameter. Death supervened on December 2d, 1863. 270 WOUNDS AND INJURIES OF THE HEAD. Case.—Private Joseph CoAvan, Co. G, 78th Ohio Volunteers, Avas Avounded af Bear Creek, Alississippi, February 5th, H64. by a shell, Avhich fractured the cranium at its vertex. He was immediately conveyed to a field hospital in the vicinity, Avhere Surgeon AV. S. Edgar, 32d Illinois Volunteers, trephined the skull. Death took place on February 6th, 1865. Case.—Private R. F. C------, 18th Alississippi Regiment, aged 28 years, was Avounded at the battle of Chancellors- ville, A'irginia, Alay 3d, 1863, by a musket ball, which penetrated the cranium near the upper edge of the left temporal bone. Trephining Avas performed, and the ball removed on the 10th. He was conveyed to the Confederate general hospital at Charlottesville, Virginia, and the case progressed Avell, without any symptoms of constitutional disturbance, until July 3d, AA'hen he was seized with general convulsions, Avhich lasted Avith great severity for some fifteen minutes, and Avere succeeded in about an hour by a second attack. There Avas no perceptible cause, but the patient had complained of headache all the morning. The convnlsions recurred frequently; at first Avith irregular intervals until the 15th, the later ones being slight. On the 5th, a cathartic and enema were administered, producing a copious discharge. The bowels Avere kept regular by cathartics, stimulating diet given, and cold applications were made to the head. There Avas loss of power in the right arm, with partial paralysis ofthe right side, impaired speech, and imperfect ideas. On the 8th, several fragments of both tables Avere removed through a straight incision about one and a half inches in length, and on the following day a small spicula resting on the brain Avas removed. His speech had improved by the llth, memory and ideas by the 13th, and the wound Avas nearly healed, but again began to discharge on the 15th, and on the 18th it was examined, aud a spicula removed. The head symptoms seemed to increase on the 19th, and patient appeared languid and confused, and was disposed to keep the head Ioav; the wound Avas nearly healed and not discharging. A severe rigor occurred at three o'clock P. M. of the 21st, and patient seemed to be suffering pain; wound discharging a sanious pus. An incision was made over the seat of injury, and an exploration Avith probe revealed a large abscess, Avhich was emptied of about tAvo ounces of purulent matter. He passed a very restless night, and on the folloAving morning was greatly prostrated; pulse 100 and feeble; extremities cool; anorexia complete; nausea. Egg-nogg, one ounce every t'vo hours, Avas ordered, and under its influence reaction Avas fully established at five o'clock P. M.; face flushed; pulse 120. Patient died at five o'clock a. m. on the 23d, without any marked change in his condition during the night. At the autopsy, the opening through both tables of the frontal bone, over the seat of injury, measured one and one-fourth inches from the line of sagittal suture at supra-posterior angle of the left half of the frontal bone. A Avidely separated fissure extended from the loAver border of the oval opening, and parallel with the line of sagittal suture, down to the supra-orbital ridge; thence obliquely through the orbital plate of the foramen caecum. The frontal sinus Avas found filled with pus. Upon examining the brain and its membranes, a spicula of bone was found imbedded in the dura mater, and resting upon the brain. The membranes Avere much discolored and injected for some distance around the seat of injury. The substance ofthe brain Avas found to be softened for an inch around the circumference of the ragged opening in the dura mater. A large cerebral abscess Iavo and a half inches deep by one and a half inches in diameter existed, from which the pus had been evacuated. Purulent lymph was found effused over the pons A'arolii, and an abnormal quantity of serous fluid in the lateral ventricles. Case.—-Private Patrick Condon, Co. B, 27th Connecticut Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot fracture of the right side of the cranium. He Avas conveyed to Washington, and on December 25th admitted to Douglas Hospital, where the skull was trephined. He died on December 28th, 1862. Case.—Private AlattheAv Cantwell, Co. B, 3d Minnesota Volunteers, received, on September 22d, 1862, a gunshot fracture of the left side of the frontal bone, exposing the brain. He was admitted to the post hospital at Fort Ridgely, Alinnesota, AA'here trephining was performed. He died on October llth, 1862. Case.—Private Joseph Condant, Co. H, 48th New York Volunteers, aged 37 years, was wounded at Olustee, Florida, February 20th, 1884, by a round musket ball, which fractured and depressed the frontal bone at its centre. He Avas taken on board the hospital transport Cosmopolitan and conveyed to Beaufort, South Carolina, entering Hospital No 4, on the 23d, whence he Avas returned to his regiment on April 19th, 1864. On April 24th, he Avas admitted into the Hampton Hospital, Fort Alonroe, Virginia, from Y'orktown, as a convalescent from gunshot wound of forehead, and on April 26th, sent north. He entered DeCamp Hospital, David's Island, New A'ork Harbor, on the 29th of April, and remained there until October 30th, when he was trans- ferred to the Ladies' Home Hospital, New York City. The Avound had entirely healed; but the patient suffered from tertian intermittent fever and epilepsy, the latter resulting from depressed bone. About four Aveeks after his admission the wound reopened, and on December 29th, the patient being greatly depressed from the recurrence of convulsions, Surgeon Alexander B. Alott, U. S. V., cut doAvn upon the anterior and middle portion of the frontal bone, Avhen it was found that the external table had exfoliated to the extent of a ten cent piece. The inner table was trephined, and the depressed portions of bone were removed; but no relief Avas afforded, and death occurred on the same day, a feAV hours after the operation. The case is reported by Surgeon A. B. Mott, U. S. V. CASE.-Private Joseph Dupont, Co. G, 37th Wisconsin A'olunteers, aged 32 years, was wounded near Petersburg, Virginia, April 2d, 1865, by a conoidal ball, which fractured the left parietal bone. He Avas immediately conveyed to the field hospital of the 1st division, Ninth Corps, Avhere the operation of trephining was performed the same day by Surgeon AV. C. Shurlock, 51st Pennsylvania Volunteers. About one-tenth of the bone Avas removed. He Avas, on April 7th, transferred to Campbell Hospital, AVashington. The Avound Avas doing well, but the patient Avas suffering from inflammation of the right lung and pleura. He Avas transferred to Stanton Hospital on July 8th, where he died on September 2d, from phthisis. Case.—Corporal Joel Duel, Co. D, 37th AA'isconsin A'olunteers, Avas Avounded near Petersburg, Virginia, July 27th, 1864, by a musket ball, AA'hich fractured and depressed the cranium at the junction of the sagittal Avith the coronal suture. He Avas conveyed to the field hospital of the 3d division, Ninth Corps, where the operation of trephining Avas performed. Death super- vened on July 29th, 1864, the day folloAving the operation. The case is reported by Surgeon W. C. Shurlock, 51st Pennsylvania A'olunteers. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 271 CASE.—Corporal P. J. Doremus, Co. G, 71 h Ncav Jersey Volunteers, aged 24 years, received, at Petersburg, Virginia, June 17th, 1864, a gunshot depressed fracture of skull, just posterior to the junction ofthe sagittal and coronal sutures. He was admitted to the hospital of the 3d division, Second Corps; on the 21st sent to the Carver Hospital, Washington, and on the 28th transferred to the Alower Hospital, Philadelphia. Until July 3d, the patient's health was excellent and no fracture Avas suspected; after that a complete state of stupor ensued, and, on July 6th, Acting Assistant Surgeon J. H. Jamar made a crucial incision through the scalp, applied the trephine, and removed one-fourth of an inch of bone from the point of depression. A large amount of pus, mingled with blood, escaped through the opening made in the bone, but failed to relieve the symptoms of compression. Sinapisms Avere applied to the feet and neck, and extract of helebore, tartrate of antimony and potassa^ calomel and brandy administered internally. The patient sank rapidly, and died a few hours after the operation, July 6th, 1864. The autopsy revealed tAvo ounces of pus anterior to, and to the left of, the fracture; also considerable softening of the right lobe. The case is reported by Surgeon J. Hopkinson, U. S. V. Case.—Private George XV. Derrick, Co, B, 45th Pennsylvania Volunteers, Avas Avounded near Petersburg, Virginia, July 30th, 1864, by a fragment of shell, AA'hich fractured the cranium. He was admitted to the hospital of the 2d division, Ninth Corps, where the skull Avas trephined. He died August 4th, 1864. Case.—Private John Eisin, Co. E, 38th Georgia Regiment, was Avounded at Cedar Crerk, Virginia, October 19th, 1864, by a shrapnel shot, Avhich caused a compound fracture of the skull and middle third of the left arm. He was taken prisoner, conveyed to Winchester, A'irginia, and placed in the depot field hospital of the Nineteenth Corps, where fragments of the cranium Avere elevated and splints applied to the arm. Death ensued October 24th, from gangrene of the brain. Case.—Private Gottlieb Feisel, Co. K, 47th Pennsylvania Volunteers, was wounded at the battle of Pocotaligo, South Carolina, October 22d, 1862, by a fragment of shell, which apparently inflicted a wound in the scalp on the left side of the cranium, extending three inches from before backward over the coronal suture. He was admitted into the general hospital at Hilton Head, South Carolina, on the following day, when the head was shaved, and the edges of the wound were brought into apposition and secured AA'ith sutures and adhesive straps. No symptoms of depression appeared until the morning of the 27th, Avhen convulsion supervened. Acting Assistant Surgeon Thomas T. Smiley made a crucial incision, and upon dissecting the flap discoA'ered that the parietal bone had been fractured and a portion been driven in upon the brain. The trephine Avas applied and a triangular piece of the internal table, one by one and a half inches, extracted. The dura mater was not ruptured. The symptoms of compression immediately disappeared, and for four or five days the progress was favorable, but meningitis super- vened, and death resulted on November 9th, 1862. The case is reported by the operator, Acting Assistant Surgeon T. T. Smiley. Case.—Private Frederick Gothe, Co. H, llth Blinois Volunteers, was wounded near Aricksburg, Alississippi, May 20th, 1863, by a conoidal ball, which fractured the cranium at the junction of lambdoidal and sagittal sutures. He was, on Alay 22d, admitted to the regimental hospital, and on the 27th sent to Jackson Hospital, Alemphis, Tennessee. On the folloAving day great stupor, inability to ansAver questions, and profuse diarrhoea, with involuntary discharges, supervened. Simple dressings were applied to the Avound, and diarrhoea mixture ordered. On June 1st, no change in condition had occurred, and on June 3d, the trephine was applied, and some fragments of bone were removed, giving exit to an ounce of pus from the interior ofthe cranium. The operation failed to relieve the symptoms ; diarrhoea returned on the 6th, patient's strength began to fail, and the discharge from the Avound became very profuse. Death supervened on June 7th, 1863. The autopsy revealed an extensive abscess at the inner border of the left hemisphere of the posterior lobe of cerebrum. The dura mater had sloughed off at the junction of sagittal and lambdoidal sutures. CASE.-Private John J. Gay, Co. G, 64th Georgia Regiment, was, on June 19th, 1864, admitted to Jackson Hospital, Rich- mond, A'irginia, with a gunshot Avound of head. On June 28th the skull Avas trephined, but death occurred on the following day June 29th, 1864. ° Case.—Private Hugh Gorrigan, Co. A, 39th Illinois Volunteers, aged 37 years, Avas wounded at Petersburg, Virginia, May 16th, 1864, by a rifle ball, which extensively lacerated the scalp and caused a compound comminuted fracture of the os frontis. He was admitted to the Tenth Corps field hospital on the 18th, and sent to the hospital at Hampton, A'irginia, on the 19th. On the 22d, Acting Assistant Surgeon H. B. AVhite applied the trephine, and extracted several pieces of the inner plate, Avhich had been driven in upon the brain substance. Patient's general condition Avas good, though he was somewhat debilitated. On the 24th erysipelas supervened, and death ensued on June 3d, 1864. CASE.-Private Gottlieb Hagelburger, Co. F, 51st Ohio Volunteers, was wounded at the battle of Chickamauga, Georgia, September 19th, 1863, by a musket ball, which struck the right parietal bone, slightly grooving the outer table. He Avas admitted to the hospital of the 3d division, Twenty-first Corps, and thence conveyed to Hospital No. 8, at Nashville, Tennessee, on the 28th. There was some fever and slight mental disturbance, but no contraction or change in the pupils ; the wound Avas sloughing. Water dressings, frequently repeated, and sulph. mag. were ordered. The symptoms of compression gradually increased, till stertorous breathing set in on the morning of October 2d. The trephine was noAV applied over the seat of fracture, and all compressing bone removed, giving exit to a small amount of pus. The operation failed to relieve the symptoms, and death ensued on October 4th, 1863. The inner table presented a stellate fracture ; several spicula? of bone had penetrated the dura mater, and were imbedded in the brain substance. The case is reported by Acting Assistant Surgeon L. C. Fonts. CASE.-Private John Heise, Co. B, 26th Illinois Volunteers, received, near Atlanta, Georgia, July 29th to August 15th 1864, a gunshot fracture of the left parietal bone. He was, on August 15th, admitted to hospital Fifteenth Corps, where on August 17th, Surgeon D. P. Halderman trephined the skull while the patient was under the influence of chloroform. Death occurred on August 21st, 1864. 272 WOUNDS AND INJURIES OF THE HEAD. Cask.—PriA-ate William II. Hilborn, Co. K, 86th New A'ork Volunteers, aged 23 years, Avas wounded at the battle of Aline Kun, A'irginia, November 27th, 1863, by a conoidal ball, Avhich fractured the angle of the frontal bone, on the left side of ihe head, and lodged He was admitted to the 1st diA'ision, 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 gradually into a comatose condition, and died on the 13th. The autopsy revealed the ball, lying impacted betAveen the hard and soft palates. The case is reported by Acting Assistant Surgeon A. G. Smith. Case.—Sergeant AVilliam N. Irvin, Co. B, 1st battalion, 1st Minnesota Volunteers, aged 25 years, was wounded on June 18th, 1864, near Petersburg, A'irginia, by a conoidal ball, which entered the frontal bone, in the immediate vicinity of the left frontal eminence, passed inAvard, 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 fracture was nearly circular, and about one inch in diameter. Considerable swelling existed in the immediate vicinity of the Avound, and the left upper eyelid was cedematous. The patient reacted promptly, and appeared to be quite easy; there being no cerebral symptoms or coma. During the day, however, he Avas attacked Avith delirium, which continued 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 IoAva Volunteers, aged 20 years, received, at Shiloh, Tennessee, April 6th, 1862, a compound fracture of the skull. He Avas 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 Avas performed, but death supervened twenty-four hours after the operation. Case.—Private A. Kirkpatrick, Co. H, 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 spiculae of bone Avere removed. He died on October 30th, 1862. At the post-mortem examination, many spiculae of bone and abscesses beloAV the dura mater Avere 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, 1862. Case.—Captain W. AV. Liggett, Co. H, 12th Ohio Arolunteers, received, at the battle of South Mountain, Maryland, September 14th, 1862, a gunshot fracture ofthe 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 Avas rational on the morning following the operation, hut died on September 21st, 1862. Case.—Private Charles H. Leonard, Co. H, 57th Massachusetts Volunteers, aged 22 years, was Avounded at the battle of the AVilderness, Virginia, May 6th, 1884, by a conoidal ball, which fractured the left parietal bone at its eminence. He was conveyed to AVashington, and entered Columbian Hospital on May llth. The Avound was in good condition, the bone being slightly fractured but not depressed, but the patient was nearly comatose and greatly prostrated. On Alay 15th, Acting Assistant Surgeon II. D. Vosburgh removed portions of the left parietal bone Avith the trephine, and then took out a fragment of the inner table, Avhich was lying loose on the dura mater. Stimulants and nourishment were freely administered, hut the coma became gradually more complete, and the patient died on May 17th, 1864, from cerebritis. Case.—Corporal Philander D. L------, Co. H, 1st Maine Heavy Artillery, aged 28 years, was wounded at the battle of Spottsylvania Court-house, Virginia, Alay 19th, 1884, by a conoidal ball, Avhich inflicted apparently only a lacerated Avound 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 Armory 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 diploe. The inner table of the skull Avas found to be intact, but friable and easily broken. Several pieces of this were removed, as Avas also a clot which had formed between the inner table and the dura mater. Simple dressings Avere applied and tonics administered, but pyaemia set in, and death ensued on June 8th, 1864. The specimen is represented in the Avood-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 Fig. 138.—Disk and five fragments from left parietal, in diameter, and includes the outer table and diploe only. The specimen removed by trephining after gunshot fracture by a musket . ball. Spec. 23H3, Sect. I, A. M. M. [Nat. size.J and history were contributed by Surgeon D. W. Bliss, U. o. V. * Another report from the Armory Square Hospital states that the inner table Avas depressed at the anterior superior angle. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 273 Case.—Private Franklin Lehman, Co. F, 184th Pennsylvania Volunteers, aged 22 years, Avas wounded before Petersburg, A'irginia, October 1st, 1864, by a conoidal musket ball, which fractured the frontal bone. He was at once admitted to the hospital of the 2d division, Second Corps, where-the skull was trephined, the ball removed, and cold Avater dressings Avere applied. He was conveyed to AVashington, and admitted on the 8th into the Campbell Hospital. Death resulted on October 17th, 1864. Case.—Private William Lynch, Co. F, 122d Illinois Volunteers, aged 22 years, Avas wounded near Nashville, Tennessee, December 16th, ISiJI, by a musket ball, which penetrated the frontal bone. He entered the Cumberland Hospital, Nashville, Tennessee, on the following day, and Avas on the 18th transferred to Hospital No. 4, NeAV Albany, Indiana. The wound evinced no disposition to heal, small quantities of pus escaping continually from the external opening. The patient became comatose, the pupils contracted, and secretions scant. On January 3d, 1865, Acting Assistant Surgeon John Sloan trephined the skull at the seat of injury. Water dressings were applied to the wound, and stimulants administered. The operation failed to relieve the coma, and the patient died on January 4th, 1865. The autopsy revealed an effusion of pus from the seat of injury to the base of the brain. The case is reported by Acting Assistant Surgeon S. J. Alexander. Case.—Private H. S. McC----, Co. A, 4th Georgia Regiment, aged 27 years, was wounded at the battle of Chancellorsville, Virginia, Alay 3d, 1863, by a conoidal ball, which fractured the frontal bone two inches above the internal canthus of the right eye. The internal table was comminuted. He was admitted into Lincoln Hospital, Washington, on the 7th, being rather stupid, but not complaining of pain. These symptoms continued until the evening of the 14th, AA'hen he appeared to be in a comatose condition, and began to pass his urine involuntarily. On May 15th, at four o'clock p. M., his skull was trephined, and the depressed portions of the outer and fragments of the inner table were removed, giving exit to a quantity of fluid resembling pus in color and consistency. The comatose condition was relieved by the operation, but death supervened on May 16th. The pathological specimen is No. 1125, Sect. I, A. M. AI. The vault of the cranium is trephined just internally to the right frontal eminence. The diameter of the opening is three-fourths of an inch. The specimen and history were contributed by Acting Assistant Surgeon H. AI. Dean. Case.—Private Hiram AIcDaniels, Co. D, 149th Pennsylvania Volunteers, was wounded at Spottsylvania, Virginia, Alay 10th, 1864, by a conoidal ball, which fractured the cranial bones. He was admitted to the field hospital of the 4th division, Fifth Corps, where the operation of trephining was performed. On May 12th, he was sent to general hospital, but probably died on the way, as no further information can be obtained. Case.—Private Dominick Ale Call, Co. E, 65th New York Volunteers, aged 38 years, was wounded at the battle of Winchester, Virginia, October 19th, 1864, by a conoidal ball, which entered near the posterior fontanelle, and emerged about an inch posterior to the foramen magnum. He Avas on the same day admitted to the hospital of the 1st division, Sixth Corps, Avhere the skull was trephined. On October 23d, he was sent to the Patterson Park Hospital, Baltimore, Alaryland. Simple dressings were applied, and nourishing diet administered. *He appeared to suffer from compression of the brain, although no bone could be seen or felt pressing on the brain. On the evening of the 25th he became unconscious, and died on October 26th, 1864. The case is reported by Acting Assistant Surgeon AI. Kempster. Case.—Private Captain J. K. Mclvor, Co. F, 8th South Carolina Regiment, was, on September 17th, 1863, admitted to the hospital at Chester, Pennsylvania, Avith a gunshot fracture of the frontal bone. On October 4th, he was transferred to the hospital at Point Lookout, Maryland. A resection of the frontal bone Avas performed, but death from compression of the brain occurred on October 15th, 1863. Case.—Private Robert McCormick, Co. E, 29th Pennsylvania Volunteers, aged 23 years, received, at Pilot Knob, Georgia, June 15th, 1864, a gunshot fracture of the os frontis. He was conveyed to the field hospital at Chattanooga, and admitted there on June 20th. The skull was trephined, and the pieces of bone Avere, on June 22cl, elevated and removed by Assistant Surgeon C. C. Byrne, U. S. A. Cold water dressings were applied, but the case terminated fatally on June 30th, 1864. The case is reported by the operator. Case.—Private Michael Alurray, Co. E, 56th Massachusetts Volunteers, received, at the battle of Spottsylvania Court- house, Virginia, Alay 12th, 1864, a gunshot wound of scalp; ball lodged at vertex of head. He Avas admitted to hospital of the 1st division, Ninth Corps, and on May 14th sent to Ninth Corps Hospital at Fredericksburg, where the skull Avas trephined. He died on May 17th, 1864. Case.—Private James J. Monaghan, Co. K, 42d NeAV York Volunteers, aged 25 years, was wounded at the battle of Antietam, Alaryland, September 17th, 1862; the missile fracturing the left parietal bone about tAvo inches from the sagittal suture. He Avas conveyed to the Hoffman Hospital, where his skull Avas trephined. On September 25th, he was transferred to Frederick, Maryland, in a semi-conscious condition; pulse 80, tongue coated, pupils dilated, skin hot and dry; right arm entirely and right leg partially paralyzed; he passed urine and faeces involuntarily. On the folloAving day his condition was the same; saline cathartics were ordered, which operated quite freely, and on September 27th, his pulse Avas 140 and Aveaker. He Avas very restless during the early part of the day; still passed urine and faeces involuntarily; quite unconscious; had a chill at tAvo o'clock P. .ai., and passed a very restless night; chills recurred on the following morning; pulse 140 and easy; convergent strabismus of right eye. Considerable haemorrhage occurred from the wound during the morning; later in the day coma supervened; the countenance became almost livid, and the patient died on September 29th, 1863, in a semi-comatose condition. CASE.-Private A. Nourse, Co. H, 12th Alissouri Volunteers, received, near Kenesaw Alountain, Georgia, June 15th, 1864, a gunshot fracture of the cranium. He was at once admitted to the hospital of the 1st division, Fifteenth Corps, Avhere Surgeon A. T. Hudson, 26th IoAva Volunteers, trephined the skull, one hour after the reception of the injury. The patient died on the same day, June 15th, 1864. 35 274 WOUNDS AND INJURIES OF THE HEAD. Case.—Lieutenant Wilson B. Newman, Co. A, 13th Virginia Regiment, aged 25 years, was wounded at the battle of Winchester, A'irginia, September 19th, 1864. by a piece of shell, AA'hich fractured the left parietal bone to one-half its extent. The scalp was extensively lacerated. The patient Avas at once admitted to the depot field hospital at Winchester, where the trephine Avas applied by Surgeon A. Atkinson, P. A. C. S. The depressed bone Avas then elevated and all loose fragments were removed. Cold water dressings Avere applied to the head, and generous diet ordered. The operation failed to relieve the patient, Avho had been unconscious since the reception of the injury, and death ensued on September 27th, 1864, from compression of the brain. Case.—Corporal James B. O'Keafe, Co. C, 68th Pennsylvania Volunteers, aged 36 years, was wounded at the battle of Mine Run, Virginia, November 27th, 1863, by a conoidal ball, Avhich fractured and depressed the left side of the os frontis above the outer portion of the superciliary ridge. He AA'as conveyed to Alexandria, Virginia, and admitted into the 3d division hospital, December 5th. Two days later he complained of intense pain in the head; his skin was hot and dry, the pulse frequent, and his boAvels Avere constipated. The skull was trephined by Surgeon EdAvin Bentley, U. S. V., and spiculae of bone were removed while the patient was under the influence of ether. Simple dressings were applied to the wound, cathartics administered, and Ioav diet ordered. Extensive suppuration supervened, and death followed on the 13th, from inflammation of the brain and its membranes. At the autopsy, the membranes of the brain were found infiltrated with pus. Coagulable lymph and serum existed in the cavity of the arachnoid, and the brain Avas softened and congested. Acting Assistant Surgeon AV. G. Elliott reports the case. Case.—Adolph Oehme, Alusician, Co. I, 32d Indiana Volunteers, was wounded at Liberty Gap, Tennessee, June 26th, 1863, by a conoidal musket ball, Avhich fractured and depressed the left parietal bone at its inferior and external angle, injuring the brain substance. He was admitted into the field hospital at Murfreesboro', 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 Avas fractured and depressed one square inch; the depression of the inner table Avas more extensive. He rallied well from the operation, and the symptoms were apparently favorable until July 3d, when coma, and, shortly afterward, death, supervened. The case is reported by the operator. Case.—Private David Platner, Co. C, 39th NeAV York Volunteers, Avas Avounded at the battle of Cold Harbor, Virginia, June 1st, 1864, by a conoidal ball, Avhich fractured the cranium. He was on the same day admitted to hospital of the 1st division, Second Corps, Avhere Surgeon P. E. Hubon, 28th Massachusetts Volunteers, trephined the skull. The result is not knoAvn, 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 Avas admitted into the field hospital of the cavalry division, and thence conveyed to NeAV Orleans, Louisiana, and admitted into the Marine Hospital on April 14th. The following morning he complained of headache, Avhich gradually increased, and the face was in an erysipelatous condition. On the morning of the 20th, vomiting set in, and in the afternoon coma supervened. On April 21st, Surgeon Jacob Bockee, U. S. V., performed the operation of trephining, in order to relieve symptoms of compression 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 periosteum to the extent of three-quarters of an inch in width by two and a half inches in length. Pus to the extent of half an ounce was found in the diploic structure ; also on the surface of the brain. The patient Avas comatose, but sensible to the pain of the operation, which failed to relieve the symptoms. He was delirious and noisy during the following night; then became quiet, and continued so until the 23d, when death supervened from inflammation and suppuration of the brain and its membranes. The case is reported by the operator, Surgeon J. Bockee, U. S. V. Case.—Private Philip R------, Co. I, 10th New York Volunteers, was wounded at the battle of Fredericksburg, Virginia, December 13th, 1862, by a gunshot missile, AA'hich fractured and depressed the left parietal bone, just below the tuberosity. He Avas admitted into the Ascension Church Hospital, Washington, on the 17th, partially insensible, but answering when spoken to sharply. The pupils Avere nearly normal, pulse 72, and gradually becoming slower and more suggestive of approaching coma. On the 19th, the patient Avas placed under the influence of chloroform, and Surgeon J. H. 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 Avas 66, thready and sharp; patient semi-conscious and complaining of cold. The next morning the pupils were nearly normal; pulse 78; breathing natural, but bowels not open. There was considerable haemorrhage at noon, which Avas readily checked. Afterward, coma gradually supervened, the pupils 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 pathological specimens are Nos. 528, 965, and 966. The former shows a section of the vault of cranium, with one disk and seven fi-agments fi-om the left parietal bone. The two latter are Avet preparations of the dura mater and the left cerebral hemisphere containing an abscess. The specimens were contributed by Surgeon J. C. Dorr, U. S. V. Case.—Private AA'illiam G. Risher, Co. E, 139th Pennsylvania Volunteers, aged 22 years, was wounded in the defences of AVashington, 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 fi-agments of bone which had been driven tAvo inches into the brain substance. Ice was applied to the head, purgatives administered, and abstinence from food rigidly enforced. Death supervened on July 15th, 1864. The case is reported by Surgeon J, H. Baxter, U. S. V. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 275 Case.—Sergeant Willard Robeck, Co. G, 5th Iowa Cavalry, was treated in the regimental hospital near Fort Donelson, Tennessee, for injury and compression of the brain. When and where the injury Avas received cannot be definitely ascertained, but the operation of trephining was performed. Death occurred April 24th, 1863. Case.—Private L. Schumpert, Co. F, 20th South Carolina. Shell fracture of the left temporal bone July 18th, 1863. Trephining August 10th. Death, August llth, 1863. Autopsy.* Case.—Corporal Charles Stotter, Co. C, llth Kansas Volunteers, received, at the battle of Prairie Grove, Arkansas, December 7th, 1862, a gunshot wound of the head, Avith fracture of the posterior portion of the right parietal bone. He Avas admitted into the regimental hospital on the following day, where trephining was resorted to. Fungous excrescences formed upon the brain a feAV days later, and Avere removed by caustic applications. About the twelfth day after the operation, an abscess Avas developed in the cerebral substance, and death resulted therefrom December 27th, 1862. The case is reported by Surgeon George W. Hogeboom, llth Kansas Volunteers. Case.—Private John Sperber, Co. A, 68th NeAV York Volunteers, aged 43 years, was wounded at the battle of Antietam, Maryland, September 17th, 1862, by a conoidal musket ball, which fracturel and depressed the cranium at the junction of the occipital and parietal bones, driving fragments into the brain substance. He was admitted to the field hospital, and cold water dressings were applied. Convulsions and insensibility ensued, whereupon Surgeon 0. S. Wood trephined and elevated the depressed portion, removing all detached fragments of bone. The lodgement of the missile yvas not ascertained. Consciousness Avas restored by the operation, but convulsions recurred, and the patient died on September 23d, 1882. The case is reported by the operator, Surgeon C. S. Wood, 66th New York Volunteers. Case.—Private G. W. Summers, Co. F, llth New Hampshire Volunteers, was wounded near Petersburg, Virginia, July 22d, 1864, by a shell, which fractured the cranium. He Avas immediately conveyed to the field hospital of the 2d division, Ninth Corps, Avhere the operation of trephining Avas performed. He Avas thence sent to Washington, but death supervened on the 30th while on the Avay. The case is reported by Surgeon Theodore S. Christ, 45th Pennsylvania Volunteers. Case.—Sergeant Eugene B. Stinson, Co. F, 12th Alaine Volunteers, aged 28 years, Avas 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 tAvo inches below the coronal suture. He was admitted to the hospital of the 1st division, Nineteenth Corps, on the same day; on September 22d sent to the depot field hospital at Winchester, and on the 25th transferred, via Sandy Hook, Alaryland, to the MoAver Hospital, Philadelphia. In the course of ten days after admission, premonitory head symptoms 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. Aloon 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 spiculae of the inner table. The internal table was fractured and driven down upon the membranes, Avhile the outer table Avas only slightly indented, neither 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, complained of pain in the epigastric region, and his respiration became hurried. The next day he began to sink rapidly, coma returned, and death folloAved on October 18th, 1864. A post- mortem examination revealed an abscess in the left hemisphere, at the point of injury. The membranes were much congested. The case is reported by Acting Assistant Surgeon W. P. Aloon. Case.—Private H. L. Smith, Co. B, 1st Arkansas Regiment, received, at the battle of Shiloh, Tennessee, April 6th, 1862, a fracture of the occipital bone. He AA-as, on April 17th, admitted into Hospital No. 6, Louisville, Kentucky, the Avound being in a bad condition. On the 22d chloroform was administered, and Assistant Surgeon Benjamin HoAvard, U. S. A., applied the trephine, and removed some loose bone. Partial coma supervened and continued until death, which occurred on April 25th, 1862. Case.—Lieutenant AVilliam D. Sprouse, Co. B, 40th Illinois Volunteers, Avas Avounded near Atlanta, Georgia, August 15th, 1864, by a conoidal ball, Avhich fractured the left parietal. He was at once admitted to hospital 4th division, Fifteenth Corps, where, six hours after the reception of injury, Assistant Surgeon William Graham, 40th Illinois Volunteers, trephined the skull; the patient being under the influence of chloroform. He was on the same day sent to the hospital of the Fifteenth Corps, at Marietta, and died on August 23d, 1864. 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 Une. He 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 upon removing the disc of bone, but not injured. One week after the operation, severe chills set in, followed by fever; then double pneumonia made its appearance, with symptoms of pyaemia, 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 haemorrhage. A post-mortem examination revealed ulceration of the coats of the sinus, with small spiculae of bone resting upon it. The case is reported by Assistant Surgeon B. AV. Allen, P. A. C. S. Case.—Private William Thompson, Co. E, 12th Illinois Infantry, Avas wounded at Allatoona, Georgia, October 5th, 1864, by a conoidal ball, which fractured the external table of the right parietal 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 hospital at Rome, Georgia. On the 14th, violent convulsions occurred ; the patient Avas placed under the influence of chloroform and ether, Avhen Surgeon J. H. Grove, U. S. V., applied the trephine, and removed fragments of necrosed bone, giving exit to a quantity of pus which had formed beneath the bone. Consciousness returned, and the convulsions subsided soon after the operation, but returned on the following day; coma supervened, and death occurred on October 16th, 1864. * For a full history of this case, see the Manual of Military Surgery, page 296, by Dr. J. J. Chisholm. 1864. 276 WOUNDS AND INJURIES OF THE HEAD. Case.—Joseph A. Tracey, Musician, Co. II, 18th Connecticut A'olunteers. aged 20 years, AA-as wounded at Snicker's Ferry, A'irginia, July 20th, 1864. by a conoidal ball, Avhich fractured the right parietal bone. He Avas conveyed to Sandy Hook, Mary- land, and admitted into the hospital on the 22d. On the following day Assistant Surgeon James AVillard, 1st Potomac Home Brigade, applied the trephine and elevated the depressed portion. The meninges were found lacerated. Simple dressings Avere applied, but death ensued on August 7th, 1864. Case.—Private Julius Theobald, Co. D, 32d Indiana A'olunteers, was wounded at Shiloh, Tennessee, April 6th, 1862, by a fragment of shell, AA'hich fractured and depressed the cranium. He AA'as admitted to the General Hospital, No. 3, Evansville, Indiana, on the 12th, where, on the folloAving day, his skull Avas trephined. He Avas removed by his friends to a private house, and died on the 3d of Alay, 1862. The case is reported by Surgeon Daniel Morgan, U. S. V. Case.—Private TF. A. Tatum, Co. B, 12th Tennessee Regiment, aged 25 years, was wounded near Atlanta, Georgia, Alay 17th, 1864, by a conoidal ball, which struck the upper edge of the right parietal bone, causing depression of both tables of the skull. One hour after the reception of the injury, the trephine was applied, and all spiculae of bone were removed. He Avas admitted, on the following day, to the Institute Hospital at Atlanta. He was fully conscious, free fi-om all pain, and able to Avalk about the ward. On May 20th, the pulse was 70, and he complained of slight headache, Avhich had increased by the 23d. On the folloAving day there Avas no pain, and the patient was apparently doing Avell. From this time he greAv dull, lost his appetite, became totally unconscious; on Alay 28th, brain substance began to slough, and death occurred on June 1, 1864. The case is reported by Surgeon D. C. O'Keefe, P. A. C. S. Case.—Private X------, a Confederate soldier, was wounded at Fort Donelson, Tennessee, February 16th, 1862, by a muBket ball, which entered the occipital bone one inch to the left of the occipital protuberance, passed betAveen the tables, comminuting and depressing the internal, and made its exit one and a half inches to the right of the same protuberance, without fissuring the external table. Two days later he Avas admitted to the Academy Hospital, Nashville. He seemed droAvsy and dull, but was not comatose, nor did paralysis exist. He Avas placed under the influence of chloroform and ether, the scalp was dissected from the Avound, and the bridge of bone betAveen wounds of entrance and exit was removed. The trephine Avas then applied to the angles of the Avound, and fragments of the inner table Avere removed, laying bare the sinuses and the torcular Herophili, without injury to the meninges, and leaving an opening between the bony margins of the wound of sufficient size to admit tAvo fingers placed side by side. The dura mater Avas uninjured. The flaps were brought together by silken sutures. Cold water dressings were applied, and the bowels freely evacuated. Tincture of iron AA-as given to control the circulation. The patient continued perfectly conscious; his mental faculties retained their accustomed activity, and he Avas soon able to sit up. The sutures had come away, the Avound of scalp had nearly healed, and his general condition seemed very promising, Avhen, on the tenth day after the operation, erysipelas manifested itself on the nose, and extended rapidly over the face and neck to the lips of the wound. Delirium set in on the twelfth day, and death supervened two days subsequently, March 4th, 1862. The case is reported by Surgeon Eben Swift, U. S. A. Case.—Private Ezra O. White, Co. D, 4th Wisconsin A'olunteers, received, in the engagement at Port Hudson, Louisiana, June 14th, 1863, a gunshot Avound of the cranium, involving the brain. He Avas on June 16th admitted to St. Louis Hospital, Ncav Orleans, Louisiana, Avhere, on June 18th, the operation of trephining was performed. No relief Avas afforded, and death occurred on July 3d, 1863. Surgeon F. Bacon, U. S. A'., reported the case. Case.—Private P. C. Walker, Co. E, 4th DelaAvare A'olunteers, aged 24 years, was wounded at Ream's Station, Virginia, August 19th, 1864, by a shell, which fractured the skull near the junction of coronal with the sagittal suture. He Avas on the same day admitted to the hospital of the 4th division, Fifth Corps, and thence conveyed to Philadelphia, and admitted to the AloAver Hospital August 29th. The wound Avas in a healthy condition, but the face Avas swollen and cedematous, Avith symptoms of erysipelas. The patient's general health was good, and there were scarcely any symptoms of compression. On September 9th, Acting Assistant Surgeon AA'. P. Moon placed the patient under the influence of chloroform, made a semi-lunar incision through the integument, and trephined the skull. A large abscess had formed between the membranes of the brain and the cranium. Death from meningitis supervened on September 18th, 1864, nine days after the operation. The case is reported by Surgeon J. Hopkinson, U. S. Ar. Case.—Sergeant Lafayette l'oung, 2d Co. of Sharpshooters attached to the 27th ABchigan Volunteers, aged 27 years, Avas Avounded at the battle of the AA'ilderness, Virginia, Alay 5th, 1864, by a conoidal musket ball, which fractured the skull at the sagittal suture. He Avas conveyed to Washington, and on the 25th admitted to the Harewood Hospital. The man's mind was sound, although strabismus of the left eye indicated symptoms of compression of the brain. The left leg was partially paralyzed. On May 28th, he was placed under the influence of ether, and Surgeon R. B. Bontecou, U. S. V., applied the trephine to the left edge of the Avound, removed the loose bone, and elevated the depressed portions. The patient improved under antiphlogistic treatment, and on June 1st healthy suppuration supervened. Two Aveeks later, the left leg became entirely free from paralysis. On July 1st, small pieces of bone were removed, and the wound looked unfavorable. On the 23d, Young was transferred to the St. Mary's Hospital, Detroit, Alichigan, affected with strabismus of the left eye and paralysis of the left leg. He was furloughed on August 2d, but died before the expiration of his leave of absence, August 21st, 1864. CASE.—Private Albert D. Nelson, Co. D, 12th New Hampshire A'olunteers, was Avounded at Chancellorsville, Virginia, Alay 3d, 1863, by a conoidal ball, which fractured and depressed the squamous portion of temporal bone, laying the scalp open some three inches, and glanced off. The trephine Avas at once applied by Surgeon C. S. Wood, 66th New York Volunteers, and the loAver fragments were removed, the depressed portions elevated, and water dressings applied. He Avas then conveyed to hospital of the 1st division, Tlurd Corps, and on May 6th sent to Lincoln Hospital, AVashington. On Alay 25th, he was transferred to F'ort AA'ood, New A'ork Harbor, and on June 3d to McDougall Hospital, Fort Schuyler, whence he deserted July 2uth. 1863. Promoted corporal February 5th, 1864. Died, of disease, at Bristol, NeAV Hampshire, February 10th, 1865. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 277 The following cases of trephining for gunshot fracture resulted in recovery, the patients presenting various degrees of disability: Case.—Corporal J. A. B------, Co. C, 2d New Hampshire Volunteers, aged 21 years, was wounded at the battle of Gettysburg, Pennsylvania, July 2d, 1863, by a fragment of shell, which fractured and depressed the upper portion of the occipital bone to the extent of two inches square. He Avas admitted into the Satterlee Hospital, Philadelphia, on the 10th, very much debilitated, and complaining of pain over his eyes. His mental faculties were somewhat sluggish, but not to any marked degree. A fragment of bone had come aAvay leaving the brain exposed. The trephine was applied and the largest piece of depressed bone removed. On January 9th, 1864, another portion of the occipital bone of an oval shape, two inches in its long diameter, and including both tables, Avas removed by Acting Assistant Surgeon L. K. Baldwin. He had some inflammation of the brain and erysipelas^ but recovered under ordinary treatment. On Alarch 1st, 1864, he was transferred to DeCamp Hospital, David's Island, NeAV Y'ork Harbor, where he remained until June 7th, 1864, Avhen he was discharged from the service by reason of vertigo and constant pain in the head. The pathological specimen, No. 430, consists of a necrosed fragment of the occipital bone and was contributed by Acting Assistant Surgeon L. K. Baldwin. A communication from the Commissioner of Pensions dated January 2d, 1868, states that Barker is a pensioner, and that his disability is rated as total and permanent. The case is reported by Acting Assistant Surgeon T. G. Morton. Case.—Lieutenant Samuel H. Berry, Co. D, 82d Ohio Volunteers, Avas wounded in an engagement at Bull Pasture Alountain, A'irginia, Alay 8th, 1862, by a conoidal ball, which passed under the scalp for about two inches on the surface of the left parietal bone and emerged. There Avas no depression and but a slight fracture of the outer table. After the first shock there were no apparent brain symptoms until the fifth day, Avhen pain in the locality of the Avound and mental aberration super- vened. They did not yield to treatment, and the third day folloAving found the patient in a state of coma. As a last resort it was determined to trephine, which Avas done on the ninth day after the injury by Surgeon S. Y. CantAvell, 82d Ohio Volunteers. The internal table was noAV found to be extensively fractured, and thirteen spiculae of bone Avere removed, one piece having pierced the membranes and penetrated the substance of the brain. After the operation there Avas a marked improvement in the symptoms, notwithstanding the patient was afterward attacked by erysipelatous inflammation of the scalp and face; he gradually and finally recovered, and was discharged from the service on August 19th, 1862. The case is reported by the operator, Case.—Private David B------, Co. E, 100th Pennsylvania Volunteers, aged 33 years, Avas wounded at Petersburg. A'irginia, June 17th, 1864, by a conoidal ball, which fractured the left parietal bone at the central portion and superior border of the temporal ridge. He Avas admitted on the same day to the field hospital of the Ninth Corps, and thence conveyed to AVash- ington, and admitted to the HareAvood Hospital on the 2d of July. On the 17th, he was sent to the Alower Hospital, Philadel- phia. On admittance, the Avound appeared to be only one of the scalp. Cold water dressings were applied; calomel, tonics, anodynes, and light diet ordered, and the patient placed in a recumbent position, with the head elevated. On July 20th, he evinced a want of comprehension when addressed, and hesitated in replying. From that date there was a groAving tendency to coma, and on the 29th he was completely unconscious. His pupils were dilated, respiration Avas labored, and pulse sIoav and soft. On the 30th, ether was administered, and Acting Assistant Surgeon D. H. Agnew applied the trephine and removed a section of the outer and four small fragments of the inner table, involving one-third of a square inch of surface. A small abscess was found forming outside of the membranes. Immediately after the operation, consciousness and intelligence returned. By the 1st of August the wound had commenced to granulate; the patient was cheerful and his appetite improA-ing. In two Aveeks he AA'as able to go about the ward, though suffering from pain in the head upon exposure to the sun. He was discharged from service on September 22d, 1864. The pathological specimen is No. 3626, Sect. I, A. AI. AI., and consists of four small fragments of the parietal bone, chiefly from the inner table. The specimen and history were contributed by Surgeon J. Hopkinson, U. S. V. Case.—Private Lawrence Coffield, Co. E, 34th Illinois Volunteers, aged 30 years, Avas wounded at the battle of Murfreesboro, Tennessee, January 1, 1863, by a conoidal ball, Avhich struck the right temple; he also received a Avound of the left thigh. He was on January 5th admitted to Hospital No. 19, Nashville, Tennessee; on January 10th sent to Hospital No. 10, Louisville, Kentucky, and on January 27th to Camp Dennison, Ohio. No treatment is recorded. He was discharged from the service on August 14th, 1863, but reenlisted in Co, H, 123d Indiana A'olunteers, on February 24th, 1864. He served Avith the latter regiment until August 6th, 1864, when he was wounded near Atlanta, Georgia. The missile entered near the occipital protuberance, passed to the bone, and then into the neck, making its exit near the ear. He Avas admitted to the field hospital of the Twenty-third Corps; on September 20th sent to Hospital No. 19, Nashville, Tennessee; on October 19th to the BroAvn Hospital, Louisville, Kentucky, and on December 19th to the Main Street Hospital, Covington, Kentucky. The occipital bone was necrosed. The patient's health was good, but the muscles of the face and tongue were partially paralyzed. On examination, a fistula was found on the right side of the head, just above the arch of the malar bone, into which a probe could be passed one and a half inches, to the skull. A ball was found imbedded at the base of the petrous portion of the temporal bone; the rim (base) of the missile lying just inside of the skull. A sinus extended along the track of the missile. The ball had been there since the battle of Alurfreesboro', Tennessee, January 1, 1863. On February 24, 1865, an incision was made by Surgeon Norman Gay, U. S. A7., the trephine applied to enlarge the opening, and the ball removed. Coffield recovered as fast as could be expected; was on June 10th sent to Camp Dennison, Ohio, and on July 5, 1865, mustered out of the service. The case is reported by the operator, Surgeon Norman Gay, U. S. V. This soldier's name is not on the Pension List. CASE.-Private John F. D------, Co. E, 178th Ncav York Volunteers, aged 37 years, Avas accidentally Avounded on July 12th, 1863, by a conoidal ball, which struck the parietal bone half an inch posteriorly to the coronal, and one inch to the left of the sagittal sutures, passing backward, and emerging about four inches from the point of entrance. He was admitted into Armory Square Hospital, AVashington, the next day, in a someAvhat stupid and restless condition, with anxious countenance. 278 WOUNDS AND INJURIES OF THE HEAD. Partial paralysis of arm, and paralysis agitans of forearm of the opposite side existed. An examination of the wound reA-ealed depression of a small portion of the external plate, one-half inch in length by one quarter of an inch in Avidth. A fissure extended one inch and three-fourths posteriorly from the depressed portion of the bone. The fracture of both tables could be readily recognized by the pulsating motion of the fluid Avhich had accumulated in the cavity. Surgeon D. AA'. Bliss, U. S. A'., applied the trephine over the depressed portion. Great difficulty was experienced from the detached portions of the inner table moving under the trephine. These fragments were removed by means of forceps. The dura mater Avas abraded at several points, but not torn through. After the operation, the wound Avas carefully cleansed, water dressings were applied, the patient placed in a semi-recumbent position, and quiet enjoined. A gradual improvement took place, and by July 29th the case presented all indications of a speedy recovery. Paralysis /VrV" ^^-7,. ,.) .\ '.vMy' ^> ^Ti'ii' I steadily diminished. He Avas sent to the DeCamp Hospital, NeAV York Harbor, October 29th, 1863, and transferred to the Veteran Reserve Corps, Alarch 3d, 1865. The specimen is figured in the wood-cut, and sIioavs a disk and five fragments of bone. One and a half square inches of the internal table Avere removed. The specimen and history were contributed by Surgeon D. W. Bliss, U. S. V. FIG. 139.—Disk and fragments removed for gunshot fracture of the parietal bone. Spec. 1474, Sect. I, A. M. M. Case.—Private John E- -, Co. C, 39th New York Volunteers, aged 35 years, was wounded in a melee in a railroad car, near Chicago, Illinois, November 16th, 1862, by a pistol ball, which caused a compound fracture of both tables of the os frontis, right side, near the border of the temporal bone. He arrived at Washington on the 26th, and was admitted to Armory Square Hospital, being quite delirious. There was much tumefaction, and extensive suppuration had already commenced. His strength, appetite, and secretions were normal, his pulse slightly accelerated and tense. An examination revealed a wound of the scalp, two inches in length, crossing the coronal suture at right angles, tAvo inches above the border of the temporal bone. On the morning after admission, the delirium Avas so intense that it was impossible to keep the patient in the ward. There Avas occasional difficulty in articulation and a tripping of the left foot in walking, denoting slight hemiplegia. The memory was someAvhat impaired, but lucid intervals occurred. The constitutional symptoms had remained the same, denoting irritation rather than compression of the brain. On the 22d, the tumefaction having someAvhat subsided, a further examination revealed another Avound of the scalp, one and a half inches below the first, and a ball imbedded in the cranium. Ether was administered and an incision made through the integument. The trephine was then applied, and the portion of the cranium containing the ball was removed, as also a fragment of the inner table, triangular in shape, three-eighths of an inch in length and one-fourth of an inch in width at the base. The latter Avas found driven into the substance of the brain, piercing the dura mater and standing point doAvmvard, its broad base displacing the meningea media. After the operation the patient rose from the table, perfectly sane, and walked to his bed. Cold water dressings Avere applied, laxatives administered, and low diet ordered, and by the 25th he was improving rapidly, there having been no delirium since the operation. On December 10th, the general health of the patient was good, and the Avound across the coronal suture had nearly closed by healthy granulations. The wound of operation had healed by first intention, except at the place where the flaps met; at that point there was healthy granulation going on. On January 6th, 1863, he was discharged from the service, having entirely recovered. The specimen removed is a disk of bone, one-half an inch in diameter, with fracture and depression of both tables, and was contributed by Surgeon D. AV. Bliss, U. S. V. It is figured in the Avood-cut. Case.—PriA-ate Charles AI. E— Fig. 140.—Disk with a depressed gunshot fracture in its centre. — Spec. 422, Sect. I, A. M. M. -, Co. H, 17th Pennsylvania Cavalry, aged 21 years, was Avounded at Shepherdstown, A'irginia, August 25th, 1864, by a musket ball, which entered the right parietal bone near the sagittal suture and emerged at the posterior superior angle of the left parietal bone, producing a compound comminuted fracture. The ball in its passage carried aAvay a piece of the external table one and a half inches in length, and half an inch in width, and depressed the inner table. He was taken to Sandy Hook, Maryland, and thence conveyed to Annapolis Junction on August 27th. Complete paralysis of the right and partial of the left leg existed. Patient was debilitated and anaemic; had lost considerable blood, and was much depressed, physically and mentally. Acting Assistant Surgeon Streeter applied the trephine to the external table and removed fragments of the fractured and depressed inner table, leaving the brain pulsations distinctly visible. The soft parts were then brought together with adhesive strips, and cold water dressings applied, lint and dry oakum being substituted, when the Avound began to suppurate. The pulse daily increased in frequency and strength until it reached 72, and the patient regained the use of his limbs sufficiently to Avalk Avith a cane. On October 10th, he Avas transferred to Haddington Hospital, Philadelphia, the wound closing with healthy granulations and bidding fair to heal rapidly. He Avas transferred to the A'eteran Reserve Corps on March 2d, 1865, and discharged June 28th, 1865. The pathological specimen is No. 3600, Sect. I, A. AI. AI., and consists of a disc and six fragments of diploe and vitreous table removed by the trephine from the left parietal bone. The case is reported by Acting Assistant Surgeon H. S. Streeter. On March 19th, 1866, Pension Examiner J. G. Koehler reports that the patient suffers from partial paralysis of the left side of the body. He rates his disability one-half and temporary. Case.—Private Samuel G- -, Co. C, 183d Pennsylvania Volunteers, aged 17 years, Avas Avounded at the battle of Spottsylvania Court-house, A'irginia, Alay 12th, 1864. by a conoidal ball, which depressed the right parietal bone at its posterior superior angle. A spicula, one and one-fourth inches in length and three-fourths of an inch in breadth, Avas driven in upon the dura mater. He was admitted to the hospital of the 1st division, Second Corps, and on the 23d sent to the Armory Scjuare Hospital, AA'ashington. Slight paralysis of the left leg and hand existed. The pupils Avere normal, hut the tongue protruded. There Avere also slight symptoms of compression. On the folloAA-ing day, the patient Avas placed under chloroform, and Surgeon TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 279 D. W. Bliss. U. S. X., trephined the skull and removed twelve pieces of bone. The dura mater was ruptured, and the pulsa- tions of the brain were distinctly visible. Simple dressings were applied, and on May 29th the patient was doing Avell. On July 17th, he Avas transferred to Philadelphia and admitted into the AIoAver Hospital, Avhere he remained until January 28th, 1865, AA'hen he Avas transferred to the Veteran Reserve Corps. The pathological specimen is No. 2375, Sect. I, A. M. M., and consists of a disc and three small fragments of bone. The specimen and history were contributed by Surgeon D. W. Bliss, I'. S. V. The man Avas discharged on November 20th, 1865, and pensioned. On April 10th, 1867, Pension Examiner Thomas B. Reeve reported that there Avas a large depression at the seat of injury which was very sensitive. The patient said that he lost seventeen pieces 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. Case.—Private E. Herring, Co. E, 38th Georgia Regiment, was wounded at the battle of Antietam, Alaryland, September 17th, 1862, by a conoidal ball, which struck in the middle of the right parietal bone, carrying away a considerable portion of both tables. The wound was hurriedly dressed upon the field, after which he was sent to hospital, where his wound soon closed Avithout haA-ing undergone any further examination for spiculae or depressed portions of bone. Soon after the wound had healed, he was attacked Avith epileptic fits, which continued at uncertain intervals until the 18th of Alay, 1864, when he was again admitted to a Confederate hospital. Upon examination of the cicatrix, 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 Avas decided to operate. Acting Assistant Surgeon R. R. Ritchie, P. A. C. S., administered chloroform and made a T incision, the first part lying parallel with the sagittal suture, and the second striking it at about its upper third, over the cicatrix and above the point of fluctuation. The scalp was found adhering to the skull, and abnormal in structure and thickness. The opening through the inner and outer table Avas covered with a firm cartilaginous layer, on removing Avhich considerable haemorrhage from within took place, which Avas, however, promptly controlled by the application of a heated needle to the orifice of the vessel. The trephine Avas first applied above the opening toward the corono-sagittal suture; after the removal of Avhich portion, it being evident that the depression extended farther, and the loss of substance around the open skull, near the point of fluctuation, precluding the idea of elevating the depressed bone, the trephine was again applied, posteriorly, and somewhat beneath the first place, at about one inch distance, and the bone having been removed, the edges of the skull between the first and second openings, and between either and the point Avhere both tables had been destroyed by the missile, were taken away by means of Hey's saAv, 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 membrane 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 flow of blood arrested, the wound Avas closed by interrupted sutures, and cold water dressings applied. Patient reacted Avell from the effects of the chloroform, and did unusually well until the morning of the fifth day, when he had another convulsion, which Avas attributed to the accidental disturbance of the bandage, and did not recur. The Avound healed by first intention, and there was every probability of a complete recovery. The case is reported by Surgeon B. Roemer, P. A. C. S. Case.—Private Charles L------, Co. B, 55th NeAV York Volunteers, aged 30 years, was wounded at the battle of Alalvern Hill, Virginia, July 1st, 1862, by a conoidal ball, which struck the right frontal bone about an inch above the right superciliary ridge, and lodged. He was conveyed to AVashington, and admitted into the Judiciary Square Hospital on the 4th. On the 10th he complained of constant headache and nausea; the right eye Avas injected, but the tongue, pulse, and bowels were normal. A portion of the frontal bone was depressed, and the pulsations of the brain could be seen fluctuating up and down the fissures of the fracture. It being feared that the depressed portions might irritate the dura mater and give rise to inflammation, and in view also of the constant headache, the skull was trephined on the llth by Acting Assistant Surgeon David W. Cheever and tAvo large pieces and some splinters of depressed bone Avere removed. At one point the dura mater had a depression as if made by the passage of the ball; otherwise it looked uninflamed and healthy, but there Avas some effusion of blood. AYater dressings and low diet were ordered. On the second day after the operation, pain was felt as the head Avas moved about, but no fever existed. There Avas considerable discharge of laudable pus. The brain was still seen pulsating on the 15th, but not so plainly as before. On the 20th, his condition was every way favorable; the pulse quiet, tongue clean, skin cool, appetite good, no pain in head, the wound closing, and granulations seen over the dura mater. He recovered, and Avas discharged from the service January 4th, 1863. A communication from the Commissioner of Pensions, dated January 2d, 1868, states that Lawrence is a pensioner, and that his disability is rated at one-half and temporary. The pathological specimen is No. 261, Sect. I A. M. M. The disk and fragments of cranium removed by the trephine embrace one-fourth square inch in surface. The specimen and history Avere contributed by Acting Assistant Surgeon D. W. Cheever. Pension Examiner P. SteAvart, of Peekskill, reports that the patient suffers from giddiness and vertigo. Case.—Private G. W. Mcintosh, Co, H, 40th Indiana Volunteers, aged 31 years, was 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 Avas on the same day admitted to the hospital of the 2d division, Fourth Corps; thence transferred to the Cumberland Hospital, Nashville; and on the 29th sent to the Totten Hospital, Louisville, Kentucky. His constitutional condition Avas excellent. Only simple dressings were applied to the wound, but small pieces of bone were discharged from time to time. The patient complained of dizziness and headache, and was strongly impressed Aviththe idea that the ball remained in the Avound, of which there seemed every probability. On August 17th, Acting Assistant Surgeon D. J. Griffith administered chloroform, trephined the skull, and removed two buttons of bone, but failed to find the ball. The wound healed, and Alclntosh was furloughed on September 19th 1865, and mustered out of service on December 21st, 1865, still suffering from headache and dizziness, especially after being exposed to the heat of the sun. A communication from the Commissioner of Pensions, dated March 26th, 1868, states that Private Alclntosh is a pensioner at §15 per month, and that his disability is rated total and permanent. The report of Examining Surgeon AI. Herndon, of Montgomery County, Indiana, states that the ball cannot be extracted without injuring the membranes of the brain, in the opinion of the best surgeons of the country. 280 WOUNDS AND INJURIES OF THE HEAD. Fig. 141.—Exfoliation from the right parietal bone. Spec. 3452, Sect. I, A. M. M. Case.—Private John AIcK------, Co. H, 105th Pennsylvania Volunteers, Avas wounded at Petersburg, A'irginia, June 14th 1*64. by a conoidal musket ball, Avhich struck the right side of the skull very obliquely, and produced a slightly depressed fracture of the right parietal bone. He Avas admitted to Alount Pleasant General Hospital, Washington, on June 24th, with the report that the progress of the case had been so far eminently satisfactory. After admission, he Avas found to be insensible, and a few hours subsequently, convulsions supervened in rapidly recurring paroxysms. TAvelve ounces of blood Avere taken from the temporal artery without apparent benefit. A trephine Avas then applied to the seat of fracture, and, upon the removal of a button of bone, a portion of the inner table was found slightly depressed. This Avas elevated, and the patient soon afterAvard regained consciousness. On June 28th, the wound in the scalp became erysipelatous, and before the inflammation subsided, there avus extensive loss of substance of the integuments and pericranium, denuding a large portion of the parietal bone. Necrosis ensued, and involved the Avhole thickness of the bone. On September 3d, 1864, a portion of the parietal, three inches by four, had become so much loosened that it Avas readily removed. Cicatrization then went on rapidly, and on December 2d, 1864, the wound had contracted to an ulcer less than an inch in diameter. The patient's mental faculties were impaired somewhat, the ward physician thought, but not to a great extent. A colored drawing Avas made representing the appearance of the parts prior to the separation of the exfoliation, No. 74, Surgical Series of DraAvings, S. G. O., by Hospital SteAvard P. Baumgras, . U. S. A. It is copied, in chromo-lithography, in the plate opposite page 207. The exfoliation, which Avas contributed, Avith a minute of the hospital record of the case, by Assistant Surgeon C. A. AlcCall, IT. S. A., is represented in the accompanying wood-cut, taken from page 16 of Circular 6, S. G. O., 1865. The patient Avas discharged from service August 31st, 1864, and from the hospital February 1st, 1865. He was pensioned; the examiner, Dr. Julius Nichols, stating that he was totally disabled, and that the case was the most extraordinary that had come under his observation; the pulsations of the brain, uncovered by dura mater, and the trunk of the meningeal artery being distinctly visible. He went to his home in Montgomery County, Pennsylvania. In April, 1871, he Avrote to the compiler of this volume as folloAvs: * * " 'Ihe space the bone was taken out of is three and a half by two inches. In feeling the place lightly, it goes all through my head. It is all healed over like a thin shell. I am compelled to lie on my left side when sleeping. When exposed to the sun a dull pain through my head is caused. * * I have received but seven dollars a month. My pension papers call for eight dollars." Case.—Sergeant George Oughiltree, Co. A, 12th United States Infantry, aged 22 years, was Avounded at the battle of Gaines Alills, A'irginia, June 27th, 1862, by a conoidal ball, which entered the skull on the right side, on a line with and one inch in front of the parietal eminence, and fractured and slightly depressed the internal table. The wound bled freely, and he AA'as rendered insensible for a short time. When sensibility returned, he found that his left arm Avas completely paralyzed. He AA-as taken prisoner, and conveyed to a Confederate field hospital, where he was accidentally wounded by a round ball, which comminuted the tibia and fibula, and lodged beneath the skin, but which was removed by a Confederate surgeon. Cold water dressings were applied to the Avounds. During the first night patient had three or four convulsions. The paralysis of the arm continued for eight days after the injury, Avhen it gradually disappeared. The ball still remained in the head, but no brain symptoms appeared. On July 27th, he was exchanged, and removed to a hospital boat. The upper end of the lower fragment of the tibia Avas protruding, and the soft parts Avere in such a condition as to render amputation through the upper third necessary, Avhich Avas performed by Dr. Drake Avhile the patient Avas under the influence of ether. At the same time the skull was trephined by Dr. Pierson. Several pieces of necrosed bone were removed from the posterior superior angle of the right parietal bone. A piece of ball, irregular in shape, was also removed at the same time. The removal of the latter was followed by the discharge of about tAvo drachms of healthy pus fi-om an abscess in the substance ofthe brain. He Avas subsequently transferred to Philadelphia, entering Broad and Cherry Streets Hospital, on the 31st, in good general condition. The stump looked well, the Avound of head Avas discharging healthy pus, and the brain pulsations Avere distinctly visible. A dry dressing was applied to the stump, and a flax-seed poultice to the head. He was ordered a good diet, Avith milk punch and beef tea. In a feAV days inflammation of the stump appeared, followed by slight sloughing of the loAver flap, and a stimulating poultice was applied. He improved rapidly. The stump healed by granulation, but the last ligature was not removed until two months later, and during that time tAvo small pieces of* exfoliated bone were removed. In November, the stump Avas discharging slightly, and brain pulsations Avere still visible in the Avound of head. On April 22d, 1883, he was sent to the Ward Hospital, NeAvark, NeAv Jersey, and transferred to the Veteran Reserve Corps on August 14th, 1863. He Avas perfectly Avell, and wore an artificial leg; the opening in the cranium Avas nearly closed by ne\v deposit of bone. A communication from the Commissioner of Pensions dated April 22d, 1863, states that Oughiltree was a pensioner, and that his disability was rated as total and permanent. The early history of the case is reported by Acting Assistant Surgeon John Neill. Case.—Sergeant F. M. Robinson, Co. I, 2d Kentucky Regiment, aged 26 years, was wounded on Alay 14th, 1864, by a shell, which fractured and depressed both tables of the cranium at the right parietal eminence to the extent of one-half square inch, and denuded the skull for a space as large as the palm of the hand. There was also a severe flesh Avound near the inferior angle ofthe scapula. He was unconscious for fourteen hours folloAving the injury, butAvhen admitted into the Institute Hospital, Atlanta. Georgia, on the 17th, he Avas conscious. There Avas great pain, with ecchymosis, extending around the right eye and OA-er the face; the pupils Avere contracted; pulse sIoav and feeble; skin cool. From this time until the 23d, his condition remained about the same; the AvoUnd did not suppurate, and he suffered great pain over the Avhole head, for which opiates were freely given. On the 25th, suppuration Avas estabhshed, and a soft, fluctuating tumor formed, extending over the left side of the scalp and left eye. On the 30th, the wound began to slough badly, Avith a gangrenous tendency. On June 8th, he had a slight convulsion, folloAved by another on the 9th, but on the 10th, he was very cheerful, his pulse being regular/appetite good, and TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 281 the Avound looking healthy. Late at night of the llth, he had another very slight convulsion. On the following day chloroform Avas administered, and the depressed plate of bone, half an inch square, removed by saAving through a small triangular portion of the outer table. This gave free access to the depressed portion, Avhich, with several spiculae, was removed by forceps and elevator. About a teaspoonful of pus, Avith disorganized membranes and cerebral substance, was removed at the same time. The patient Avas very cheerful on the day folloAving the operation. On June llth, he had another slight convulsion, but from that date he steadily improved, and on the 30th, the wound was in a healthy granulating condition; the large surface of denuded skull seemed to be diminishing and covering over sloAvly, and there Avas every prospect of speedy recovery. The case is reported by Surgeon D. C. O'Keefe, P. A. C. S. Case.—Private Jonathan G. S------, Co. D, 209th Pennsylvania Arolunteers, aged 28 years, was wounded at Fort Steadman, A'irginia, Alarch 25th, 1865, by a conoidal ball, which fractured the cranium. He was admitted to the hospital of the 3d division, Ninth Corps, and thence sent to the Armory Scpiare Hospital, AVashington, where he arrived on Alarch 28th. An examination revealed a fracture of both parietal bones, immediately over the sagittal suture and superior longitudinal sinus on a line draAvn from ear to ear. The patient's intellect appeared unimpaired; pulse sIoav and tolerably full. He Avas unable to move his loAver extremities, but the sensation remained unaffected; tickling the sole of the foot caused involuntary shrinking of the foot and leg. He voided his urine and fieces without difficulty. On the 30th, Surgeon D. AV. Bliss, U. S. A'., applied the trephine, and remoA-ed a small portion of sound bone and several detached pieces, which Avere firmly Avedged between the two parietal bones, and had partially been driven beneath the internal table. Simple dressings Avere applied, and stimulants and nourishing diet ordered. After the operation, patient suffered no pain, and Avas able to move his legs. He recovered, and was discharged from the service on Alay 26tb, 1865. The specimen is No. 4036, Sect. I, A. M. AI., and consists of tAvo fragments of bone from the sagittal suture, about one-half square inch in surface, including both tables. The specimen and history were contributed by Surgeon D. XV. Bliss, U. S. V. This patient was pensioned, and in October, 1865, Pension Examiner J. L. Swesserott reported that he had left hemiplegia, a large depression along the sagittal suture; the toes of the left foot Avere constantly cold and destitute of sensation. In April, 1871, no further information regarding the case could be found on the files of the Pension Bureau. Case.—Private William J. Scheetz, Co. C, 95th Pennsylvania Volunteers, aged 25 years, Avas Avounded at the battle of Gaines's Mill, Virginia, June 27tb, 1862, by a conoidal ball, which entered the os frontis two inches anterior to the coronal suture, and a little to the right of median line, and fractured both -tables. He Avas conveyed to the hospital at Annapolis, Alaryland, where his injury Avas treated as a Avound of scalp only. He was, on August 16th, transferred to Annapolis Junction, and thence returned to duty on August 26th, 1862. The middle of Alarch, 1863, he Avas suddenly seized with symptoms of meningitis. He was taken to the regimental hospital, and thence sent, on April 27th, to the 1st division, Sixth Corps, hospital, Avhere he arrived in a comatose condition. He remained so until the 30th, when it Avas decided to operate. Ether Avas administered, and Surgeon E. B. P. Kelly, 95th Pennsylvania A'olunteers, made a crucial incision three inches long, and removed nearly two inches square of the os frontis Avith trephine and Heys's saw. A piece of bone three-fourths of an inch in length, Avas found firmly imbedded in the dura mater, and Avas with some difficulty removed by a pair of forceps ; a dark coagulum of blood was also taken out. The integuments Avere drawn together by five interrupted sutures, and cold-water dressings Avere ordered to be diligently applied. Half an hour after the operation, patient expressed a sense of relief; being the first word spoken in four days. Forty-eight hours afterward, there being much tumefaction of the parts, tAvo sutures Avere removed. On June 13th he was transferred to Lincoln Hospital, AVashington. Cicatrization of the Avound Avas almost complete, and the patient's general health Avas much improved. On June 20th he was transferred to AloAver Hospital, Avhere he remained until the 25th of February, 1864, Avhen he Avas transferred to the A'eteran Reserve Corps. He entered the general hospital at Frederick, Alaryland, on the 29th of August, 1864; was, on September 8th, transferred to Jarvis Hospital, Baltimore, Maryland, and September 12th sent to McClellan Hospital, Philadelphia, where he Avas discharged from the service on October llth, 1864. Case.—A Confederate Soldier Avas admitted to the Confederate hospital at Resaca, Georgia, Avith a shell Avound of the head, received tAvo days previous. The missile had struck just above the left ear, dividing the integuments two inches perpendicularly. The wound was immediately opened, revealing a rectilinear fracture full two inches in length ; at the upper end it extended at an obtuse angle in the direction of the junction ofthe sagittal and lamboidal sutures ; at the loAver end the fracture run obliquely in the direction of the mastoid process of temporal bone, making a line fracture of at least four inches. The whole of the posterior fragment was depressed the entire thickness of the skull bone; there Avas also a semi-lunar fracture anterior to the above, having a fragment near half an inch in Avidth partially detached. There were symptoms of compression of the brain, and the patient was comatose and insensible. On the fifth clay after the reception of the injury, the trephine Avas applied in such a manner as to cut across the fragment into the sound bone anterior to the fracture. A portion of loose bone Avas removed, the elevator applied, and the depressed bone brought to its natural position. On the surface ofthe dura mater was found a collection of coagulated blood and fibrin, AA'hich Avas removed; no anaesthetic Avas used. As the dressings Avere applied, consciousness returned, and the patient asked several questions as to the condition of his head, and the probability of a fatal termination; thenceforward improvement was uniform, and ultimately the recovery was perfect. Case.—Private W. H. Underwood, Co. D, 44th Indiana Volunteers, aged 19 years, received at the battle of Shiloh, Tennessee, April 6th, 1862, a gunshot Avound in the head. After the reception ofthe injury, he walked from tree to tree until he became insensible; revived the next morning by a drink of water from a Confederate soldier, he walked to an encampment near by, and Avas thence removed to a hospital transport. He lay in the hold of the boat, very near the furnace, for two days and a half. He Avas admitted to Hospital No. 6, Louisville, Kentucky, on April 15th, 1862. There Avas a wound of entrance in the left temple, with apparently no.corresponding wound of exit; but a small incision was found in the middle of the forehead, from which the patient stated a ball had been extracted on the field. On the outer aspect of the left upper eyelid Avere two incisions, made by buckshot, Avhich caused so much swelling as to entirely close the eye. He complained of severe pain in the head, and numbness of the left leg. The left pupil was dilated. The probe was introduced into the wound of the left temple and made 36 2s2 WOUNDS AND INJURIES OF THE HEAD. its exit through the small incised Avound at the middle ofthe forehead ; but the pain caused by the examination Avas so excessive that further attempts at an accurate diagnosis Avere discontinued. Ice bags Avere applied to the scalp, and tepid Avater to the aa-ouikIs. As coma gradually supervened, a more thorough examination of the wound Avas determined upon. The patient was placed under the influence of chloroform, a "T-shaped incision made over the os frontis, and the flaps Avere dissected up so as to expose the main seat of injury. This revealed a well-marked triangular depression ; the base of the triangle being intact, Avhile its apex Avas more depressed than any other part of it. The point ofthe apex Avas broken off, leaving an aperture through AA'hich an ordinary probe could be introduced readily. From either side of the depression, a line of fracture extended to the squamous portion ofthe temporal bones. Near the aperture in the jaws ofthe triangular fracture was a single hair, Avhich had been forced there and left behind in the track of some foreign body. The centre pin of the trephine Avas noAV placed so as to include parts of the triangular depression in the button of bone which Avas removed. The brain appeared black and disorganized, as if ploughed by a foreign body ; and at the depth of about one and three-fourths inches the probe struck a bullet, Avhich Avas extracted and proved to be elongated and of a cork-screAv shape. The eleA-ator AA-as then applied to raise the depressed portion of the frontal bone, but it sprung back by its OAvn elasticity. The flaps Avere hoav brought together again, cold-Avater dressings applied, and the patient taken to a quiet, darkened room. The coma had been relieved by the operation. On June 10th the wound of operation had entirely healed, the eyelid and track of the ball across.the forehead Avere almost well, and the patient complained of nothing but Aveakness. On June llth, in consequence of the excitement caused by the arriATal of his sister, a relapse took place. Delirium occurred, lasting for tAvo or three hours, the eyelid became rapidly inflamed, and free suppuration recurred. Antiphlogistic treatment Avas at once resumed, and in a feAV days the unfavorable symptoms disappeared. The patient was discharged from the service September 20th, 1862. He reenlisted, however, July lLth, 1863, in the 2d Indiana Cavalry, and died at the post hospital at Alacon, Georgia, of intermittent fever, Alay 14th, 1865. In this case, the course of the ball was very remarkable. After striking the left temple, it coursed across the forehead, until it reached the centre, AA'hich was indeed the most prominent part, and gave the greatest angle of divergence ; yet strangely enough, at this point the ball fractured the skull; the triangular portion defined by the fracture yielding so as to let the ball pass iinvard, and then springing back, left a very small aperture. The ball AA'hich the patient stated Avas removed on the field, Avas evidently only a part of the ball extracted from the cerebrum, shaved off as it bored its aa ay through the skull. The case is reported by the operator, Assistant Surgeon B. HoAvard, U. S. A. Case.—Private H. Yauducson, Co. C, 4th Texas Regiment, was Avounded at the battle of Gettysburg, Pennsylvania, July 3d, 1863, by a musket ball, Avhich fractured the anterior superior portion of the right parietal bone, making a radiated depression of the outer table. The cicatrix formed regularly, and he returned to his command. Epileptic fits supervened in September, 1863, and gradually became more frequent and intense until Alarch, 1884, when he Avas again admitted to a hospital. At that time the cicatrix Avas four and a half inches in length, pointing obliquely backward under an angle of 60° Avith the coronal suture, deepening and widening in its centre, and presenting a depression of three-eighths of an inch in depth; the scalp here is radiated, as if the covering had assumed the abnormal condition of the bone beneath. The epileptic paroxysms Avere noAV composed of a number of successive convulsions. His general condition previous to an attack avus marked by dejection of spirits, vertigo, and apathy; his boAvels habitually costive, appetite Avanting, urine scanty, pulse 60 and feeble, and face pale. Extravasations being supposed to exist, it Avas decided to apply the trephine. Chloroform having been administered, Surgeon B. Roemer, P. A. C. S.. made tAvo incisions in the form of a T; one nearly parallel with the coronal suture, upon the upper margin of the parietal bone, about half an inch from the cicatrix, and uniting Avith 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 Avas applied at the upper part of the depression. The bone came away Avith 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 someAvhat convex extravasation, covered by the dura mater, AA'hich Avas divided by a simple cut. No haemorrhage occurred from beneath the skull, and three small arteries of the scalp had been readily controlled Avithout ligation. The extravasation being removed, the Avound Avas closed Avith adhesive straps, and cold Avater dressings and a cross-bandage applied. The patient reacted well from the effects of the chloroform, and Avalked about in his quarters on the second day. The Avound healed by first intention. Tavo Aveeks after the operation he expressed himself as free from any unpleasant feelings. The condition of his bowels became healthy, his general aspect cheerful, and the prognosis Avas highly favorable to complete recovery. The case is recorded by the operator, Surgeon B. Roemer, P. A. C. S. Case.—Corporal Frederick AA'eber, Co. E, 116th Ncav Y'ork Volunteers, aged 22 years, Avas struck at the battle of Cedar Creek, A'irginia, October 19th, 1864, upon the upper 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, producing, as Avas stated by the attending physician, an indentation at the place of impingement, but no apparent fracture. The man Avas insensible for some time, though perfect reaction at length ensued. He AA-as on the following day admitted to the depot field hospital; on October 22d, transferred to the hospital at Y'ork, Pennsylvania; and on November 7th furloughed to visit his friends in Buffalo, NeAV A'ork. On his arrival at that place he Avas attacked with pneumonia, and came under the care of Acting Assistant Surgeon S. AV. AVetmore. Upon examination ofthe wound of the head, AA'hich Avas at this time discharging freely, a fracture in the external table Avas discovered ; a piece measuring one and a half inches by two and one-fourth inches being loose, though not displaced. Having recovered from pneumonia, he was, on December 1st, admitted into the hospital of the city. On December 17th, Acting Assistant Surgeon J. F. Aliner removed the irregular-shaped loose piece of bone of the external table, as well as fragments of the internal plate. The AA'ound afteiAvard healed kindly though slowly, and the man was discharged from service on June 7th, 1865, enjoying then good health, Avith the exception of an occasional pain in the region of the Avound. In July, 1868, he Avas a pensioner at SS per month, his disability being total and permanent. The case is reported by Acting Assistant Surgeon S. XV. AVetmore. Sub- sequently Dr. H. N. Loomis of Buffalo reported that this patient had a painful cicatrix depressed half an inch, and suffered from defective vision and vertigo, with chronic irritability of the brain, which unfitted him for any kind of labor. Thereupon his pension Avas increased to $20 per month. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 283 CASE.-Private Philip A. AV-----, Co. A, 50th Pennsylvania A'olunteers, aged 21 years, was wounded at Petersburg, A'irginia, July 30th, 1864, by a conoidal ball, which imbedded itself in the integument and muscles of the left side of the head, fracturing aud depressing a portion of the skull a little above and to the left of the occipital protuberance. The missile was removed°by the hand. He Avas someAvhat stunned by the bloAV, but arose and Avalked to the hospital of the 3d division, Ninth Corps, Avhen he became unconscious and remained so for eighteen hours. On the following day he returned to his regiment, not knoAving that his injury Avas severe, but he was returned to the hospital, Avhere he remained for one week. He suffered severe headache and Avas unable to see or hear Avell. On August llth, he was admitted into the Soldier's Rest, branch of 1st division hospital, Alexandria, A'irginia. He seemed to improve for tAvo days, then greAV Avorse, complaining of pain in the frontal region of the head, especially over the left orbital ridge. On the 16th, he became unconscious for about tAvo hours. It being deemed advisable to remove the depressed portion of bone, ether Avas administered, and Assistant Surgeon Theodore Artaud, U. S. V., made a crucial incision, half an inch in length, directly over the injury, and dissected up the occipito-frontalis muscle, revealing an indentation, half an inch in length, making a very regular cup-shaped depression, three-fourths of an inch in diameter, with a slight fissure around its edge and an irregular one across its centre. The trephine Avas applied so as to partially cover one side of the depression, and a portion of the skull Avas removed. The depressed bone was then removed by the elevator, exposing the dura mater, which Avas found to be healthy. A circular tent Avas applied over the exposed portion of brain, the Avound dressed Avith cold Avater dressings, and morphia given to quiet the patient. The following day he Avas able to sit up, and by the 20th could walk about. On the 26th, he was seized with violent signs of compression, but was soon relieved by sinapisms to the neck, abdomen, and extremities. Croton oil Avas given, and afterward the wound, which had nearly healed, Avas enlarged and kept open Avith tents for three days, Avith but slight inconvenience to the patient. He had slight headache on the morning of September 1st, but his general condition Avas good and improA-ing. He ate and slept Avell, and by the 22d, the wound had entirely closed. He occasionally complained of slight headache, and Avas, to all appearances, cured. He was transferred to Slough Barracks, branch of 3d division hospital, on October 5th, remaining until Alay 10th, 1865, Avhen he was sent to the Augur Hospital, Alexandria, and thence, on the 20th, transferred to the AlcClellan Hospital, Philadelphia. He Avas discharged from the service on July 6th, 1865. A communication from the Commis- sioner of Pensions, dated July, 1868, states that Wiest is a pensioner at $8 per month, his disability being rated total and temporary. The specimen was contributed, with an history, by the operator, Assistant Surgeon Theodore Artaud, U. S. Ar. Fig. 142.—Disk and fragments removed after a fracture by a spent ball. Spec. 5042, Sect. I, A. M. M. 'Nat. size.] Case.—Captain Alvin AI. W- -, Co. K, 17th NeAV York Volunteers, was wounded at the battle of Fredericksburg, Fig. 143.—Disk and fragment from a gunshot depressed fracture of the left parietal. Spec. 404U, Sect. I, A. M. M. A'irginia, December 13th, 1862, by a musket ball, which fractured the left parietal bone near the eminence. He walked Avith some assistance to the hospital of the Third Corps, a distance of more than a mile. His voice became thick and had an unnatural hesitancy and sloAvness. The middle and ring finger of the right hand were paralyzed, but the motion and sensibility in the first and fourth fingers Avere only slightly impaired. His mental faculties Avere clear. He complained of a slight headache and his pulse Avas sIoav and full. The trephine Avas applied by Assistant Surgeon LeAvis Tice, 17th NeAV 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 were approximated by adhesive strips, and cold water dressings were applied. During the operation, blood flowed profusely from the perforation. One large fragment of bone, evidently from 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 power of articulation returned immediately after the operation, and the numbness of the fingers became less marked. On January 2d, 1863, the paralysis of the fingers had entirely disappeared and the Avound AA-as healing by granulation. The patient Avas mustered out with his regiment on June 2d, 1863. The pathological specimen is No. 4049, Sect. I, A. AI. M., and was contributed by the operator. The Commissioner of Pensions reports that this officer was pensioned at 820 per month. A musket ball entered the upper portion of the right parietal bone; bones have been removed so that an irregular opening exists of the size of a silver dollar. Pension Examiner T. C. Pitt states that his right hand and tongue Avere partially paralyzed. Exercise produces violent throbbing at the Avound and at a point opposite on the back of the head. His general health is very poor, probably OAving to the constant irritation about the brain. CASE.-Private Joseph Wolf, Co. F, 7th NeAV York Heavy Artillery, aged 22 years, was wounded on April 3d, 1865, before Petersburg, Virginia, by a conoidal ball, which entered the scalp near the posterior superior angle of the right parietal bone, and glanced upward, denuding the bone of periosteum for a space one inch in circumference. He Avas on the same day admitted to the hospital of the 1st division, Second Corps, and thence conveyed to Washington, where he entered the Armory Square Hospital on the 12th, with complete paralysis of the left arm and leg. He was slightly comatose, but could easily be aroused, and answered questions intelligently; the pupils Avere contracted. An examina- tion revealed a fissure extending beyond the denuded portion, through which pus slowly exuded, but no depression Avas observed. Ether was administered on the 14th, and Surgeon D. AV. Bliss, U. S. V., applied the trephine. Upon removing the button of bone, a similar fissure through the internal table was discovered. The dura mater protruded through the mov'ed ^gunshoffra^e^orthe opening, and, upon puncturing the membrane, about three ounces of sero-sanguineous fluid ^t P"r>etal. Spec. 4105, Sect. I 2s4 WOUNDS AND INJURIES OF THE HEAD. escaped. The operation afforded no immediate relief to the patient, but at the end of six hours he could move his hand and foot, and on the folloAving day could raise his head. On the 20th, the Avound Avas granulating finely, and the patient doing Avell. He could move his leg and arm freely on the 26th, and Avas able to stand upon his feet. On May 1st the paralysis had almost disappeared, and the Avound Avas entirely covered Avith granulations. Taa-o days later a small circle of necrosed bone was removed from the external table. The patient Avas noAV able to Avalk about the Avard, and on the 26th, Avas transferred to the AA'hitehall Hospital, near Bristol, Pennsylvania, whence he Avas discharged from the service on June 20th, 1865. His claim for pension was -'pending" December 7th, 1871. The specimen is a disk of bone Avith a serrated fragment of the inner table of the right parietal bone, and is represented in the wood-cut. The disk is one inch in diameter, and is traversed by the line of fracture. The specimen was contributed by the operator, Surgeon I). W. Bliss, U. S. V. Case.—Private George A. Shaffer, Co. D, 190th Pennsylvania A'olunteers, aged 19 years, was Avounded at Five Forks, Alrginia, April 1st, 1865, by a conoidal ball, Avhich fractured the parietal bones at the junction of the coronal and the sagittal sutures, the fracture extending back about three inches over the sagittal suture. He Avas on the next day admitted to the hospital of the Fifth Corps, and on April 4th sent to the Lincoln Hospital at Washington. There Avas but slight evidence of compression, but on April 6th, he complained of pain in the head; the pupils became dilated, and coma supervened. He Avas placed under the 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 the dura mater intact. The patient was kept quiet in a recumbent position, cold applications Avere made to the head, and Ioav diet ordered. He recovered, and was discharged from the service on a surgeon's certificate of disability on June 24th, 1865. See Photographs of Surgical Cases, Vol. Ill, page 10. He is a pensioner. The case is reported by Surgeon J. C. McKee, U. S. A. The following remarkable instances of patients recovering sufficiently to resume their military duties are reported: Case.—Lieutenant H. S. Robinson, Co. G, 36th Alassachusetts Volunteers, received, at Blue Springs, Tennessee, October 12th, 1863, a gunshot depressed fracture of the right parietal bone. He was admitted into the hospital at Knoxville, Tennessee, the same day, where a portion of bone Avas removed by Hey's saw. He recovered, was returned to duty on December 26th, 1863, and was discharged fi-om the service on July 7th, 1864. He was a pensioner in 1867. Active exertion caused headache and a feeling of pressure on the brain. Case.—Corporal Phineas Bird, Co. C, 100th Pennsylvania Volunteers, aged 21 years, was wounded at the siege of Knoxville, Tennessee, November 20th, 1863, by a conoidal ball, AA'hich fissured the left parietal bone without depression. He was conveyed to Hospital No. 5, where, on November 25th, the bone was trephined. He was furloughed on February 17th, 1864, and shortly afterAvards returned to his regiment. On October 1st, he Avas admitted into the general hospital at Pittsburg, Pennsylvania, and, on the 20th, again returned,to duty. He does not appear to have been an applicant for pension. Case.—Asa D. Broody, bugler of the 7th Indiana Battery, aged 20 years, was Avounded at the battle of Kenesaw Mountain, Georgia, June 22d, 1864, by a conoidal musket ball, which fractured and depressed the right temporal bone. He was at once admitted to the 3d division, Fourteenth Corps, hospital, and thence sent to Chattanooga, Tennessee, where he arrived on the 29th of the month; tAvo days subsequently, however, he Avas transferred to Hospital No. 2, at Nashville. He recovered, was furloughed, and finally returned to duty on September 19th, 1864. This soldier was discharged the service December 7th, 1864, and Avas pensioned. On September 4th, 1866, Pension Examiner J. G. Hendricks reports that the operation of trephining had been performed. There was paralysis of the left arm, and the flexor tendons of the fingers Avere contracted. His disability is rated total and permanent. CASE.-Private Robert S. Erwin, Co. B, 86th Blinois Volunteers, aged 32 years, was wounded at Atlanta, Georgia, July 20th, 1864, by a conoidal ball, Avhich fractured the superior portion of the frontal bone, and lodged in the cranium. A portion of the fractured bone Avas driven into the substance of the brain. He Avas, on the same day, admitted to the field hospital of the 2d division, Fourteenth Corps; conveyed, on July 22d, to No. 2, Chattanooga, Tennessee, and thence sent to Nashville, where he 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 the trephine, and removed the fractured bone. The soft parts were SAVollen, and the dura mater lacerated. There was a free discharge of pus, of an unhealthy character, but the patient's constitutional condition Avas good. Simple dressings were applied to the wound. Erwin was transferred on December 12th, entered Jefferson Hospital, Jefferson- ville, Indiana, on the 13th, and Avas returned to duty on December 21st, 1864. He was again admitted into Jefferson Barracks Hospital, St. Louis, on January 10th, 1865; on the 14th of April sent to Small-pox Hospital; and for the second time returned to duty on June 3d, 1865. This soldier Avas discharged the service August 16th, 1865, and afterwards pensioned. On January 19th, 1870, Pension Examiner I. H. Reeder reports that the patient had been subject to frequent attacks of epilepsy since he Avas Avounded, AA'hich, within the last year had so increased in frequency and violence as to totally disqualify him for any kind of business or labor. He rates his disability total and permanent. CASE.-Private Wm. H. Freslnvater, Co. G, 45th Ohio Arolunteers, aged 18 years, Avas Avounded at Resaca, Georgia, May 14th, 1864, by a conoidal musket ball, Avhich fractured the left parietal bone. He was admitted to the hospital of the Twenty-third Corps on the same day. The trephine Avas 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 the 23d; to Clay Hospital, LouisA-ille, 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, returned on August 8th, and Avas sent to his regiment for duty on August llth, 1864. He was discharged June 12th, 1865, and pensioned. His disability is rated one-half and temporary. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 285 CASE.-Private Edward Gordon, Co. II, 6th NeAV York Cavalry, Avas Avounded while on picket near Yorktown, Virginia, September 18th, 1862, by a conoidal ball Avhich fractured and depressed the left parietal bone near the anterior inferior angle. He Avas admitted to the Nelson Hospital, being unable to speak, yet able to Avalk, and seemingly 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 Avas subject to violent convulsions, Avhich ceased as soon as the fragment had been removed. A pretty free hasmorrhage from the middle meningeal artery ceased spontaneously, apparently from pressure of the brain. The patient recovered rapidly and Avas returned to duty on December 10th, 1862. He is not a pensioner. CASE.-Private AA'illiam Hines, Co. A, 20th AVisconsin Volunteers, was wounded at Prairie Grove, Arkansas, December 7th, 1882, by a conoidal ball, Avhich 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, Avhen the man was admitted to the hospital at Keokuk, Iowa, suffering from typhoid fever. He Avas discharged from service on November 12th, 1863. It seems that he afterAvard re-enlisted in Co. D, 2d Wisconsin Cavalry, and served until January 2d, 1865, Avhen he was admitted to the Adams Hospital, Alemphis, Tennessee, on account of the injury received at Prairie Grove. The state of the patient Avas 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 Avas 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. On the fifth day after admission, he was placed under the influence of chloroform, AA'hen 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, saAved through the skull. After the operation the patient's progress was rapid. The treatment consisted of cold Avater dressings for thirty-six hours, AA'hen erysipelas set in, and tepid Avater dressings Avere 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 patient Avas going about the Avard, and expressed himself as feeling well and free from all the head symptons which had existed prior to the operation. On February 12th, 1865, he was returned to duty entirely recovered. The case is reported by the operator. This man Avas discharged the service November 15th, 1865, and pensioned. On September 16th, 1867, Pension Examiner W. A. Anderson reports that the patient suffers great nervous disability, Avhich is increased upon the least excitement. He is also blind in the right eye, the result of a kick by a mule at A'icksburg, Alississippi, 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 Avounded while on picket on December 4th, 1864. by a conoidal ball, which fractured the occipital bone. He Avas admitted on the same day to the field hospital of 2d division, Ninth Corps, where Surgeon L. AV. Bliss, 51st N'evy York Volunteers, trephined the skull. On the 7th, he Avas sent to City Point, A'irginia, where he remained in the depot field hospital of the Ninth Corps until the 20th, when he was transferred to the AIcKim's Alansion Hospital, Baltimore, Alaryland. On January 9th, 1865, he was sent to York, Pennsyl- vania, where he remained until April 17th, 1865, when he Avas returned to duty. This soldier was discharged the service June 20th, 1865. On December 14th, 1866, Pension Examiner A. \V. Woodhull reports that the man complained of much pain in the Avound. Upon a change of weather this Avas 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, llth Missouri Volunteers, aged 20 years, was wounded at Tupelo, Alississippi, July 14th, 1864, by a buckshot, which fractured the left parietal bone and lodged betAveen 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 folloAving day severe and frequent convulsions occurred. Acting Assistant Surgeon S. S. Jessup admin- istered chloroform, applied the trephine, and removed the buckshot and the depressed bone. Several convulsions occurred after the operation, but Avere 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, 1865, the patient was returned to duty. The case is reported by Surgeon J. G. Keenon, U. S. V. He is not a pensioner. CASE.-Private A. P. LoAvry, Co. I, 6th Iowa Volunteers, aged 19 years, Avas wounded in a skirmish on the Big Black River, Mississippi, July 6th, 1863, by a conoidal ball, which struck at a point two inches from and directly above the right ear, fractured the skull, and emerged two inches above and behind the wound of entrance. He Avas treated in the regimental hospital, where, on July 21st, Assistant Surgeon William S. Lambert, 6th IoAva 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. Alark's Hospital, Paducah, Kentucky, and, August 3d, sent to Alound City, Illinois. He stated that the first fifteen days after injury the wound Avas dressed Avith poultices, and that he Avas able to Walk about until July 10th, when the Avound became greatly inflamed. On admission to Mound City Hospital the wound had almost healed, and his health and appetite were good. He Avas furloughed on September 17th, 1883, and returned to duty December 2d, 1863. He Avas discharged 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 Ramsey, Co. H, 93d Pennsylvania Volunteers, aged 21 years, was Avounded at the battle of Chancellorsville, Virginia, Alay 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 Avas admitted into HareAvood Hospital, AVashington, Avhere Acting Assistant Surgeon O. D. Brooks applied the trephine, and removed the depressed portions of bone. Cold water dressings were applied to the Avound, 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 reported by the operator, Acting Assistant Surgeon O. D. Brooks. 2S6 WOUNDS AND INJURIES OF THE HEAD. Case.—Private James B. SaAvyer, Co. G, 27th Michigan A'olunteers, aged 25 years, Avas AA'ounded in an engagement near Petersburg A'irginia, October 27th, 1864, by a musket ball, which entered the frontal sinus above the left e}-e. He AA'as admitted into the field hospital of the 3d division, Ninth Corps, Avhere the operation of trephining was performed by Surgeon AW B. Fox, Hh Alichigan A'olunteers. He Avas subsequently transferred to the hospital of the Ninth Corps at City Point, and thence, on the 29th, to AA'ashington, entering HareAvood Hospital on the 31st. He recovered, and Avas returned to duty on February 10th, 1865. He is not recorded as a pensioner. Case.—Private Robert AV. Thompson, Co. D, 99th Pennsylvania A'olunteers. aged 18 years, Avas wounded at the battle of the AVilderness, A'irginia, Alay 5th, 1884, by a conoidal ball, AA'hich fractured and depressed the upper part of the occipital bone, and lodged. He Avas conveyed to AA'ashington, and entered Judiciary Square Hospital on the llth. On the folloAving day he Avas placed under the influence of ether, and Assistant Surgeon Alexander Ingram, U. S. A., trephined the skull, and removed the depressed portion of bone, beneath AA'hich the ball and a large firm clot Avere found. A piece of bone one inch long and half an inch Avide, 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 sAvelling, and completely closed the eyes. By the 19th, erysipelas had entirely disappeared, and the patient Avas nearly well. On the 27th of June, he Avas transferred to the Satterlee Hospital, Philadelphia, and on the 31st placed on duty as nurse; his wound being nearly healed. On November 28th, 1884. he Avas returned to duty. He is not a pensioner. Case.—Sergeant Alajor George AV. AVadsworth, 19th Alaine A'olunteers, aged 22 years, received, at the battle of Gettys- burg, Pennsylvania, July 3d, 1863, a depressed gunshot fracture of the cranium. He Avas admitted to the Seminary Hospital, and on July 7th sent to Alower Hospital, Philadelphia. At intervals convulsions occurred, supposed to have been caused by depression of internal table. On July 22d the trephine Avas applied, and the depressed portion of bone removed by Acting Assistant Surgeon David AIcLean. On September 10th, a piece fi-om the outer table came aAvay. On November 14th the Avound had nearly healed, and on December 4th, 1863, the patient Avas returned to duty. He was promoted to Lieutenant, and discharged June 30th, 1866, and pensioned. Pension Examiner Israel Putnam reports that the patient must aA-oid violent exercise and exposure to sun, being subject to vertigo. Case.—Private Charles E. AVood, Co. D, 14th NeAV A'ork Cavalry, aged 18 years, received, near Petersburg, Alrginia, June 22d, 1884. a gunshot fracture of the mastoid process of right temporal bone, also wound of right arm and hip. He Avas admitted to hospital 3d division, Ninth Corps, AA'here Surgeon A. F. AVheelan, 1st Alichigan Sharpshooters, excised spiculae of the temporal bone. On July 2d the patient Avas sent to Alount Pleasant Hospital, Washington, and on July 22d to MoAver Hospital, Philadelphia, AA-hence he Avas returned to duty September 27th, 1864. He is not a pensioner. Four patients recovered sufficiently to be returned to modified duty in the Veteran Reserve Corps : Case.—PriA-ate John G. Colgan, Co. F, 5th New Jersey Volunteers, aged 22 years, was wounded at the battle of Chancellorsville, A'irginia, Alay 3d, 1863, by a piece of shell, Avhich struck the upper portion of the frontal bone, causing a fracture Avith depression. He was conveyed to AA'ashington, and on May 9th admitted to HareAvood Hospital, Avhere the trephine Avas applied, and the depressed portion of bone removed. On Alay 30th, the wound was doing well, and on June 24th, 1863, the patient Avas transferred to Satterlee Hospital, Philadelphia, Avhere he Avas assigned to the 2d battalion, A'eteran Reserve Corps. This soldier Avas discharged the service November 22d, 1865, and pensioned. There Avas a large cicatrix. Avith depression from loss of the outer table of the os frontis, near the junction of the coronal and sagittal sutures, with tenderness upon pressure, and the patient complained of vertigo when exposed to the sun, or when undergoing active exercise. His disability is rated one-half, and probably permanent. Case.—Captain John AA'. Dempsey, Co. H, 82d NeAV York Arolunteers, received at the battle of Bull Run, Virginia, July 21st, 1861, a gunshot fracture of the skull. He Avas captured and not released until 1863, reaching AA'ashington July llth. The skull Avas trephined. He Avas furloughed on July 13th, and transferred to the Veteran Reserve Corps July 23d, 1863. Case.—Sergeant Frank AV. Douglass, Co. C, 141st Pennsylvania Volunteers, aged 20 years, Avas wounded at the battle of the AVilderness. A'irginia, Alay 6th, 1884, by 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 Hospital on Alay 13th. Thence he Avas sent to the AVest's Buildings Hospital, Baltimore, on the 16th, and finally transferred to York, Pennsylvania, on Alay 21st. On June 1st, Surgeon H. Palmer, U. S. A'., trephined the skull and removed thirty-four pieces of hone. He recovered, and on Alarch 7th, 1865, was transferred to the A'eteran Reserve Corps. The case is reported by the operator, Surgeon H. Palmer, U. S. A'. Douglass aa as a pensioner in 1869, his disability being regarded as three-fourths and permanent. The examining surgeon, Dr. Turner, reports that both tables had been driven in upon the brain; that the patient suffers pain, is incapable of much exposure to the sun, and is afflicted AA'ith loss of memory and sometimes unconsciousness. CASE.-Private Collis H. Smith, Co. E, 118th New A'ork A'olunteers, aged 30 years, was Avounded near Fort Darling, A'irginia, Alay 16th, 1864, by a conoidal ball, which fractured and depressed the frontal bone near the longitudinal sinus. He w as conveyed to the field hospital of the Eighteenth Corps, and on the 19th sent to the general hospital at Hampton, A'irginia. On Alay 26th, Acting Assistant Surgeon H. B. AVhite applied the trephine and removed several pieces of bone, giving exit to a large collection of pus. The patient AA'as in a comatose condition and the external parts AAere softened and much contused. The removal of the bone and consequent discharge of pus, in a manner relieved the coma, but the reaction Avas very sIoav. By June 3d, the wound Avas closed and. healing finely, and the patient was doing well. On October 15th, he Avas sent to the hospital at TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 287 Whitehall, Pennsylvania, and on January 20th, 1865, he Avas transferred to the Veteran Reserve Corps. The case is reported by Ely AlcClellan, Assistant Surgeon, U. S. A. This soldier Avas discharged the service September 4th, 1865, and was afterward pensioned. On Alay 12th, 1866, Pension Examiner George Page reports a depression at the original seat of injury. The patient suffered from cephalalgia, Avith occasional blindness and dizziness, and his memory Avas someAvhat affected. His disability 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 Patrick Lane, AA-as Avounded at Irish Bend, Louisiana, April 14th, 1863, by a conoidal ball, which fractured and depressed the right parietal bone at its posterior superior angle and lodged, carrying with it portions of cap and hair. Simple dressings Avere applied. Four days after the reception of the injury, epilepsy supervened, and Surgeon W. N. Trow- bridge, 23d Connecticut A'olunteers, removed tAvo buttons of bone Avith the trephine. No further treatment is recorded, but the report of Surgeon AV. N. Trowbridge states that the patient recovered. Case.—Private James H. Richardson, Co. B, 19th Louisiana Regiment, was Avounded at the battle of Shiloh, Tennessee, April 7th, 1862, by a round musket ball, Avhich caused a depressed fracture of the cranium. He Avas admitted into Hospital No. 3, Evansville, Indiana, April 18th, 1862, being at the time in a state of general paralysis. The operation of trephining was soon afterward performed. The patient improved sloAvly, and on August 31st, Avas enabled to walk. On November 30th, he Avas transferred to Indianapolis, Indiana, and paroled on November 26th, 1862, still suffering from paralysis. Case.—Private John Cotton, Co. G, 17th Georgia Regiment, aged 23 years, received at Cedar Run, ATirginia, August 9th, 1862, a gunshot fracture of the cranium, near the left parietal protuberance. The internal table Avas injured to a greater extent than the external plate. He Avas admitted into the Confederate hospital at Charlottesville, Virginia. On September 14th, the trephine Avas applied, and several pieces of bone Avere removed. The mind Avas not affected by the operation, but there Avas slight paralysis of the right side of the body. Ten days after the operation, erysipelas supervened, but was readily subdued. The patient did Avell, constantly improving until October 9th, 1862, Avhen he was furloughed. The wound had entirely healed. Case.—Private J. W. Hambleton, of Latham'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 parietal bone. AVhen he was admitted into the Confederate hospital at Charlottesville, Virginia, on August llth, his mental and physical faculties Avere unimpaired. On the 24th the trephine Avas applied, and all fragments of bone were removed. About a Aveek after the operation the patient had a slight attack of erysipelas ofthe scalp, but soon recovered from it. In Alarch, 1865, he had entirely recovered, but Avas injuriously affected Avhen exposed to the heat of the sun. The case is reported by Assistant Surgeon B. AV. Allen, P. A. C. S. Case.—Private J------ F------, 9th Louisiana Regiment, was Avounded at the battle of Alurfreesboro', Tennessee, December 29th and 30th, 1862, by a shell, Avhich struck over the right parietal bone, causing a contusion Avithout producing any external wound, but depressing nearly one-half of the bone, leaving a cavity of considerable size. When admitted to the Lagrange Hospital his health AA'as very poor; the left side was paralyzed and his intellect obtuse; the extremities were cedematous. 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, Avhose apex was removed by the trephine. The dura mater Avas in very good condition, though traces of inflammation were evident. A marked improvement manifested itself in a few days. His appetite improved, the oedema disappeared, and he was soon able to Avalk about the Avard. Case.—Corporal J. A. Gray, Co. I, 12th Alississippi Regiment, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a fragment of shell, Avhich struck the left parietal bone at the posterior superior angle, depressing both tables fully half an inch. He was conveyed to Washington, and on Alay 7th admitted to St. Aloysius Hospital. No untoward symptoms occurred until Alay 9th, when he was attacked by epileptiform convulsions, with complete loss of consciousness. On the folloAving day the trephine Avas applied, and a button of bone, consisting of the external table only, Avas remoA'ed from the interior edge of the fracture. Fragments of the external table Avere then removed which had been driven backAvard betAveen the tables beyond the point of fracture, depressing, to a considerable extent, the inner table, AA'hich presented on its exposed surface no fracture or even fissure. It being deemed that the removal 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 Avithout applying the trephine in a new position, it was determined to leave the case without further interference, unless symptoms of convulsions recurred. Ice was applied, and no untOAvard symptoms occurred. The inner table partially resumed its natural position, and became covered with new granulations. He Avas doing well on July 27th, 1863, and Avas sent to provost marshal's office August 25th, 1863. The following thirty-five cases recovered after trephining for gunshot fractures of the skull, with different degrees of physical disability, and Avere discharged from service: Case.—Private John H. Ballard, Co. B, 42d Indiana Volunteers, aged 26 years, was wounded at Dallas, Georgia, Alay 25th, 1864, by a conoidal ball, Avhich fractured the left frontal and temporal bones. He Avas admitted to the hospital of the 1st division, Fourteenth Corps, on May 27th, where the skull Avas trephined, and three inches of bone Avere removed. He Avas sent to the field hospital, Chattanooga, Tennessee, on June 2d; transferred to the Cumberland Hospital, Nashville, on the 3d; and thence furloughed on July 30th, and ordered to report to the medical director at the expiration of his leave. On September 13th he was admitted to general hospital, Evansville, Indiana, and discharged from service on February 13th, 1865, by reason of loss of vision of left eye. The case is reported by Surgeon G. Perin, U. S. A. Ballard was pensioned. On February 23d, 1865, 288 WOUNDS AND INJURIES OF THE HEAD. Pension Examiner B. J. Day, of EvansA'ille, Indiana, reports that the Avound has several times reopened, and that a piece of lead was removed. The man suffers from pain in head and dizziness. Case.—Corporal AA'. XV. Barlow, Co. B, 1st Alaine Cavalry, aged 23 years, was wounded at Dinwiddie Court-house, A'irginia, Alarch 31st, 1855, by a conoidal musket ball, AA'hich caused a compound fracture of outer table of the os frontis, left side, Avith compound comminution of inner table. He avus admitted into the Cavalry Corps Hospital at City Point, A'irginia, on the following day, and transferred on April 4th to AA'ashington, per hospital steamer Thomas PoAvell, entering Alount Pleasant Hospital on the same day. The case progressed favorably until the morning of the 7th, AA'hen the patient had convulsions, folloAved by intense headache. The fractured portion of the outer table Avas then removed. On the following day ether and chloroform Avas administered, and Assistant Surgeon H. Allen, U. S. A., removed two large pieces of the inner table through the opening which had been enlarged by the trephine. Small fragments of bone came aAvay from time to time, but the ease progressed favorably, and on the June 15th, 1865, the patient Avas discharged from the service and pensioned. His disability is total. Case.—Captain A. V. Barber, Co. C, 31st Ohio A7olunteers, aged 25 years, was Avounded near Atlanta, Georgia, August Sth, 1864, by a ball, AA'hich entered tAvo inches above the left orbital plate, fracturing the frontal bone. He was admitted to the field hospital of the 3d division, Fourteenth Corps, on the same day, and on August 27th Avas transferred to the hospital at Chattanooga, Tennessee. On September 10th, the patient Avas sent to the Officers' Hospital, at Lookout Alountain. Trephining Avas resorted to, and a portion of bone one inch in diameter Avas removed. The Avound gradually healed; a cartilaginous septum taking the place of the removed disk of bone. He resigned on December 15th, 1864, and is not a pensioner. Case.—Private Lorenzo Beaver, Co. E, 76th NeAV York Volunteers, aged 24 years, Avas wounded at Gettysburg, July 1st, 1863. by a piece of shell, which fractured the cranium. He was conveyed to Seminary Hospital, Gettysburg, thence Avas sent to McKim's Alansion Hospital, at Baltimore, where he received a furlough on October 17th. At its expiration he entered the post hospital, Albany, New A'ork. The operation of trephining had been performed some time previously, but at Avhat date cannot be exactly ascertained. He Avas transferred to Baltimore, readmitted into McKim's Alansion Hospital on December 9th, and Avas transferred to Jarvis Hospital, Baltimore, Avhere he was discharged the service on February 5th, 1864. On Alay 16th, 1864, Pension Examiner S. D. AVillard reports that the man suffers from dizziness on bending or stooping. Being unable to bear exposure to the sun, and subject to epilepsy, he was entirely unable to labor. His disability is rated total and permanent. Case.—Private AVesley Bonnett, Co. D, lilth NeAV A'ork A'olunteers, Avas wounded at the battle of Gettysburg, Pennsylvania, July 3d, 1863, by a conoidal musket-ball, AA'hich fractured the right parietal bone. A feAV pieces of bone, and the ball, which Avas split in its long diameter, Avere removed on the field. He had received in the same engagement a penetrating Avound of the lower lobe of right lung. He Avas taken to the regimental hospital, thence sent to Letterman Hospital, and on September 8th, 1863, admitted to AloAver Hospital, Philadelphia. The Avound of chest had entirely healed, and the patient's health Avas good. He stated that he had been attacked, about four days after the reception of the injury, by epileptiform convulsions, Avhich continued at intervals of tAvo days until July 16th, when they ceased; but on September 5th they returned Avith increased violence. On September 9th, eight small fragments Avere removed. On September 16th, a convulsion threatened, but Avas Avarded off by counter irritation and half a grain of morphia. On the 20th convulsions suddenly occurred, and recurred twice aftenvard on the 26th and the 27th, followed each time by slight fever. On September 30th, the patient Avas doing well Avith the exception of some headache occasionally, and the wound Avas healing kindly. He Avas discharged from the service on November 2d, 1863. From January, 1864, to Alay, 1868, with the exception of one interval of forty days, he had tAvo or three convulsive seizures a Aveek. On May 25th, 1868, the trephine Avas applied by Dr. Darwin Colvin, and some depressed bone removed. A large piece of semi-osseous material was removed by Hey's saAv. and also two spurs of bone, Avhich dipped doAvn so that some pressure must have been constant upon the brain. In July, 1868, the Avound had closed Avith healthy granulations, and the patient Avas nearly Avell. A complete history of the operation is published in the NeAV York Aledical Journal, vol. 7, page 422. The man is not a pensioner. Case.—Private Sterling Bunnel, Co. G, 6th Connecticut A'olunteers, aged 22 years, was Avounded at Bermuda Hundred, A'irginia, Alay 20th, 1864, by a conoidal ball, which fractured the right frontal bone, near its union Avith the parietal. He Avas admitted on the folloAving day into the hospital at Hampton, Virginia, and thence transferred, on June 3d, to the Knight Hospital, New Haven, Connecticut, Avhere he arrived on the 7th. Hemorrhage had occurred the day previous, and the patient was very feeble. The Avound looked healthy, and the case progressed favorably until the morning of the 12th, when severe hemorrhage recurred from a branch of the anterior temporal artery. The bleeding vessel was ligated, and the hemorrhage ceased. On June 16, 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 July 2d, severe convulsions, followed by loss of consciousness, supervened. The wound was carefully examined, but no depression could be discovered. An accumulation of pus being diagnosed, Acting Assistant Surgeon S. D. AVilcoxson applied the trephine. No pus was found, but a slight depression of the inner table was discovered and elevated. Low diet and perfect quiet were enjoined. No unfavorable symptoms recurred. The patient was furloughed on August 6th, 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 September 3d, 1664, he was discharged from the service; his term of service having expired. The case is reported by the operator, Acting Assistant Surgeon S. D. AVilcoxson. On October 20th, 1864, Pension Examiner Henry Pierpont reports that the wound had not perfectly healed. The right eye was affected, and pulsation was plainly visible. Any excitement, or even a short Avalk, caused severe pain. His disability is rated total and temporary. Further information states that in 1869 Bunnel's disability was considered total. A portion of the skull four and three-fourths by one and three-fourths inches was missing. The pulsations of the brain were plainly visible, and excitement caused severe pain. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 289 Case.—Private AA'illiam Burt, Co. G, 2d NeAV York Heavy Artillery, aged 30 years, Avas Avounded near Petersburg, Virginia, June 17th, 1864, by a conoidal ball, which fractured and depressed the left parietal bone. He Avas admitted to the Second Corps field hospital at City Point, on June 19th, and conveyed to the Campbell Hospital, AVashington, on the 28th. He Avas in a stupid condition, and the right arm and log had become paralyzed. On the following day, Surgeon A. F. Sheldon, U. S. A'., removed about one and a half inches square of depressed bone Avith 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, Avhere he remained until the 24th of August, AA'hen he Avas sent to the McDougall Hospital, Fort Schuyler, NeAV A'ork Harbor. He Avas discharged the service on December 15th, 1864. On August 13th, 1865, Pension Examiner E. Bradley reports that the patient's hearing and eyesight are very poor. There was partial hemiplegia ofthe right side, accompanied by anemia and Aveakness to such a degree as to incapacitate him for any manual labor. It appears that this man's health continued to deteriorate, as his pension Avas subsequently increased. Case.—PriA-ate George AV. Burton, Co. E, 5th AA'isconsin Volunteers, aged 21 years, received, near Petersburg, Virginia, April 2d, 1865, a compound fracture of the occipital bone, and also a fracture of the left tibia. He Avas admitted to hospital 1st division, Sixth Corps, Avhere the skull Avas trephined, and a portion of the left tibia excised. He Avas, on April 10th, admitted to Broad and Cherry Streets Hospital, Philadelphia, and on May 8th sent to Satterlee Hospital, Avhere he Avas discharged from the service July 24th, 1865. He Avas pensioned, and in July, 1865, Pension Examiner E. A. Smith rated his disability total and permanent. The pulsation of brain was still visible. The leg Avas 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 Avas admitted to a Confederate field hospital near Perryville, Avhere the skull AA'as trephined. He was discharged October 24th, 1862. Case.—Private George AA'. Coates, Co. F, 8th Minnesota Volunteers, aged 18 years, was wounded at Alurf'reesboro', Tennessee, December 7th, 1864, by a conoidal ball, AA'hich 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 Avound was hot and painful. Violent and frequent epileptic convulsions commenced on the third day after the injury. On the llth he was groyving stupid, with tonic spasm ofthe muscles of the jaw and neck, and irregular and depressed pulse. He Avas placed under the influence of chloroform, and Surgeon Samuel D. Turney, U. S. X., trephined -a portion of the inner table. Considerable hemorrhage from the veins of the diploe ensued. He reacted promptly. A silver plate Avas inserted, and'Avater-dressings were' applied, and cathartics administered. The convulsions diminished in frequency and A'iolence, and finally ceased entirely. On February 16th, 1865, the patient Avas transferred to Hospital No. 2, Nashville, Tennessee, and furloughed on February 28th, 1865. On April 2d he was admitted to the hospital at Murfreesboro', and Avas discharged from service July 4th, 1865. The case is reported by the operator. On August 2d, 1865, Pension Examiner S. AA'illey reported that the patient was Aveak and anemic. The right limbs Avere smaller than the left, the pupils Avere dilated, and there Avas inability to distinguish objects with the left eye. His disability is rated total and temporary. Case.—Private Andrew Cole, Co. D, 145th Pennsylvania Volunteers, was Avounded at the battle of Fredericksburg, A'irginia, December 13th, 1862, by a conoidal ball, which fractured the frontal bone, right side, near the coronal suture. Another ball passed through the muscular substance ofthe thigh. He Avas admitted to Harewood Hospital, Washington, December 17th, 1862. On December 23d the skull was trephined, and loose fragments of bone Avere removed. No inflammation existed, and Avound suppurated freely ; several pieces of bone Avere remoA'ed at different periods, but in Alarch, 1863, the Avound had nearly healed. He Avas discharged December 21st, 1863, and pensioned. In February, 1864, Pension Examiner D. E. Belknap reports that the wound is still open and discharging, and that more bone Avill probably come away. The disability is rated total. Case.—Private Russell AI. Cool, Co. E, 9th Illinois A'olunteers, aged 19 years, was wounded at Fort Donelson, Tennessee, February 15th, 1862, by a conoidal musket ball, AA'hich 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, AA'hen 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 Avere removed; the largest Avas 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 Avas 85, the breathing natural, and the appetite good. Cold Avater dressings Avere applied. In about a Aveek sloughing commenced and increased the size of the Avound to five inches in length, by one inch in breadth. Two Aveeks after admission, Cool Avas furloughed. He returned to the hospital on June 21st, and Avas discharged the service on the following day. In the early part of 1866, he Avas examined by Pension Examiner Thomas S. Stamvay, who states that " a little to the left of the junction of the parietal and occipital bones a depression is found, which Avould hold about two drachms of fluid. The man's health Avas good, but exposure to the sun's rays 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 NeAV York Volunteers, aged 48 years, Avas wounded at the battle of the Wilderness, Virginia, May 5th, 1864, by a musket ball, which struck anterior to the superior angle of the occipital bone, fracturing both tables of the skull and depressing a portion of the bone to the extent of one-fourth of an inch. He was conveyed to Alexandria, Virginia, and entered the 3d division hospital on Alay 12th. Little, if any, constitutional disturbance existed; the patient ate and slept well and Avas able to walk about. On the 16th, he AA-as placed under the influence of chloroform and ether, equal parts, and Surgeon Edwin Bentley, U. S. V., trephined the skull, removed a few small fragments, and elevated the depressed bone. No hemorrhage folloAved the operation. Cold water dressings were applied, the head slightly elevated, and quiet and abstemious diet strictly enjoined. The case progressed without any untoward symptoms. On June 25th some small 37 290 WOUNDS AND INJURIES OF THE HEAD. pieces of skull and shreds of cloth were removed from the AA-ound. 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, ls<54, he Avas discharged from the service on surgeon's certificate of disability, by reason of dizziness and headache AA'hich 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. A'. On January 28th, ]H70, Pension Examiner J. AV. FoAvard reports from the National Alilitary Asylum at Augusta, Alaine, (of which institution the patient Avas an inmate,) that there was a deep indentation at the seat of the Avound. There Avas complete loss of sight of left eye and the A'ision of the right eye was much impaired. The patient suffered from headache, dizziness, temporary loss of sight of right eye, and Avas unable to remain in the sun or perform any labor requiring stooping or much exertion. Since he Avas Avounded he was subject to fits of an epileptiform character, AA'hich supervened upon unusual exertion. His disability is rated total and permanent. Case.—Corporal E. Eugene Flagg, Co. K, 94th Blinois A'olunteers, was Avounded at the battle of Prairie Grove, Arkansas, December 7th, 1862, by a conoidal musket ball, which fractured and depressed the cranium tAvo inches posterior to the coronal, and one and one-fourth inches to the left of the sagittal suture. Assistant Surgeon Archibald E. Stewart, 94th Blinois A'olun- teers, trephined the skull, and removed all fragments of bone, on the field. The patient Avas immediately admitted to the field hospital at Prairie Grove. In the beginning of January, 1863, his condition Avas favorable and daily improving, but the right leg was partially paralyzed. He Avas 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 Alay 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 Avas 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, Avas Avounded before Petersburg, Virginia, July 30th, 1864, by a shell, which fractured the cranium. He Avas at once admitted into the hospital 4th diA'ision, Ninth Corps, Avhere, on August 2d, Surgeon David Mackay, 29th U. S. Colored Troops, trephined the skull, and removed one and one-fourth inches of right parietal bone, AA'hile the patient Avas under the influence of chloroform. He was, on August 3d, transferred to hospital for colored troops at City Point, Avhere he remained until August 8th, Avhen he Avas transferred to L'Ouverture Hospital, Alexandria. The left arm and leg Avere paralyzed. He Avas discharged the service on June 8th, 1865. On Alay 15th, 1866, Pension Examiner B. Gesner 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 NeAV Jersey A'olunteers, was wounded at the battle of AVilliamsburg, A'irginia, May 5th, 1862, by a musket ball, Avhich fractured and carried away a portion of both tables of the parietal bone near the central part of the sagittal suture. The brain Avas involved. For several weeks he remained in the field hospital. On June 12th, 1862, he Avas admitted into the AVood Street Hospital, Philadelphia. The Avound healed, and the patient Avas discharged from service on August 8th. 1862, in consequence of a partial paralysis of the right side. The case is reported by Assistant Surgeon C. AV. Horner, U. S. A'. On January 25th, 1867, Pension Examiner AV. S. Combs reports that the operation of trephining had been performed. The result Avas 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 Aliimesota Volunteers, aged 24 years, Avas wounded on August 9th, 1864, during a skirmish on the Tallahatchie River, Alississippi, by a conoidal ball, Avhich 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 Avas conveyed to Alemphis, Tennessee, and entered the Jackson Hospital on the 12th. The lower extremities Avere paralyzed. The pulse Avas 85, feeble and compressible, and his spirits Avere very much depressed. The soft parts around the injury yvere extensively lacerated, and the depressed bone Avas so Avedged that it was impossible to move it Avith an elevator. A few hours after admission, he Avas placed 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 Avere then brought together again by sutures. The patient reacted promptly. Ice Avater dressings were applied to the wound, drastic purgatives administered, and the patient placed on Ioav diet. The paralytic condition ceased within a week after the operation, and progress Avas rapid. On October 6th, he Avas furloughed, the Avound being nearly healed. He reported at the general hospital at Fort Suelling, Aliimesota, on November 30th, 1864. and Avas discharged from the service on April 29th, 1865. 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 betAveen the frontal and occipital bones; had pain in head, perverted sensation in the limbs, and physical exercise produced* a mental condition in Avhich he Avas unable to recognize his most intimate friends. He is a pensioner. Case.—Private Franklin Harris, Co. E, 145th Pennsylvania A'olunteers, Avas Avounded at the battle of Fredericksburg, A'irginia, December 13th, 1862. by a conoidal ball, Avhich fractured both tables of the left parietal bone, depressing the inner table ; he also received flesh wounds of left shoulder and right hand. He Avas taken to the field hospital of Hancock division, Second Corps, where, on December 22d, the trephine was applied, and fragments Avere removed and the edges of bone elevated. The patient improved gradually ; was transferred to Broad and Prime Streets Hospital, Philadelphia, on January 6th, 1863, and thence sent to South Street Hospital, on January llth. The brain pulsations Avere distinctly visible. Small pieces of bone came away nearly eA-ery day, but the scalp Avas granulating freely, and disposed to close over the opening. On January 2Uth, there being a boggy feeling in the A*icinity of the Avound, and considerable discharge from betAveen it and the bone, free incisions were made in the scalp by Acting Assistant Surgeon J. Walter Tryon. By February 15th the discharge of pieces of bone had ceased; the patient had become drowsy and listless, but the discharge from beneath the scalp continued. Iron, quinine, and TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 291 beef tea Avere ordered. The patient's general condition Avas much improved, and the wound had nearly closed by the 23d of Alarch, but he complained of much pain over the left eyebrow. He was discharged from the service on May 6th, 1863. 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, 1862, by a shell, AA'hich 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, yvhen be Avas conveyed per steamer Star of the South to NeAV A'ork City, entering St. Joseph's Hospital, Central Park, January 1st, 1863. He suffered from cephalalgia, occasional attacks of vertigo, and impairment of intellect. He Avas discharged February 2d, 1863, and pensioned. In May, 1864, Pension Examiner W. EllsAvorth reports that the operation of trephining has apparently been performed ; that the patient has pain in the head Avhen exposed to the sun. Partial loss of thumb interferes materially with his work. The disability is one-third and permanent. Case.—Private Alvan A. Hasty, Co. K, 38th Alassachusetts Volunteers, was, on June 17th, 1863, admitted to St. Louis Hospital, NeAV Orleans, Louisiana, with a gunshot Avound of the cranium. The operation of trephining Avas performed. The patient recovered ; Avas furloughed on September 6th, and discharged December 15th, 1863, and pensioned. Pension Examiner George Stevens Jones reports that he suffers from pain in 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 AA'illiam H. Hurst, Co. I, 150th Pennsylvania Volunteers, aged 22 years, was wounded before Petersburg, A'irginia, July 15th, 1864, by a piece of shell, Avhich fractured the left parietal bone, Avithout 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, AVillet's Point, New l'ork Harbor, where he remained until September 21st, when he was sent to the Cuyler Hospital, Germantown, Pennsylvania. On May 10th, 1865, he Avas transferred to the AIoAver Hospital, Philadelphia. Only simple dressings had been applied to the Avound up to this time. It seems that at this latter hospital the operation of trephining was performed. The man recovered, and Avas discharged fi-om serA-ice 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. He rates the patient's disability one-half and probably permanent. A communication from the Commissioner of Pensions, dated Alarch, 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 Avounded 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 Avas rendered insensible by the shock, but soon recovered, and was carried to the hospital on Alorris 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 AA'as transferred by steamer to the McDougal 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 Avas able to walk about; indeed, he declared that he felt well. On February 12th, 1864, he was sent to the DeCamp Hospital, and on June 21st, 1864, discharged from service at his OAvn request. On August 29th, 1866, Pension Examiner W. Ramsey reports that the operation for trephining had been performed, and that the patient then complained of pain in the head, and dizziness. He Avas compelled to avoid mental as well as physical labor. His disability is rated one-half and permanent. Case.—Private Ambrose F. Jackson, Co. G, 7th Rhode Island Volunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot injury of the cranium. He Avas 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, Avhere he was discharged on June 10th, 1863. 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 Avounded. He recommends that the patient should have a full pension. Case.—Private Hezekiel Jackson, Co. K, 39th U. S. Colored Troops, aged 24 years, Avas wounded near Petersburg, Virginia, July 30th, 1864, by a shell, which fractured the right parietal bone. He also received a Avound of right leg. He Avas admitted to hospital 4th division, Ninth Corps, Avhere 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 Avere removed. He Avas, on the same day, transferred to hospital for colored troops at City Point, Virginia, where he remained until August 8th, Avhen he was sent to L'Ouverture 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 Avas admitted into Capitol Hospital, Washington, on the 23d, and thence transferred to the De Camp Hospital, David's Island, New A'ork Harbor, on the 28th. On October 3d, Acting Assistant Surgeon AVilliam K. Cleveland applied the trephine to the point of fracture, and removed two pieces of the depressed internal table an inch and a quarter in diameter. A feAV 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 Avas discharged from the service on December 4th, 1862. The case is reported by Surgeon S. AV. Gross, U. S. V. On December 23d, 1869, Pension Examiner D. L. Beeser, reports that the parts are well closed by a firm tissue, and that the patient alleges to suffer neuralgic pains and vertigo at times. His general appearance Avas good, and he seemed robust and healthy. He rates his disability at one-third. His claim for a pension Avas pending at the aboA-e date. 292 WOUNDS AND INJURIES OF THE HEAD. Case.—Private John R. Kell, Co. G, 22d Illinois A'olunteers, received, at the battle of Belmont, Alissouri, November 7th 1861, a depressed fracture of both tables of the occipital bone, about one inch to the right of lateral sinus. He Avas conveyed bv steamer to Mound City, Illinois, and entered the hospital at that place on the 13th. Surgeon E. C. Franklin, 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 Avas found driven into the substance of the brain. The case progressed favorably, and on January 22d, 1863, Kell Avas furloughed. He subsequently returned to his regiment, and Avas 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, Avas 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, Ncav Albany, Indiana. The AA-ound Avas doing Avell, and there Avere no indications of injury to the brain. He continued to improve for Iavo Aveeks, when he became restless at night and slightly delirious. On October 28th, symptoms of compression appeared, and an operation became necessary. Taao sections of the injured bone Avere removed Avith the trephine. The inner table avus found to be greatly comminuted, but there Avas no evidence of pus having formed in the brain. For several days he had yvild delirium, which finally gave way to active purgation. He recovered, Avith the exception of a slight nervous derangement, and was discharged December 4th, 1862. The case is reported by Acting Assistant Surgeon M. N. Elrod. On January 21st, 1863, Pension Examiner George AV. Alears reports that the Avound had healed, and that the man, although previously yveak, then labored Avithout inconvenience or pain in the head. He rated him as not disabled. A communication from the Commissioner of Pensions, dated January 3d, 1868, states that Loughrey is not entitled to a pension, having been rejected by the examining surgeon July 17th, 1863. Case.—Private Thomas A. Moore, Co. K, 33d Missouri Volunteers, aged 23 years, Avas wounded 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 AA'as conveyed to Alemphis, Tennessee, and admitted into the Gayoso Hospital on the 7th, with slight symptoms of compression. Acting Assistant Surgeon S. Leslie performed the operation of trephining, leaving an opening an inch and three-fourths by one inch. The depressed portion of bone was much comminuted, and a portion ofthe ball was Avedged into the fracture. A large quantity of blood was found in the brain. The following day the patient was doing well. AVater dressings and low diet Avere ordered. On the 9th, and again on the llth and 12th, hemorrhage occurred from the wound, amounting to tAA'elve or thirteen ounces; otherwise the case progressed without any untoAvard symptoms, and on September 1st Aloore 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, 1868, Pension Examiner J. Bates reports that the patient suffered from headache, frequent giddiness, and a conscious failure of memory. He Avas unable to perform any manual labor. His disability is rated total and permanent. Case,—Private Lewellyn Alowry, Co. B, 25th Alassachusetts Volunteers, aged 18 years, Avas wounded at Cold Harbor, Virginia, June 3d, 1864, by a conoidal ball, Avhich entered over the left eye at the outer margin of the superciliary ridge, fractured the bone and lodged. He Avas sent to Washington, and on June 8th was admitted to Finley Hospital On November 1st, he Avas transferred to the hospital at Readville, Alassachusetts, and on December 20th, 1864, was discharged the service. The vision of the left eye was 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 shape, with equal sides, one inch long. The frontal bone AA'as rough, and at tAvo points a probe could be passed through 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 profusely, and the patient Avas very feeble. On October 2d, 1868, Dr. Metcalf states that the wound had healed, leaving an indentation about three-fourths of an inch deep. The patient's disability is rated total and permanent. Case—Corporal Ira B. Newkirk, Co. E, 5th AVisconsin Volunteers, aged 23 years, was Avounded May 5th, 1864, at the battle of the AVilderness, Virginia, by a conoidal ball, Avhich fractured and depressed the os frontis above the superciliary ridge. He Avas admitted into Judiciary Square Hospital, AA'ashington, on the llth. Tavo days later he was 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 depressed bone, a portion of which was pressing on the dura mater. The parts Avere brought into apposition, and tAvo sutures applied. The patient's constitutional condition Avas very good. Ice Avater dressings were applied, and saline cathartics administered. No untoward symptoms occurred, and on July 16th the patient Avas returned to his regiment. He was discharged July 30th, 1864. He is not a pensioner. • Case.—Private William G. Parker, Co. A, 76th New York Volunteers, aged 32 years, was Avounded at the battle of Cold Harbor, A'irginia, June 2d, 1864, by a conoidal ball, which fractured the cranium. He Avas, on the following day, admitted to the hospital of the 4th division, Fifth Corps, where the operation of trephining was performed. On June 12th, he Avas sent to the Campbell Hospital, AVashington, where he Avas discharged from the service on July 10th, 1865. He 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 Alichigan Cavalry, temporarily assigned to the 27th Michigan Sharpshooters, aged 43 years, Avas Avounded at the battle of Spottsylvania Court-house, Virginia, Alay 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 Corps, and thence conveyed to AVashington, Avhere he entered Harewood Hospital on the 25th. The skull Avas trephined and simple dressings Avere applied. He recovered rapidly, avus furloughed on June 28th, and discharged from the service on October 22d, 1*61, by reason of expiration of term of service. He is not a pensioner. TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 293 Case.—Corporal George W. Phillips, Co. B, 30th Indiana Volunteers, aged 21 years, was wounded during the siege of Nashville, Tennessee, December 16th, 1864, by a shell, which fractured the cranium at the posterior fontanelle. Portions of the bone Avere removed on the field, while the patient was in a state of partial insensibility. He was admitted to the hospital of the 3d division, Fourth Corps, and thence conveyed to Nashville, Avhere he Avas admitted to Hospital No. 3 on the following day. On January 8th, 1865, he Avas 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 ofthe 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 Avas good. Cold Avater dressings were applied. He Avas discharged from the service on Alay 26th, 1865, the Avound having healed, except a small sinus. There Avas a crucial cicatrix two inches long from before backward, and one inch Avide, a depression 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 reported 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 he could not bear exposure to heat without falling over. He rates his disability permanent. Case.—Private John Shaffer, Co. D, 18th Alissouri Volunteers, aged 38 years, was wounded at the battle of Shiloh, Tennessee, April 7th, 1862, by a conoidal ball, Avhich fractured the left parietal bone, near the sagittal suture. He was taken prisoner, and probably remained in the hands of the enemy 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, Alound City, Illinois. The records of the latter hospital state that the trephine had been applied, 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 Avas suffering from headache and epilepsy, On the 22d of the same month he was transferred to Jefferson Barracks, Alissouri, and discharged from the service March 1st, 1865. He is not a pensioner. Case.—Private M. F. Sheffler, Co. E, 39th Blinois 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 inches from the apex of the frontal bone. The injury at the time Avas considered a slight scalp wound, which healed rapidly. The patient was placed on light duty, and no bad symptoms Avere 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 ofthe spine. On his second visit he told Dr. Johnson that he had been Avounded 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. AI. Clark, who decided on an operation, which he performed on December 9th, 1867. Ether Avas administered to the patient, and a crucial incision made through the scalp and the flap turned back; the periosteum Avas scraped off, when the bone immediately over the fracture seemed loose in texture, and blood began to ooze from the Avound. The trephine was applied by Surgeon C. AI. 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 anesthetic before the section Avas complete; sensation and motion returned the instant it Avas lifted, and he walked unaided to his bed. On the folloAving day a mild aperient was given; he rested well, but had a slight chill in the morning. On the 12th, there Avas still slight numbness about the perineum; the wound had united except at point of incision, Avhere 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 not a pensioner. Case.—Private Nelson J. Ward, Co. K, 62d Ohio Arolunteers, 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 parietal bone. He Avas immediately conveyed to the field hospital of the Twenty-fourth Corps, where the depressed portion of bone Avas removed Avith the trephine by Surgeon S. A. Richardson, 13th NeAV Hampshire Volunteers. On April 10th, he was transferred, and on the 17th entered the hospital at Point of Rocks, Virginia. He was, on Alay 16th, sent to the West's Buildings Hospital, Baltimore • on Alay 22d, to the Jarvis Hospital; on July 24th, to the Hicks Hospital, and finally discharged from the service on August 26th, 1865, and pensioned. In June, 1866, Pension Examiner G. W. Livesay reports that the man has frequent attacks of epilepsy, sometimes several within twenty-four hours, and that the disability is permanent. Hernia Cerebri.—This complication was observed not infrequently: Case.—Private W. A. Baden, Co. E, 1st Maryland Cavalry, Avas 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 doAvn- Avard and backward, and made its exit in a track of one and a half inches in length. He Avas admitted to the Chimborazo Hospital, Richmond, A'irginia, October 19th, 1863, at which time he could give no account of himself, seemed timid, shy, and easily agitated. On October 22d, the scalp Avas 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 Avith probe and forceps. 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, the protruded brain began to disappear by suppuration, and had disappeared entirely by October 31st, when the patient Avas someAvhat more intelligent. On November 3d, an abscess appeared over the occipital bone a little to the left of the median line and about four inches from vertex, which was opened. On examination a 294 WOUNDS AND INJURIES OF THE HEAD. fracture of the occipital bone was discovered. The outer table Avas elevated and a piece of lead was found closely impacted between the plates ; all attempts to remove it without trephining proved ineffectual. The ball had been split aahen impinging upon the parietal bone and a portion of it had passed within the cranium, making its partial exit ihrough the occiput. On January 31st, 1864, the patient Avas doing well, all the Avounds 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 betAveen the tables of the bone. The patient recovered, but remained somewhat childlike and Avas easily confused in mind. He Avas discharged on October 4th, 1864. Case.—Private Thomas Haley, Co. D, 91st New A'ork Volunteers, aged 28 years, was wounded at Petersburg, A'irginia, Alarch 29th, 1865, by a piece of shell, Avhich fractured the frontal bone just above the right eye, causing hernia cerebri. He Avas 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 Avound. 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 Avas transferred to NeAV York for muster out. He is not a pensioner. Case.—Private William H Hogan, Co. K, 14th ATrginia Infantry, was accidentally wounded on January 15th, 1863, by the discharge of a musket. The missile entered on the postero-lateral portion of the right side of the head, passed fonvard and upAvard across the parietal protuberance and emerged, exposing the skull for a distance of three inches, and fracturing the parietal bone. He Avas admitted to the Chimborazo Hospital, Richmond, Virginia, on January 23d. His mental faculties were perfect, and there Avas very little constitutional disturbance and no paralysis. A triangular portion of the bone had been removed through which opening the brain Avas protruding. He stated that Avhen wounded, there Avas complete paralysis of the left side. Cold-Avater dressings were applied to the wound, and a compress to the protruding portion of the brain, which caused it to slough. The bowels Avere kept open, and the patient kept on light diet. The bone became necrosed along the whole track of the ball, and was removed, exposing the brain for two inches, after which the wound healed rapidly, with a depressed cicatrix. The patient Avas 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 Cav-alry, Avas wounded near Sulphur Springs, Virginia, on October 12th, 1863, by a conoidal ball, which entered the cranium directly over the right eye, about two inches above the superciliary ridge. He entered the Judiciary Scpiare Hospital, Washington, on the 14th, and was furloughed for forty days. On Alarch 18th, 1864, he entered Ward Hospital, Newark, NeAV 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 Alay 3d, Acting Assistant Surgeon James B. Cutler, made a crucial incision at the wound of entrance, reflected back the flaps, and extracted the ball, which Avas partially impacted in the skull, and partly in contact Avith the substance of the brain. The missile Avas very irregular and misshapen. Cold Avater Avas kept applied to the Avound, the head Avas kept elevated, and strict antiphlogistic treatment employed. Hernia cerebri formed, three or four days after the operation, Avith a profuse discharge from the Avound. The hernia Avas pared off on a level with the scalp, but, on July 6th, it reappeared, when slight pressure Avas 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 Avas doing remarkably well. On August 26th, 1864, he was transferred to Trenton, NeAV 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 hospital of the 1st division, Alexandria, A'irginia, on Alay 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, yvhence 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-Avater dressings were applied, and the swelling gradually subsided. On Alay 20th, an incision Avas 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 orbital region. The Avound 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 Avas 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 Avas dissected, and isinglass plaster applied. The edges of the Avound were then gradually approximated, and a steady improvement followed. He Avas sent to the provost marshal on July 20th, 1863. The case is reported by Surgeon W. A. Conover, U. S. A'. Case.—Lieutenant Charles Kennedy, Co. I. 28th Pennsylvania Volunteers, aged 25 years, was Avounded at the battle of ChancellorsA-ille, A'irginia, Alay 2d, 1863, by a fragment of shell, which produced a wound tAvo inches long and one inch Avide, 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 Alay 7th, he Avas admitted to Armory Square Hospital, AVashington. The Avound had a burnt and black appearance, and the pulsation of the brain was very distinct Avith every beat of the heart. The patient's intellect Avas greatly impaired, and there Avas total loss of vision, so that he could not distinguish day from night. The pulse Avas at 60 and full, and there Avas 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 Avith tepid Avater. His bowels Avere constipated for seven days from the date of the injury, and he had scarcely any sleep. Cathartics, injections, and anodynes Avere administered. On Alay llth, tAvelve leeches Avere applied to each temple, and three behind each ear. On the folloAving day the symptoms Avere greatly ameliorated. On Alay 13th, spiculae of bone were removed, and also on Id St.LUl b pi .1 Bir-n clnimvl1 '1 HERNIA CEREBRI FOLLOWING GUNSHOT FRACTURE OF THE OCCIPITA TREPHINING AFTER GUNSHOT FRACTURES OF THE SKULL. 295 the 15th, when the fungus had receded someAvhat, and a healthy granulation Avas progressing. His appetite was good, no fever, vision partially restored, and able to get out of bed. He continued to improve, and on June 16th the fungus had entirely retracted, and vision Avas restored. The intellect Avas perfect and the general health good. On June 20th, Lieutenant Kennedy- Avent home on leave of absence. He was subsequently admitted to the Officers' Hospital at Philadelphia. On September 9th, 1863, the Avound had entirely healed. On November 12th, he Avas ordered before an examining board at Annapolis, and Avas returned to duty January 12th, 1864. On Alay 5th, 1864, he Avas admitted to the field hospital at Lookout Alountain, being again returned to duty about July, 1864. He was discharged the service July 20th, 1864, and afterward pensioned. Pension Examiner AA'ilson JeAvell, under date of April 19th, 1865, reported that the patient suffers from cephalalgia, vertigo, and Aveakness, Avhen exposed to the sun or much excited. His disability was rated one-third and temporary. It yvas subsequently stated by Dr. C. C. AIcGlaughlin, late surgeon 95th Pennsylvania 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 Alay and June, 1863. Case.—Private P. E. A. Williams, Co. I, Palmetto Sharpshooters, aged 23 years, was wounded in an engagement near Petersburg, ATrginia, June 19th, 1864, by a conoidal ball, which impinged upon the superior portion of the frontal bone, left side. The Avound Avas one inch and a half in length antero-posteriorly, and one inch in Avidth. The inner edge Avas 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 spicule, 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 spicule of bone Avere remoA-ed, and simple Avater dressings applied. He was sent to the Jackson Hospital, Richmond. His condition remained critical for weeks. For two Aveeks symptoms of coma continued. Spicule were removed as soon as they became detached, and the Avound Avas kept carefully cleaned. By August 14th, his general condition had improved; most of the spicule had come aAvay, leaving a large orifice, with clean edges. The dura mater Avas exposed and perforated by small orifices. Tavo months after the reception of injury, Avhen 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, descharging more or less until December, 1865, Avhen 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 on stooping suddenly, or after much mental exertion. The case is reported by Confederate Surgeon F. S. Parker. Case.—Private Richard H. BaldAvin, Co. H, 4th New A'ork Artillery, aged 26 years, Avas Avounded near Petersburg, ATrginia, October 2d, 1864, by a conoidal ball, which fractured the frontal and parietal bones, left side. He was sent to hospital 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, Alrginia, July 21st, 1861, a gunshot fracture of the cranium. He Avas conveyed to a Confederate hospital at Culpeper, Virginia. Hernia cerebri supervened, and death occurred August llth, 1861. Case.—Private 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 ofthe 2d division, Ninth Corps, where seA-eral spicule of bone Avere removed; thence he was transferred to Philadelphia, entering the Alower Hospital on July 22d. A fungous growth, 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 compression were developed. Damp compresses of patent lint, saturated with lime-water, Avere bound as firmly as consistent upon the fungous growth. Absolute quiet, a recumbent position, and light diet were ordered. On August 3d, the hernia had increased to the size of a pullet's egg, and was taking on a vascular condition. The general condition Avas but slightly changed, the pupils were 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 was perceptible on the 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 well as usual. The hernia steadily increased, and the patient's health beginning to be compromised, it was decided to remove the protruding mass, which was now the size of an ordinary orange. Accordingly, on August 20th, Acting Assistant Surgeon W. 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 excresence Avas shaved off to a level Avith 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 anesthetic was used. Moderate pressure Avas noAV applied by means of a compress saturated Avith lime- water. On the 22d, the patient, though rational, began to fail. Incoherency, Avith a tendency to coma, Avere manifest on the 25th, Avhile the groAvth seemed disposed to reappear. On the folloAving day the patient was rapidly sinking. Alotion and sensation of the right side were 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, with softening of the surrounding tissue. All the vessels of the brain were considerably congested. A large trephine had been employed to remove the cranial fracture at the seat of injury. The case is reported by the operator. Case.—Private James E. Bridge, Co. C, 156th New York Volunteers, aged 20 years, was 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 AA'as admitted to the hospital of the 1st division, Nineteenth Corps, and on October sent via Sandy Hook, Alaryland, to the National Hospital in Baltimore, Avhere 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 Avound, the brain substance became exposed. Death ensued on October 18th, 1864. Case.—Corporal EdAA-ard Briner, Co. B, 9th New A'ork A'olunteers, aged 23 years, a very robust man, was Avounded at the battle of Fredericksburg, A'irginia, December 13th, 1862, by a conoidal musket ball, Avhich, crossing the coronal suture, fractured the right temporal and carried aAvay a portion of the parietal bone tAVoand a half inches in length and half an inch in Avidth, exposing the membranes of the brain. He was immediately admitted to the field hospital, and on December 18th Avas transferred to the Armory Square Hospital, Washington. The pulsations of the middle meningeal artery Avere 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 on the 29th. A hernia cerebri half an inch in diameter appeared the next day. On January 3d, 1863, the patient had so far recovered that he could ansAver questions correctly. The hernia Avas then excised. Hemiplegia supervened on the 5th, and hernia of the size of a Avalnut again protruded. Though the poAver of prehenson Avas lost, the patient would eat AA'ith avidity Avhatever was placed in his mouth. On the 7th, an attempt was made to excise the hernia, but a severe hemorrhage occurred from the small branches of the meningea media, which was Avith difficulty arrested by compression, and the operation was abandoned. Hemorrhage recurred on the next day, and death ensued January 8th, 1883. The case is reported by Surgeon D. W. Bliss, U. S. V. Case.—Private Joseph Butterfield, Co. H, 120th NeAV York Volunteers, aged 16 years, Avas wounded before Petersburg, Virginia, September 25th, 1864, by a conoidal ball, Avhich extensively fractured the left parietal bone. He Avas admitted to the hospital of the 3d division, Second Corps, where he remained until about October 29th, when he was conveyed to AVashington, and admitted into the Armory Square Hospital. A large hernia cerebri had already formed. The subsequent treatment Avas of a simple character. Death occurred December 13th, 1864. The case is reported by Surgeon D. W. Bliss, U. S. V. Case.—Private, Albert Colchier, Co. D, 114th Pennsylvania Volunteers, Avas Avounded at the battle of Chancellorsville, Virginia, Alay 3d, 1863, by a gunshot missile, Avhich lacerated the scalp and fractured the cranium, causing the cerebrum to protrude. He Avas admitted to the hospital of the Third Corps, Avhere fragments of bone were removed from the wound, but death occurred on May 8th, 1863. Case.—Corporal Abraham C------, Co. D, 93d Pennsylvania Volunteers, aged 24 years, was Avounded at the battle of Spottsylvania Court-house, Virginia, May 12th, 1864, by a conoidal ball, Avhich penetrated the right parietal bone near its posterior inferior angle. He was admitted to the 2d division, Sixth Corps, field hospital, and thence was conveyed to Washing- ton, and admitted to Carver Hospital, May 19th. He was very emaciated; the Avound sloughed and discharged foetid pus, and hernia cerebri had appeared. His pulse Avas 50 and full, the pupils dilated, the tongue coated, and his bowels constipated. On the same day spicule were removed from the brain, giving exit to several ounces of pus. Delirium folloAved and continued until the 27th, when death supervened. The pathological specimen is No. 2900, Sect. I, A. M. M. From the vault of the cranium fragments have been removed for a space of three inches upAvard and forward, and from one to one-half inch in Avidth, at the upper extremity of which four fragments of the inner table remain attached, depressed two lines at the free edge. One fissure passes downward into the mastoid portion of the temporal, and a second passes upward and backAvard to the posterior fourth of the sagittal suture. The specimen and history were contributed by Acting Assistant Surgeon R. E. Price. Case.—Private Patrick Conway, Co. —, 12th Blinois Volunteers, Avas Avounded near Fort Donelson, Tennessee, February 14th, 1862, by a conoidal musket ball, which penetrated the frontal bone, near and to the right of the left eminence and lodged, forcing spicule of bone upon the membranes. He was, on February 17th, admitted to a hospital, being conscious but unable to articulate distinctly. He could not raise his voice above a whisper, and Avas unable to walk or stand in an erect position. On examination the ball Avas found at the inner edge of the skull, lying upon the membranes, and Avas, Avith difficulty, removed, together Avith some fragments of bone, Avhich had penetrated the membranes. After the operation the patient Avas able to speak Avith distinctness and seemed improved. On February 20th, he Avas Avorse and someAvhat morose. The wound discharged slightly and a small quantity of brain substance Avas oozing out. There was slight hernia cerebri, with some heat about the head; pulse rapid, full, and compressible. On February 22d, he became unconscious and refused nourishment. Paralysis of the right side occurred, and death ensued on February 24th, 1862. Case.—Corporal Clarence C------, Co. G, 123d NeAV A'ork Volunteers, aged 24 years, Avas Avounded at the battle ot Chancellorsville, Virginia, Alay 3d, 1863, by a piece of shell, Avhich comminuted the parietal bone, near its posterior superior angle. A state of temporary insensibility supervened in the course of an hour. He remained on the field for three days, Avas conveyed to the field hospital, and thence sent to the 2d division hospital, Alexandria, on June 15th; being at the time in a state of heaA-y stupor. The Avound suppurated freely, and presented near its centre a pulsating tumor, covered by granulations; hemiplegia ofthe left side supervened, and the patient A'oided the urine and feces involuntarily ; the three smaller toes ofthe left foot were partially gangrenous. While dressing the Avound, Acting Assistant Surgeon T. H. Stilhvell removed a fragment of the external table, one-fourth of an inch in diameter. On the afternoon of the 16th, Coulton recovered from his stupor and conversed rationally, though with difficult articulation. On the 18th he again sank into a lethargic state, in which he perspired freely. On the 20th and on the 22d, he Avas again rational for a few hours. Two small pieces of bone Avere removed, one of which Avas a portion of the internal table. On the 24th, his breathing was stertorous all day, but at night a marked improvement in his condition took place; the slough had fallen from one of his toes, disclosing a healthy, granulating surface ; he began to regain poAver over the paralyzed leg, A'oid the excrements at Avill, and could talk Avithout difficulty. On the 30th and 31st, he suffered from convulsive attacks of nervous delirium. One-fourth of a grain of morphia Avas administered every half hour. By August 5th, the paralysis of the left side had so far ceased that he could flex his extremities and extend his leg, though not with HERNIA CEREBRI AFTER GUNSHOT FRACTURES OF THE SKULL. 29; precision. From this date, nothing unfavorable occurred until September 7th, Avhen he again experienced attacks of delirium. On the 27th, after a slight chill, he fell into a state of insensibility. A tumor, which had formed at the wound beneath the scalp, Avas opened, and upon its discharging about an ounce of blood, sensibility was at once restored. Again a state of unconsciousness ensued on the 30th, and though in a measure relieved by the administration of purgatives, it Avas evident that dissolution was near. Death occurred on October 2d. At the autopsy, a circular opening one inch in diameter was found, just above the right parietal eminence, Avith the edges rounded off and beveled at the expense of the inner table. There was also an opening in the dura mater, through which a hernia cerebri appeared. Upon removing the skull cap, three small fragments of the inner table, depressed one-fourth of an inch at their free edge, Avere observed attached and agglutinated by new ossific deposit, traces of Avhich could also be seen in the immediate vicinity. A cerebral abscess was found extending from the hernia cerebri to the right lateral ventricle containing about two ounces of very offensive lead-colored pus. The pathological specimens are Nos. 1724 and 1725, Sect. I, A. AI. AI., and Avere contributed, with the history, by Acting Assistant Surgeon T. II. Stillwell. Case.—Private Thomas Deshler, Co. I, 103d Ohio Volunteers, was accidentally wounded at Carter Station, Virginia, September 22d, 1863, by a musket ball, which entered just below and in front of the left ear, carried away a portion of the temporal bone and probably made its exit above and in front of the ear. He was admitted into the regimental hospital at Bull's Gap, Virginia, on the same day. The brain protruded from the Avound and about one ounce dropped off. He was partially conscious, for the most part, until his death on September 24th, 1863. There was no post-mortem examination. The case is reported by Surgeon L. D. GrisAvold, 103d Ohio A'olunteers. Case.—Corporal Jerry Green, Co. A, 68th United States Colored Troops, Avas wounded at Fort Blakely, Alabama, April 9th, 1883, by a shell, Avhich fractured the left temporal and the frontal bone. He was admitted to hospital, 1st division, United States Colored Troops, Alontgomery, Alabama, in a comatose condition. The brain protruded and the left side Avas paralyzed. He died April 13th, 1865. Case.—Private Thomas H- -, Co. I, 56th Pennsylvania Volunteers, aged Fig. 145.—Internal vieAv of a skull-cap, with a large aperture, through Avhich a fung-us cerebri protruded. Spec. 3264, Sect. I, A. M. M. 23 years, Avas wounded at the battle ot Petersburg, Virginia, June 22d, 1864, by a conoidal ball, Avhich fractured the right parietal bone at its anterior superior angle. He Avas admitted to the 4th division, Fifth Corps, hospital, and thence conveyed to Washington, and admitted, on July 1st, into the Finley Hospital. On the 4th, fragments of bone were removed from a space measuring two inches downward from the sagittal suture by one in width. Tavo days later, hernia cerebri appeared at the opening. The details of the further progress of the case are not recorded, but death resulted on July llth, five days after the appearance of the hernia and twenty days from the date of injury. At the autopsy, the edges of the opening in the bone were found necrosed and cribriform. The dura mater and parts of the cerebral substance in the vicinity Avere congested and filled with coagulated blood. The specimen is figured in the wood-cut, and Avas contributed, Avith the history, by Surgeon G. L. Pancoast, U. S. V. CASE.-Private AndreAV W. Hess, Co. B, 46th Illinois Volunteers, aged 19 years, Avas Avounded in the engagement near Fort Blakely, Alabama, April 8th, 1865, by fragments of shell, Avhich fractured the cranium and injured the right shoulder. He was admitted to the hospital of the Thirteenth Corps on the same day, and, on April 15th, was sent to the St. Louis Hospital, NeAV Orleans, Louisiana. Hernia cerebri supervened, and death occurred on April 23d, 1865. The case is reported by Surgeon A. McMahon, U. S. V. CASE.-Private Arthur H------, Co. F, 40th New York Volunteers, aged 28 years, was Avounded at the battle of Spottsyl- vania Court-house, Virginia, Alay 10th, 1864, by a conoidal ball, which entered the cavity at the middle portion of the right branch of the coronal suture and lodged in the brain, from Avhich it was removed on the field. He was conveyed to Washington, and, on the 12th, admitted to the Douglas Hospital. At the dressing of the wound, Alay 13th, some pieces of bone Avere removed^ and the finger could be passed deeply into the cerebral substance. Paralysis of the left side ensued, and, at times, involuntary discharge of the feces and urine occurred. The tongue was drawn to the left or paralyzed side. Hernia cerebri appeared, the protruding part occasionally becoming strangulated and sloughing. The patient retained the possession of his mental faculties in a remarkable degree, answering all questions addressed to him with accuracy. Death supervened on June 20th, 1864 forty- one days after the reception of the injury. At the autopsy, the fractured portion of the outer table was found to measure two inches in length by one in width; that of the inner table somewhat less. Two small fragments of the inner, and two of the outer, remained; the rest had been removed. The surrounding bone was cribriform and slightly carious, and the edges rounded off, shoAving an attempt at repair. No evidence of meningeal inflammation existed; there was, however, extensive softenin- of the right hemisphere, involving the thalamus opticus and corpus striatum; the lateral ventricles were filled with serum The case is reported by Assistant Surgeon William Thomson, U. S. A. The specimen is No. 3566, Sect. I, A. AI. AI. CASE.-Private George Hopkins, Co. G, 8th Ohio Volunteers, aged 32 years, was wounded before Petersburg Virginia June 17th, 1864, by a conoidal musket ball, which fractured and depressed the frontal bone, left side. He was admitted to the Ninth Corps field hospital, Avhere spicule of bone were removed and water dressings applied. He was thence conveyed bv steamer to AVashington, and admitted, on June 24th, into the Emory Hospital. On June 27th, coma; on June 30th delirium and on July 1st, hernia cerebri supervened, which latter was, on July 3d, removed and cauterized with nitrate of silver Denth occurred on July 8th, 1864. .ueatn 38 298 WOUNDS AND INJURIES OF THE HEAD. Case.—Private William Hubbard, Co. B, 2d Alaryland Regiment, aged 24 years, received, on September 30th, 1864, a gunshot fracture of the right parietal. He AA-as admitted, on October 3d, 1864, to Chimborazo Hospital No. 2, Richmond, Virginia. The brain gradually protruded from the wound, and death occurred on October 4th, 1864. Case.—Sergeant Austin Hudson, Co. F, 60th Ohio Volunteers, Avas Avounded near Petersburg, Virginia, July 15th, 1864, by a conoidal ball, Avhich entered near the anterior superior angle of the left parietal bone, ploughing through bone and brain to the lambdoidal suture. He Avas admitted to the hospital of the 3d division, Ninth Corps. The brain protruded. Death occurred July 15th, 1884. Case.—Private John Irvin, Co. D, 88th Pennsylvania Volunteers, aged 20 years, Avas wounded at the battle of Spott- sylvania, Virginia, Alay 10th, 1864, by a conoidal ball, Avhich fractured the left parietal bone. He Avas immediately admitted to the regimental hospital, transferred to 2d division, Fifth Corps, hospital on the 12th, and sent to the Emory Hospital, Wash- ington, on the 13th. An examination revealed a lacerated Avound of the scalp and pericranium, three inches long and one and a half inches at its widest point. The fracture of the parietal bone extended from the lambdoid suture along the median line, tAvo inches by one-half inch. The posterior end of the fractured portion of the cranium Avas depressed. On the 13th, the patient's right side was paralyzed and his mind Avandering; the pulse Avas normal, and the appetite good. He Avas placed under the influence of ether and chloroform. Surgeon N R. Moseley, U. S. V., then enlarged the wound by a straight incision, and removed a piece of bone about two inches in length; several smaller fragments Avere taken out. Water dressings were applied to the wound, but no marked improvement took place. On May 18th, hernia cerebri supervened, the breathing became stertorous, and the pulse accelerated. Death ensued on May 31st, 1864. The case is reported by Surgeon N. R. Moseley, U. S. V. Case.—Corporal EdAvard Jones, Co. A, 8th Ohio Volunteers, was Avounded at Gettysburg July 3d, 1863, by a conoidal ball, Avhich entered the cranium at the articulation of the nasal with the frontal bone, passed through the superior and posterior portion of the left orbit, and displacing the os unguis, emerged through the articulation of the frontal and malar bones. The eye had apparently escaped serious injury. He Avas admitted to the Seminary Hospital, Gettysburg; thence was sent to Bedloe's Island Hospital, New York Harbor. Partial insanity supervened, and the extreme inflammation consequent upon the injury disorganized the structures of the eye. On October 29th, he was transferred to De Camp Hospital; thence, on December 23d, to AIcDougal Hospital, and on December 30th to Camp Dennison, Ohio. There was at this time a free discharge, supposed to be from the Avounded appendages of the eye; but his strength was good. On January 10th, 1864, he Avas seized with vomiting and hiccough; the tongue became dry, with red border and dark centre; bowels torpid, and general condition typhoid. He complained of occasional pain in the front part of his head ; was drowsy and disinclined to talk. Two Aveeks later he became unconscious; paralysis of the right side supervened, attended with involuntary evacuation of urine and feces. Meantime the discharges from the left orbit had nearly ceased. About February 10th, he sank into a well marked coma. Beneath the inflamed superior palpebra, a sharp edge of bone could be felt, and at the internal canthus quite a prominence was observed, produced by another portion of displaced bone. On the morning of the 16th, the indications denoting compression of the brain Avere strongly marked. On the next day Acting Assistant Surgeon W. C. Cole made an incision to the bone from the external canthus of the left eye to the upper point, to tie the anterior branch of the temporal artery. A second incision Avas carried from the internal canthus obliquely upAvard, and dissection made of the flap, Avhich included the upper eyelid. This disclosed a fracture of the orbital plate of the frontal bone and the displacement of the os unguis, and betAveen them a hernia cerebri one inch in diameter, Avhich Avas removed, opening a cavity within the anterior lobe of the left hemisphere, from which escaped about six ounces of a semi-transparent fluid, apparently disorganized serum. The flap Avas brought down and secured by a stitch at each side, with a tent placed in the aperture. Prompt reaction, with full consciousness, ensued before the patient was removed from the operating table. He Avas then carried to bed, and a nurse was appointed to apply cold water dressings and carefully watch him. In the course of two days the paralysis passed off, and the involuntary evacuations ceased; the pulse rose from 55 to 85, and the tongue became natural. The discharge from the Avound soon changed to a thick healthy lookin" pus, and for ten days all the functions of life were harmoniously performed. But on the morning of the 27th he complained of pain in the back part of the head; the face became flushed, the tongue dry and red, and the pulse more frequent. Two grains of calomel, with one grain of ipecac, were now given every four hours. By the next day the pulse was 120, and he was unable to ansAver any questions. Veratrum viride was carefully administered. He sank steadily, and died on the afternoon of the 28th. At the autopsy, the meninges and brain, as viewed in situ, showed marked venous congestion, but the arachnoid membrane had evidently suffered most from inflammation. A cavity, lined with a thick firm cyst, was found in the anterior superior part of the left hemisphere, communicating with the orbit of the eye; the ventricles were empty, and a deposit of lymph covered the upper surface of the tentorium. The case is reported by Acting Assistant Surgeon AV. C. Cole. CASE.-Private N. B. Jones, Co. I, 3d North Carolina Regiment, aged 30 years, was wounded in the battle of Winchester, A'irginia, September 19th, 1864, by a conoidal ball, Avhich comminuted the skull. The brain substance was loosened, and protruded through the aperture in the cranium. He Avas immediately conveyed to the depot field hospital of the Nineteenth Corps. Brain symptoms Avere fully developed, and on the following day Assistant Surgeon G. M. Burdette, P. A. C. S., removed all loose fragments of bone. Cold applications were made to the head, but progress was very unfavorable, and death ensued on September 28th, 1864, from ''laceration of brain substance, with cerebritis and meningitis." Case.—Corporal AY. O. K------, Co. F, 3d Indiana Cavalry, aged 29 years, Avas Avounded at Funkstown, Maryland, July 8th, 1863, by a fragment of shell, which comminuted the os frontis a little to the right of the median line, and half an inch above the orbit. He remained insensible only a few hours after the reception ofthe injury. The Avound was then enlarged, a number of fragments of bone were removed, and cold Avater dressings applied. On the 18th, he was admitted into the general hospital at Frederick, Alaryland, Avith the wound in a healthy condition, and no functional or cerebral derangement. A HERNIA CEREBRI AFTER GUNSHOT FRACTURES OF THE SKULL. 299 hernia about the size of a pullet's egg was protruding from the opening, which was surrounded by healthy granulations. He complained of slight, dull, heavy headache: the tongue Avas slightly furred; boAvels constipated, but the appetite fair. Aperients Avere ordered, Avhich entirely relieved the headache. Ho was someAvhat morose, but conversed readily. No paralysis existed. On the 24th, his appetite and general condition Avere most excellent. The hernia shoAved a disposition to slough, and the soft parts Avere granulating finely. On the 27th, the hernia had sloughed aAvay. and profuse suppuration supervened, parts looking healthy. Headache again came on, which continued for several days, and on the 23d the patient's appetite began to fail. On the 7th, the Avound Avas suppurating profusely, and the granulations, Avhich nearly covered the opening, Avere pushed outAvard by the hernia. Fluctuations Avere well marked on the 10th. The abscess, Avhich evidently communicated AA'ith the brain, AA-as freely opened, giving exit to half an ounce of pus. On the 12th, he became quite delirious; the right pupil Avas contracted, while the left Avas someAvhat dilated; pulse sIoav and feeble; no appetite. August 14th, subsultus tendinum set in, and the patient died at half-past one o'clock the folloAving morning. The post mortem revealed the entire brain substance softened, and the left lateral ventricle filled AA-ith pus. The pathological specimen is represented in the adjacent wood-cut. Fragments have been removed from a space tAvo inches in diameter, including the right frontal eminence. From the inner table the remoA-al of bone has been more extensive, including the posterior Avails of both frontal sinuses. The anterior Avails of the sinuses are comminuted, and the fragments are consolidated by new ossific deposit, and depressed from one-fourth to one-half an inch at their upper and free edges. From the upper part of the opening a fissure runs outward to the extremity of the right great ala of the sphenoid. The specimen and history were contributed by Assistant Surgeon R. F. AVeir, U. S. A. Case.—Private Charles H. K------, Co. I, 12th Massachusetts Volunteers, was Avounded at Antietam, September 17th, 1862, by a musket ball, Avhich fractured and depressed both tables of the frontal bone. He was sent to the regimental field hospital, thence Avas conA-eyed to Baltimore, and admitted into the NeAvton University Hospital on the 20th. The ball, Avith the fragments ofthe external table, had been removed. The patient was suffering from slight symptoms of compression ofthe brain, Avhich gradually increased. On the 23d, Surgeon C. W. Jones, U. S. V., after having enlarged the external opening, removed several large depressed pieces of the internal table, to the manifest relief of the patient. During the removal of the fragments, slight hemorrhage occurred from the superficial enlargement of the Avound, and, at the conclusion of the operation, the pulsations of the meningeal artery were distinctly visible beneath the dura mater. The edges of the scalp Avere brought together by adhesive strips, and the head elevated by pilloAvs. He conversed coherently, his breathing was easy and natural, and the edges of the scalp commenced to adhere by granulation. Nine days after the operation the wound Avas slightly elevated, and in the centre could be seen the someAvhat darkened dura mater. Slight compression was used; but, on the folloAving morning, the protrusion of the brain, covered by the dura mater Avas greatly increased, having, in its progress, broken up all the adhesions formed at the edges of the Avound. The patient was depressed, dull, and slightly comatose. Convulsions shortly after ensued and death occurred October 3d, 1862, ten days after the operation and tAvo clays after the appearance of the hernia cerebri. The pathological specimen is No. 410, Sect. I, A. AI. AI. The nine small fragments removed from the frontal bone consist chiefly of diploe and vitreous table, and include one-fourth square inch of surface. The specimen and history were contributed by the operator, Surgeon C. AV. Jones, U. S. V. Fio. 146.—Section of a skull trephined after a fracture by a shell fragment. Spec. 3834, Sect. I, A. M. M. CASE.-Private T. L- -, Co. C, 25th New York Volunteers, aged 34 years, was Avounded at the battle of Fredericks- burg, Virginia, December 13th, 1862, by a conoidal musket ball, Avhich struck the os frontis about one inch above the right orbit, fracturing and depressing both tables for a space one inch in diameter. He Avas stunned for a moment, but soon recovered; Avas taken to a field hospital, and thence admitted into Hammond Hospital, Point Lookout, Maryland, December 15th, apparently doing Avell in every respect. His appetite was good, bowels regular, and he was able to Avalk about as usual. Cold Avater dressings were applied, and absolute rest and low diet ordered. The case progressed favorably until the 23d, Avhen violent pain in the head supervened. On the next day he became stupid and drowsy, understanding, with difficulty, questions put to him. The pupils were slightly dilated, but no paralysis or loss of sensation existed. It being decided that an operation Avas imperative, the patient was placed under the influence of chloroform, and Assistant Surgeon C. Wagner, U. S. A., applied the trephine on the anterior border of the fracture, and removed a number of fragments of bone. One piece, measuring three-fourths of an inch in length by one-half inch in width, had lacerated the dura mater and imbedded itself in the brain substance, and was, with great difficulty, extracted. The dura mater was much congested. After the operation, the patient was free from all pain and the brain symptoms had entirely disappeared; but, on the 28th hernia cerebri appeared and rapidly increased, the patient sinking into insensibility, with widely dilated pupils, cold skin and sIoav, feeble pulse. He died on the following morning in a state of complete coma. At the post-mortem examination the Hernia was of a dark color, very soft, and protruding an inch and a half. The dura mater was softened, and covered with a slimy exudation near the seat of iniury. Its laceration corresponded very nearly in extent with the opening in the skull The membranes of the whole of this side were much congested ; the anterior portion of the right cerebral hemisphere was disorganized Fig. 147.—Segment of skull trephined after fracture by a musket ball. Spec. 922, Sect. I, A. M. M. 300 WOUNDS AND INJURIES OF THE HEAD. soft, of a greenish color, and infiltrated Avith very offensive pus. The posterior portion presented a more normal appearance on the surface, but on cutting it a small abscess Avas found. The left cerebral hemisphere and membranes were comparatively healthy. The specimen is represented in the adjoining wood-cut. The os frontis sIioavs tAvo fissures, one commencing at the posterior and outer border of the opening in the skull, and running doAvnward and backward across the temporal ridire for the distance of an inch ; the other commencing an inch anterior to the first, passes doAvnward into the roof of the orbit, along its outer border for the distance of half an inch. The piece of bone betAveen the fractures is quadrangular in shape, and has been forced outward at its detached borders for the distance of a quarter of an inch from the surface of the skull, remaining still attached at its inferior surface. The specimen and history Avere contributed by Assistant Surgeon C. Wagner, U. S. A. Case.—Sergeant D. M. Livingston, Co. I, 27th Georgia Regiment, was admitted to Jackson Hospital, Richmond, Virginia, on June 20th, 1864, Avith a gunshot fracture of the cranium. Hernia cerebri supervened, and death occurred June 27th, 1864. The case is reported by Surgeon J. G. Cabell, P. A. C. S. Case.—Sergeant James L- -, Co. I, 153d New York Volunteers, aged 19 years, was wounded at the battle of Cedar Creek, Virginia, October 19th, 1864, by a conoidal ball, Avhich entered the cranium at the superior border of the occipital bone, just to the left of the median line, and lodged in the left hemisphere of the brain ; his left elboAV joint Avas also fractured. On the 21st heAvas admitted into the depot field hospital ofthe Nineteenth Corps, at Winchester, Virginia; thence was transferred to the Jarvis Hospital, Baltimore, which he entered on October 26th. The ball and several pieces of dead bone were extracted, and cold-Avater dressings applied. Hernia cerebri followed, and death occurred on November 20th, 1884. The autopsy revealed the portion of scalp surrounding the wound in a very unhealthy condition. The skull cap Avas unusually thick. The ball had carried with it a number of small pieces of bone. Surrounding the spinal cord were found about four ounces of purulent fluid. The elboAV joint Avas comminuted. The pathological specimens are Nos. 3729 and 3725, Sect. I, A. AI. M. The former represents a segment of the cranium; fragments have been remoA-ed fi-om an elliptical opening, measuring one and a half inches from below downward, by one inch in width. The edges of the opening are necrosed and beveled at the expense of the inner table, and there are traces of attempt at repair. The latter specimen is a Avet preparation of the cerebrum, in the left hemisphere of which a conoidal ball remained lodged for more than a month before death. The specimens are contributed by Acting Assistant Surgeon B. B. Miles. -, Co. I, 12th Alississippi Regiment, aged 26 years, Avas Avounded at the battle of Spottsylvania, Case.—I *ri vate James L- Virginia, Alay 10th, 1864, by a fragment of shell, which produced a comminuted fracture of a portion of the left parietal and temporal bones. He Avas conveyed to Washington, and on the 14th admitted into the Carver Hospital, suffering constant and excruciating pain in the head. He Avas obliged to lie upon his left side in a recumbent position, and remain perfectly quiet. Simple dressings were regularly applied to the wound, and a restricted diet enjoined. A hernia cerebri appeared at the seat of fracture. Unconsciousness supervened, the breathing became slow and stertorous, and as the coma deepened, large quantities of laudable pus Avere discharged from the wound. He died on the 20th of the month. At the autopsy the fractured surface was found to measure three and one-half inches dowiiAvard and backward, by one-half inch in width, from which fragments had been removed. One fissure run from the anterior inferior angle of the parietal, nearly to the sagittal suture, and a second crossed the lambdoidal. There Avas no attempt at repair. The specimen is represented in the adjoining wood-cut, and was contributed by Acting Assistant Surgeon O. P. Sweet. Fig. 148.—Segment of skull fractured by a piece of shell. Spec. 2901, Sect. I, A. M. M. Case.—Afajor Thomas McClurken, 30th Illinois Volunteers, received, at the battle of Belmont, Missouri, November 7th, 1861, a gunshot fracture of the cranium. Three inches of the skull Avere shot away, and the brain substance protruded. He died on November 15th, 1863. Case.—Private Jacob Morford, Co. A, 29th Pennsylvania Volunteers, was wounded at the battle of Gettysburg, Penn- sylvania, July 2d, 1863, by a conoidal musket ball, Avhich fractured the frontal bone immediately above the nose, and a little to the left of the median line, crushing the bone and driving the fragments into the brain. He Avas admitted to the field hospital at Gettysburg on the following day. Several small pieces of bone were removed, and cold water dressings applied. He complained of severe pain in his head, and Avould ansAver questions irrationally. His pulse Avas somewhat excited, but the tongue was natural and the eyesight unimpaired, although a portion of the orbital process had been removed. He would leave his tent at night, under the impression that he Avas acting as picket. He remained in this condition until July 17th, when again several pieces of bone were removed, leaving an opening large enough to admit the index finger, Avhich could be passed in almost its entire length, Avthout meeting Avith any resist- ance or producing any considerable „ ,,.„,, • - ., 1 . . 1 -(;- 150—Exterior view of the pain, a considerable portion of the brain illustrated by the cut opposite. Fio. MO.—Internal view of the skull-cap tre- phined after gunshot fracture. Spec. l?>o'J, Sect. 1, A. M. .AI. HERNIA CEREBRI AFTER GUNSHOT FRACTURES OF THE SKULL. 301 being softened. A small fungus projected from the brain. After the removal he expressed himself relieved, and the pain in his head ceased almost entirely, and he became more rational. On July 19th, he was taken to the Seminary Hospital. Coma supervened, which was relieved for a time by the application of Avater dressings, but hernia cerebri appeared, and death occurred on August 16th, 1863. The specimen, represented in the adjoining Avood-cut, is the vault of the cranium. Two disks inter- secting each other have been removed by the croAvn of a three-fourth inch trephine, the entire opening measuring one and one- fourth by three-fourths of an inch. There is a slight stellate Assuring of the inner table. Case.—Private Amer Aloore, Co. G, 2d United States Artillery, aged 20 years, was wounded in a skirmish near Culpeper, A'irginia, on September 13th, 1863, by a carbine ball, which struck the vertex of the cranium at the centre of the coronal suture, passed directly backward along the sagittal a distance of three inches, and lodged. The missile Avas extracted the same day. Both tables of the skull Avere fractured, leaving an opening, through Avhich pulsations of the brain could be seen. The dura mater Avas uninjured. Complete paralysis of the lower extremities and of the left arm existed. He was admitted into the Armory Square Hospital, AVashington, on September 14th, and on the following day a plate of bone, three-fourths by one-fourth of an inch, and seA'eral small particles, were extracted by Acting Assistant Surgeon E. Brooks. Creosote wash and permanganate of potash Avere used to dress the Avound, Avhich looked Avell. The general condition of the patient was apparently good on September 21st, when an oblong piece of lead Avas removed from beneath the scalp; but hernia cerebri followed this operation, and death occurred on October 10th, 1863. The case is reported by Surgeon D. W. Bliss, U. S. V. Case.—Captain Thomas Moyer, 7th Georgia Regiment, received, at the battle of Bull Run, Virginia, July 21st, 1861, a shell fracture of the cranium. He Avas admitted to a Confederate hospital at Culpeper, Virginia, on July 23d. Hernia cerebri ensued, and death occurred August 5th, 1861. Case.—Private J. A. Nichols, Co. B, 12th South Carolina Regiment, was admitted to Jackson Hospital, Richmond, Virginia, on August 18th, 1864, AA'ith a gunshot fracture of the cranium. Hernia cerebri complicated the case, Avhich resulted fatally, August 24th, 1864. Case.—Lieutenant AVilliam A. O------, Co. B, 25th Connecticut Volunteers, aged 28 years, was Avounded at Irish Bend, Louisiana, April 14th, 1863, by a conoidal ball, which entered the frontal bone beneath the supra-orbital arch, passed downward, and lodged in the antrum of Highmore. He Avas conveyed to NeAV Orleans, and admitted into the University Hospital on the 17th, being at that time in a semi- comatose condition. He continued so for many days, at times answering questions very correctly, but manifesting symptoms of mental disturbance. The right eyelid Avas swollen to such an extent as to prevent any vieAv of the eyeball. On the 22d, a fragment of bone, which had become entirely detached, was removed. When the tumefaction of the eyelid disappeared, it Avas found that the sight of the eye was uninjured. An abscess discharged its contents through an opening just beneath the supra-orbital arch. During the first iavo Aveeks of May the patient Avas very com- fortable, but about the 15th of the month he began to decline. Hernia cerebri appeared through the opening in the frontal bone, but was readily reduced, and its recurrence prevented by a few turns of a roller. The original Avound having quite firmly cicatrized, the hernia was afterAvard prevented from appearing externally. On the morning of the 20th the patient became suddenly worse; coma supervened, and death ensued on Alay 21st. At the autopsy, the meninges Avere found much inflamed, and a portion of the cerebral substance, about the size of the opening in the frontal bone, was completely disorganized to the depth of about three-fourths of an inch. No pus was discovered in the ventricles. The specimen is represented by the cut, and consists of a segment of the frontal bone and two fragments. The opening in the os frontis is nearly quadrilateral, measuring one inch from right to left, and one and one- fourth inches from above downward. A fissure of the external table extends to the temporal rid"e history Avere contributed by Assistant Surgeon P. S. Connor, U. S. A. Fig. 1.->1.—Segment of frontal bone fractured by a musket ball, AA'hich is shown in situ. Spec. 1297, Sect. I, A. M. M. The specimen and Case.—Private Philip P- -, Co. A, 1st Maryland Regiment, aged 29 years, Avas Avounded at the battle of Gettysburg, Pennsylvania, July 1st, 1863, by a musket ball, Avhich fractured both tables of the right parietal bone at its eminence. He Avas conveyed to Seminary Hospital, Gettysburg, and thence, on July 17th, transferred to the general hospital at Chester. The wound was in a healthy condition. On the 28th, several fragments of bone Avere removed, leaving an opening one-half by three-fourths of an inch, through which the pulsations of the brain could be distinctly seen. On August 8th, the Avound began to slough. Hernia cerebri supervened and gradually increased to the size of an egg. All the symptoms of compression of the brain and paraplegia sinistra followed. The patient began to fail rapidly, and died on August 21st, 1863. The specimen is figured in the Avood-cut, (FiG. 152,) and exhibits the aperture left after the removal of the depressed fragments of the right parietal bone. The edges of the opening are necrosed, and slight deposits of neAV ossific matter appear on the inner surface. The specimen and history Avere contributed by Acting Assistant Surgeon J. A. Draper. 'skull, fractured A. M. U. by a musket 302 WOUNDS AND INJURIES OF THE HEAD. Case.—Lieutenant John H.Porter, Bradford's Battalion, Tennessee Cavalry,aged 27 years, Avas Avounded at Fort PilloAv Tennessee, April 12th, 1864, by a conoidal ball, Avhich entered at the upper portion of the left side of the forehead, and in its passage chipped out a part of the frontal and left parietal bones, exposing the meningeal artery and the brain to the extent of an inch. He avus conveyed by steamer to Alound City, Illinois, and admitted to the hospital at that place on April 14th. He Avas unable to speak, though quite rational, and Avould folloAV his friends at Avill AA'ith his eyes. In the progress of the case, periods of quiet and great restlessness alternated. On April 19th, the wound commenced to discharge, and on the 22d the patient could eat a little, but Avas still unable to speak; the boAvels Avere costive. The discharge from the head increased, and on the 27th considerable brain matter protruded. For a day or tAvo he seemed better, but on Alay 4th he became delirious, and remained in that condition until death supervened, June 21st, 1864. Case.—Private James Ringwood, Co. A, 14th Connecticut Volunteers, was Avounded at the battle of Cold Harbor, A'irginia, June 7th, 1864, by a conoidal ball, which caused a compound comminuted fracture of right temporal and parietal bones. He was at once admitted to the hospital of the 1st division, Second Corps. His left side Avas paralyzed, and a portion of the brain protruded from the opening; the discharge of feces was involuntary. Dr. A. Garcelon removed a portion ofthe bone. No further history can be obtained; but the man probably died in transit to a general hospital. Case.—Private AA'illiam Rogers, Co. G, 7th Ohio Volunteers, aged 23 years, was wounded at the battle of Port Republic, Virginia, June 9th, 1862, by a conoidal ball, which struck the os frontis, one inch above the edge of the right orbit, and about half an inch fi-om the median line. He was rendered insensible for a feAV moments, but soon recovered sufficiently to Avalk from the field. He Avas admitted to Cliffburne Hospital, AA'ashington, on the 15th. The wound was healthy in appearance, and dis- charged a thin, sero-purulent fluid ; the pulsation of the brain Avas distinctly visible, and splinters and loose fragments of bone could be felt. Absolute quiet was enjoined, and light diet and simple dressing, with aperients, ordered. On the 17th he complained of increasing pains. Assistant Surgeon John S. Billings, U. S. A., enlarged the Avound of entrance, and removed the fragments of bone Avith forceps. The ball could not be found, it having evidently entered the brain. The wound was left open, and lightly dressed AA'ith wet lint. The patient felt better the next day. The second day after operation, he complained of slight, persistent pain in the back of the head, Avhich continued until the 20th, when a small fungus growth made its appearance in the Avound. Suppuration, Avhich had previously been profuse and healthy, was much diminished, and the pain increased. The fungus Avas readily detached Avith the handle of the scalpel, and its removal gave exit to an ounce of pus, which someAvhat relieved the pain. Hernia cerebri again appeared on the 27th, and death took place on the evening of the 28th, 1862. The patient was never delirious, and could answer questions correctly up to an hour before his death. The autopsy revealed the ball, much fissured and tAvisted upon itself, lying in a sac of false membrane, about one inch beneath the dura mater. The AA'hole anterior lobe was broken doAvn, and of a pultaceous consistence, dark sanious pus filling the ventricular cavity. The adventitious tissue, which formed the bulk of the hernia and the cyst containing the ball, was soft, and under the microscope Avas seen to be composed of interlacing fibres, containing large cells in its meshes. The history of the case was contributed by Assistant Surgeon John S Billings, U. S. A. Case.—Private James Seely, Co. D, 55th Ohio Volunteers, aged 21 years, was wounded near Atlanta, Georgia, July 20th, 1864, by a conoidal ball, which struck the right side of the frontal bone, one inch above the supra-orbital ridge, fracturing both tables. He was admitted into the field hospital at Chattanooga, Tennessee, on the 26th, and, on August 10th, transferred to Nashville, entering Hospital No. 1 the following day. A hernia cerebri protruded through the fracture. There was a slight discharge of pus from the wound. Patient suffered from pain in the head, irritability of stomach, and constipation of the boAvels. His tongue Avas coated, pulse intermittent and pupils slightly dilated. On the 24th, he Avas placed under the influence of chloroform, and Acting Assistant Surgeon AI. L. Herr removed several spicule of bone and excised the sharp edges, Avhich were encroaching upon the brain, through a crucial incision tAvo inches in extent. Spicule of bone were found forcibly driven between the inner table of the skull and the dura mater. Cold Avater dressings were applied to the Avound, a compress placed over the hernia, and Ioav diet prescribed. Death supervened on September 7th, 1864. At the post-mortem examination a large abscess in the brain was found, extending into the lateral ventricle, containing about five ounces of pus. The case is reported by Surgeon B. B. Breed, II. S. V. Case.—Private George Taylor, Co. B, 157th Pennsylvania Volunteers, aged 18 years, Avas Avounded at the battle of the AVeldon Railroad, A'irginia, August 20th, 1864, by a round musket ball, Avhich entered the cranial cavity through the right lambdoid suture at a point about two inches from the median line. He Avas admitted to the hospital of the 4th division, Fifth Corps; thence, Avas sent to City Point, and, on August 28th, Avas admitted to the 3d division hospital at Alexandria, Virginia. Hernia cerebri protruded through the opening. The treatment consisted in the use of cold water applications to the head and counter irritation to the feet. The patient died, hoAvever, on August 29th, 1864. At the autopsy, seventeen hours after death, the perforation of the skull Avas found to be circular and larger at the inner than at the outer table; the dura mater was firmly adherent along the longitudinal fissure, especially on the right side; the arachnoid of the same side was thickened by numerous tufts of lymph, Avith but little effusion beneath it. The meninges at the base of the brain around the pons Varolii, over the fourth ventricle and about the crura cerebelli were, likeAvise, thickened and adherent to the brain. The brain itself Avas hardened and pale, except in the vicinity of the Avound, Avhere it Avas of a rich cream color and evidently degenerating into pus. On section the lateral ventricles Avere found filled with a fluid containing floating tufts of lymph, a thick deposit of Avhich laid upon the choroid plexuses and Avails of the ventricle. A round ball, half sliced open, and a disk of bone had lodged at a depth of one and a half inches in the right posterior occipital lobe, a little beloAV the digital cavity, Avhich had been involved in the inflammation. The case is reported by Surgeon E. Bentley, U. S. A'. Case.—Charles T------, Co. H, 63d NeAV York A'olunteers, aged 17 years, Avas admitted to Hospital No. 1, Frederick, Maryland, on September 28th, 18G2, Avith a fracture of the skull. He Avas Avounded at Antietam, September 17th, 1862, by a conoidal musket ball, Avhich struck at the loAver anterior angle of the right parietal, fractured both tables of the cranium, and HERNIA CEREBRI AFTER GUNSHOT FRACTURES OF THE SKULL. 303 FIG. 153.—Gunshot fracture of the right parietal, followed by necrosis. Interior view. Spec. 3859, Sect. I, A. M. M. lodged under the scalp in the occipital region. The scalp was lacerated, and a dark pulsating mass protruded in the wound. The left side of the body Avas paralyzed. The patient's mental faculties Avere unimpaired. On September 29th, flaps of integument were reflected by a T-shaped incision. The ball and a number of fragments of bone were removed, some of the latter being imbedded in the brain substance. The inner table Avas found badly splintered, but the fracture of the external table was still more extensive. The protruding cere- bral mass Avas shaved off. The rough edges of the fractured bone Avere smoothed by cut- ting forceps The following day the paralysis Avas more complete than before the operation. There AA-as severe headache The pulse Avas sloAvand Aveak. On October 3d, the fungus was sprouting and sloughing. The left arm was poAverless; the paralysis of the left leg Avas less complete. On October 4th, the hernia was again sliced off and gentle compression was applied. There was great irritability and restlessness. On October 21st, the patient had improved. His appetite Avas voracious. He was less irritable and the hemiplegia Avas much less complete. very sensitive to cold. The temperature of the left side Avas lower than that of the right. The fungus was of the size of a pigeon's egg. On November 17th, a dilatation of the left pupil was first noticed. Sensation in the left leg and partial control of the muscles had returned. Since the last report the tumor of the brain had continued to grow and slough away, so that it remained about the same size. On December 7th, the report states that little change had taken place, except a gradual amelioration of the hemiplegia, and improvement in regard to the fretfulness and irritability. On this day there Avas a severe chill. After this the patient never regained his accustomed readiness and clearness of mind. The discharge from the Avound became Avatery, unhealthy, and more copious. There was an exacerbation of fever every afternoon. On December 17th, there was a severe convulsion which lasted half an hour, and Avas terminated by death. At the autopsy, an irregular portion of the right parietal, four inches in diameter, was found to be necrosed and detached. The dura mater Avas much thickened in the vicinity of the fracture, and was adherent to the margins of the healthy bone. Except in the immediate vicinity of the hernia, the brain matter appeared to be in a healthy state. Assistant Surgeon R. F. Weir, U. S. A., reported the case. Case.—An unknown soldier, belonging to the 125th Ohio Volunteers, Avas brought to the field hospital at Chattanooga, Tennessee,' on June 25th, 1864, with a gunshot fracture of the cranium, allowing a fungous mass of the brain substance to protrude. He was unconscious until the time of his death, which occurred on June 30th, 1864. Case.—An unknown Confederate soldier, belonging to the 61st North Carolina Regiment, was brought into the hospital at Fort Alonroe, Virginia, October 4th, 1864, with a gunshot fracture of the cranium, received on September 29th, 1864. He Avas insensible, and brain substance protruded from the wound. Simple dressings were applied, but death resulted on October 5th, 1864. Fig. 154.—External view of gunshot frac- ture of right parietal, followed by necrosis. He was Case.—Private Edward V- -, Co. D, 55th Ohio Volunteers, was wounded at the battle of Bull Run, Virginia, August 29th, 1862, by a conoidal ball, which struck half an inch above the right eyebrow, and the same distance from the median line of the os frontis, comminuting and carrying away both tables to the extent of one and one-fourth to two and one-fourth inches. He was AA'ounded while in the act of discharging his gun, staggered considerably under the shock, but recovered immediately, so that he fired, loaded, and fired a second time before he fell. He lay on the field for six days, during which time a considerable amount of brain matter oozed from the wound. He was afterward conveyed to Washington, and admitted, on the 7th of September, into the Emory Hospital, where the Avound was dressed for the first time. Half of the plates composing the frontal sinus Avere found turned in upon the brain, and about one-third of the ball was battered up against the fractured edge of the bone. When the missile and fragments of bone Avere remoA-ed a large quantity of foetid pus and a teaspoonful of cerebral matter exuded. The most remarkable feature of the case was that there were no symptoms of injury to the brain, either in articulation, memory, sight, or animation. The wound was dressed with adhesive strips to keep the eyebroAV from falling on the cheek. On the morning of the 8th, a hernia cerebri, an inch in diameter, made its appearance, pulsating with the heart's action The depressed walls of the frontal sinus were now removed by Assistant Surgeon J. D. Hall, 24th New York Volunteers, the operation being attended Avith slight hemorrhage, a plentiful discharge of pus, and the escape of a teacupful of softened brain matter. On the 9th, the tongue was covered Avith a thick Avhite fur; lips red, pulse nearly normal. No change occurred until the 19th, except that the Avound became more painful, though it continued perfectly healthy. The hernia had gradually receded when, on the 20th, a colliquative diarrhea set in, which, though arrested by astringents and opiates greatly reduced his strength ; his mind, however, continued perfectly clear. Tonics, Avith nouishing diet, were administered, but he failed to rally, and died on the morning of the 25th. At the autopsy a large clot was found between the dura mater and the skull, at the coronal suture; and the meninges and brain exhibited a much greater degree of congestion and inflammation than any recent symptoms had indicated. The ventricles, on section, were found filled with serum and pus. The pathological specimen is No. 276, Sect. I, A. M. AI. The cranium shows an extensive fracture of the right supra-orbital arch; a small fragment of the bone is attached. The entire arch is removed, leaving an opening into the cranium, two and one-half inches long and one and one-fourth wide, extending from the inner angle of the orbit to the anterior inferior angle of the right parietal. The orbital plate of the right superior maxilla is fractured and depressed and a fissure an inch long extends down the body of the bone. The specimen and history were contributed by Surgeon William Clendenin, U. S. V. 304 WOUNDS AND INJURIES OF THE HEAD. Case.—First Lieutenant Nicholas Woolmar, Co. C, 26th AA'isconsin Volunteers, aged 28 years, Avas Avounded in an engagement at Atlanta, Georgia, July 20th, 1864, by a conoidal musket ball, which fractured the right parietal bone. He Avas admitted to the hospital of the 3d division, TAventieth Corps; on the 28th of the month, Avas transferred to the general hospital at Chattanooga, and three days later, Avas sent to the Officers' Hospital at Nashville. Paralysis supervened, and death resulted on August 21st. 1864. At the autopsy, a hernia cerebri was discovered protruding through the dura mater. Surgeon J. E. Herbst reported the case. Of the fifty-one preceding cases, reported as examples of hernia cerebri, forty-four had a fatal result. Of the seven survivors, whose histories are first recorded, four recovered with the full integrity of their intellectual faculties, while three suffered so much from vertigo and headache as to be incapable of much mental exertion. Of the forty- four fatal cases, eight would appear to have been simply examples of primary protrusion of brain substance from extensive gunshot fractures, and thirty-six legitimate illustrations of the condition described by surgeons as fungus or hernia of the cerebrum. Four of the fifty-one patients were trephined, and in twenty-five cases fragments of bone were removed, the projectile also being extracted in four instances. The details of treatment will be discussed hereafter. Oontre-Ooup.—I have admitted, on page 214, that the fissures of the sphenoid and frontal orbital plate of specimen 13 J 8, figured by wood-cut 110, must be regarded as examples of fracture by contre-coup, unless they were accidentally produced after death. I regard the latter hypothesis as much the most probable. The case of Private L. B. Pollard, Co. Gr, 16th Maine, of which an abstract is given on page 178, is regarded by the pension examiner as an instance of fracture by contre-coup after gunshot injury of the skull. As the pensioner still survives, this diagnosis has, of course, not been verified. I am indebted to the examiner for the following letter, stating the grounds of his diagnosis: Augusta, Maine, November 23d, 1870, Sir: Perhaps this case, by a strict rendering, would not be classed as contre-coup, yet it Avas one where much of the damage was done by transmitted force, and therefore, in a general way, coming under that head. My record states the follow- ing : A ball nearly spent, as Ave may suppose, penetrated the skull in the middle of the forehead just at the edge of the hair, and there lodged without entering any farther. In addition to the local injury thus accomplished there was an extensive fracture of the right parietal bone. Although not directly opposite to the point where the force was applied, I believed it to have occurred under similar mechanical conditions, and thus classified it as I did. My record is not as full concerning details as would he the case in records of [compound?] fracture. Very respectfully, (Signed) JAMES B. BELL. Dr. George A. Otis, etc., etc. All of the cases of alleged fracture by contre-coup after gunshot injury of the skull, in which I have been able to examine the evidence, are as unsatisfactory as those already referred to. Assistant Surgeon Woodhull, U. S. A. regards1 the case recorded on page 213 (Pig. 109) as probably an instance of fracture by contre-coup; but I cannot share his opinion The preparation (No. 2871) plainly presents, I think, direct fractures only. There are three other specimens in the Army Medical Museum, which have been regarded as examples of fracture by contre-coup, from the impact of gunshot projectiles. These specimens are represented in Photographs 214, 215, and 216 of the Surgical Series,2 and their imperfect histories are as follows: " Photograph No. 214. Cranium Perforated by a Musket Ball—This cranium was presented to the Army Aledical Aluseum by Surgeon Jerome B. Green, U. S. V., and is numbered 830 of the Surgical Section. A musket ball entered at the centre of the left branch of the coronal suture, and passed out at the posterior inferior angle of the right parietal bone, the i Catalogue of the Surgical Section of the Army Medical Museum, Washington, 1866, page 12. - Photographs of Surgical Cases and Specimens. Prepared by order of the Surgeon General by Brevet Lieutenant Colonel GEORGE A. OTIS, I. S. A., Curator of the Army Medical Museum, Washington, 1869. Vol. V, page 14. GUNSHOT FRACTURES OF THE SKULL BY CONTRE-COUP. 305 opening of entrance being three-fourths of an inch, and that of exit one and one-fourth inches in diameter. There is a fracture of the right orbital plate of the frontal, of the squamous portion of the right temporal, and of the body of the right superior maxilla, ascribed to the effects of contre-coup. A fracture of the occipital bone extends from the opening of exit to the right jugular foramen. The frontal suture remains distinct, though the skull is that of a middle-aged man. The specimen is believed to have come from the Twelfth Army Corps hospital after the second battle of Bull Run." " Photograph No. 215. Perfora- tion of the Cranium by a Musket Ball.—This cranium Avas picked up on the first Bull Run battle-field by Dr. F. Schafhirt, and presented to the Army Medical Museum. It is No. 3251 of the Surgical Section. It displays a fracture caused by a musket ball, which, entering at the right fronto-parietal suture and temporal ridge, and fractured the frontal bone in a long fissure, which runs in front one inch above the orbits, and doAvmvard through the greater Aving of sphenoid and squamous portion of the left temporal into the mastoid process. One fissure branches off above the left orbit and doAvnAvard through the maxillary sinus. Another fissure passes posteriorly from the Avound of entrance and upward through the right to the left parietal protuberance. Another fissure dowmvard through the right auditory meatus has divided the petrous bone. A'et another fissure passes backAvard through the upper portion of right temporal into the occiput. The ball passed out at the upper part of occipital near the inter-parietal suture." "Photograph No. 21G. Gunshot Fracture of Skull.—At a post-mortem examination of the body of an unknoAvn soldier, at Lincoln Hospital, September 22d, 1864, it Avas ascertained that a conoidal musket ball had entered about one and one-half inches above the left ear, causing a compound comminuted fracture of the squamous portion of the temporal bone. The ball Avas found imbedded in the loAver portion of the parotid gland. The vessels of the meninges of the brain Avere very much injected. The middle lobe of the left hemisphere Avas softened to the middle corner of the lateral ventricle, which contained a small quantity of fluid resembling blood. The specimen was contributed to the Army Medical Museum by Acting Assistant Surgeon H. AI. Dean, and is No. 3254 of the Surgical Section. It is a section of the cranium, shoAving penetration and fracture of the left temporal bone just above the meatus auditorius externus, Avhich is entered by the fissure, together Avith a connected fracture of the occipital, which has been regarded as an indirect fracture by contre-coup, caused by a conoidal ball, Avhich is attached to the aperture of entrance. The opening is just above the root of the zygoma and is three-fourths of an inch in diameter. The condyle of the lower jaAV and the posterior half of the glenoid fossa are carried aAvay, together Avith the extremity of the petrous portion of the temporal bone, the line of fracture passing through the internal meatus auditorious. From the left jugular foramen two lines of fracture pass to the foramen magnum, one in front of and the other behind the condyle. On the right side the occipital bone is traversed by a fracture which runs from the foramen magnufu to the posterior angle of the right parietal." * Another case of alleged fracture by contre-coup of both orbital plates of the frontal by the transmitted shock from the perforation of the occipital by a pistol ball, has been much commented on: Case.—A. L------, aged 56 years, was shot in the head, at Washington, on the evening of April 14th, 1865, by a large round ball, from a Derringer pistol, in the hands of an assassin. Dr. diaries A. Leale being close at hand, Avent instantly to the wounded man, whom be found "in a profoundly comatose condition," * * the breathing "exceedingly stertorous." (These and other quotations in the first part of this abstract, are taken from a report compiled by Dr. Leale, from notes made at the time.) No pulsation Avas perceptible at the right wrist. When the head Avas examined, '' I passed my fingers over a large firm clot of blood, situated about one inch below the superior curved line of the occipital bone and an inch and a half to the left of the median line of the same bone. The coagulum, I easily removed, and passed the little finger of my left band through the perfectly smooth opening made by the ball, and found that it had entered the encepbalon. As soon as I removed my finger, a slight oozing of blood folloAved, and his breathing became more regular and less stertorous." After the administration of a small quantity of brandy and water, of Avhich a mouthful appeared to have passed into the stomach, the patient was removed to a neighboring house, Avith the assistance of Acting Assistant Surgeons C. S. Taft and A. F. A. King, and others. His clothing was removed, and he Avas placed in bed. His extremities Avere cold. He Avas covered with warmed blankets, and bottles of hot water were applied to the lower extremities. • It Avas noAV about eleven o'clock at night, the Avound having been inflicted about half past ten. His family physician, Dr. Robert H. Stone, and Surgeon General Barnes, and Assistant Surgeon General Crane, arrived presently, and assuming charge of the case, proceeded to examine the patient and the Avound. The pulse Avas very feeble and vaccillating, from 40 to 48; the respiration Avas oppressed and labored; the surface was cold. Over the left eye-lid there Avas slight ecchymosis. " The pupil of that eye was slightly dilated, the left pupil Avas contracted;" both Avere irrespon- sive to light. Sinapisms Avere applied to the surface. A few drops of brandy and Avater placed into the fauces Avas not SAvalloAved, and the attempt to administer internal stimulants was not insisted on. It Avas observed that Avhen blood and cerebral matter oozed unimpededly from theAvound the condition ofthe pulse and respiration improved. The Surgeon General accordingly kept the external Avound open by means of a silver probe, until, a Nekton's probe being brought, be made an exploration of the course of the ball. A splinter obstructed the track at the depth of about two and a half inches. An inch and a half further on the bulb came in contact Avith a foreign body, Avhich proved to be the disk from the occipital forced out by the ball; passing beyond this the ball Avas detected, at a distance of over six inches from the entrance Avound. Drs. Stone and Crane having also distinctly felt the ball at this depth in contact Avith the bulb of the probe, it Avas decided that no attempt should be made to remove it or the foreign bodies, further than ''to keep the opening free from coagula, which, when allowed to form and remain for a very short time, Avould produce signs of increased compression, the breathing becoming profoundly stertorous and inter- mittent, and the pulse more feeble and irregular." NotAvithstanding the free oozing from the external orifice, there Avas evidently much internal bleeding going on, as was indicated by the excessive extravasation into the orbits, accompanied by great ecchy- mosis of the eyelids. The protracted death-struggle ceased at twenty minutes past seven o'clock on the morning of April 15th, 1865. At noon, an autopsy was made in the presence ofthe Surgeon General and others, by Assistant Surgeon J. J. WoodAvard U. S. A., aided by Assistant Surgeon EdAvard Curtis, U. S. A. The following is an extract from the official report to the 39 306 WOUNDS AND INJURIES OF THE HEAD. Surgeon General by Dr. WoodAvard, compiled the same day from notes taken at the time of the post-mortem examination: ''The evelids and surrounding parts of the face Avere greatly ecchymosed and the eyes someAvhat protuberant from effusion of blood into the orbits. There was a gunshot Avound of the head, around which the scalp was greatly thickened by haemorrhage into its tissues. The ball entered through the occipital bone about an inch to the left of the median line and just above the left lateral sinus, which it opened It then penetrated the dura mater, passed through the left posterior lobe of the cerebrum, entered the left lateral ventricle, and lodged in the white matter of the cerebrum just above the anterior portion of the left corpus striatum, Avhere it Avas found. The wound in the occipital bone Avas quite smooth, circular in shape, with beveled edges, the opening through the internal table being larger than that through the external table. The track of the ball was full of clotted blood and contained several little fragments of bone, with a small piece of the ball near its external orifice. The brain around the track Avas pultaceous and livid from capillary hsemorrhage into its substance. The ventricles of the brain were full of clotted blood. A thick clot beneath the dura mater coated the right cerebral lobe. There was a smaller clot under the dura mater of the left side. But little blood Avas found at the base of the brain. Both the orbital plates of the frontal bene Avere fractured, and the fragments pushed up toward the brain. The dura mater over these fractures was uninjured. The orbits gorged Avith blood." * * * Basing his remarks on an account of this case and of the post-mortem examination published by Acting Assistant Surgeon C. S. Taft,* Professor T. Longmore, of Netley, observes: The autopsy showed that the projectile had penetrated the occipital bone one inch to the left of the longitudinal sinus; had driven before it, for about three inches, the piece of bone which it had punched out, as it were; and that, leaving this fragment behind, it had itself then passed on obliquely across, from left to right, through the brain substance to the anterior lobe ofthe right hemisphere, in which it lodged, immediately over the right orbit. The ball did not strike the anterior part of the cranium, its force having been expended before reaching so far; yet, at the autopsy, according to the report of the post-mortem appearances furnished by Assistant Surgeon C. S. Taft, U. S. A., to the Philadelphia Medical Reporter, "the orbitar plates of both orbits were found to he the seats of comminuted frac- ture, the fragments being forced inward, and the dura-mater covering them remaining uninjured. This double fracture was decided to have been caused by contre-coup. If the term 'contre-coup' be limited to its precise signification of'counter-stroke'— t. e., the impression made by the stroke on the part of the cranium opposite to that directly struck by the ball—will the force of contre-coup explain the fractures in this instance ? It seems very difficult to conceive that the orbitar plates could be fractured by such a counter-stroke, while the portion of the cranial arch opposite to that which received the primary blow, including the expanse of the frontal bone and the several processes within which the orbitar plates are held, and by which they are so strongly protected in all directions laterally remained entire and unchanged. I am inclined rather to attribute the lesions mentioned to a transmitted undulatory stroke or sudden impulse of the brain-substance itself, against the thin bony layers constituting the orbitar plates. I am in possession of the notes of a case in Avhich a similar fracture took place in one orbitar plate, from a ball passing along, only grooving, the upper surface of the hemisphere lying over the plate broken. In this instance there Avas no reason to doubt that the impulse communicated to the brain substance by the passage of the projectile had been continued on AA-ith sufficient force to the orbitar plate to effect its fracture."t The explanation offered by Dr. Longmore of the cause of fracture of the orbital plates, in this remarkable case is, in the writer's opinion, more satisfactory than the hypothesis that the fractures were produced by contre-coup. The unusually thin orbital plates on either side were exposed to the impulse of the cerebral pulp. Even if they were not fully protected from the vibrations in the vault of the cranium, by the dense supra- orbital ridges, it might be inferred that the force would be transmitted mainly to the right orbital region, or that opposite the entrance perforation. Whereas both orbital plates were fractured. That the fragments inclined upward toward the brain rather than downward and forward, was probably due to the pressure of the blood extravasated within the orbits. It may be safely asserted that, abstracting the fractures of the inner without injury to the outer table, no incontestable instance has been produced of counter-stroke fracture of the skull from gunshot, a negative result which the laws governing the transmission of forces would lead us to anticipate. Sumaiary.—Excluding those immediately fatal on the field, the cases of gunshot injuries of the cranium which were reported during the War, numbered forty-three hundred and fifty. The results are set forth in the table to be found on the next page (Table VI), which is a statistical statement of the different divisions of gunshot injuries treated of from page 95 to this point. * The Medical and Surgical Reporter, Philadelphia, Vol. XII, p. 453. Among many other inaccuracies, the reporter describes the ball as passing into the right hemisphere. Bui this error does not affect the argument of Professor Longmore.—COMPILER. tThe Lancet, London, 1865, Vol. 1, p. G49. Professor Longmore adds a report of a most interesting autopsy made by Deputy Inspector-General R. Lawson, in a > analogous case, in which the left orbital plate was fractured after a fracture of the left parietal by a musket-shot. This is the only other instance I know of in which the occurrence of this rare injury is referred to by writers on gunshot injuries of the head, and is well worth the reader's attention.—Compiler. GUNSHOT INJURIES OF THE CRANIUM. 307 Table VI. Results of Four Thousand Three Hundred and Fifty Gunshot Injuries of the Cranium reported during the War of the Rebellion. INJURIES. Contusions of the skull....................... Fractures of outer table alone (?)............... Fractures of inner table alone.................. Linear fissure of both tables................... Fracture of both tables without knoAvn depression Depressed fractures.......................... Penetrating fractures......................... Perforating fractures........................., Ecrasement or crash or smash.................. Contre-coup (?).............................. Aggregates........................ 328 138 20 19 2,911 364 486 73 9 2 4,350 n 273 128J 1 12 1,001 231 68 14 1,729 55 10 19 7 1,826 129 402 56 9 1 2,514 107 16.8 8.7 95. .36.8 64.6 35.8 85.5 80. 100. 50. REMARKS. 260 Union, 68 Confederate___ 111 Union, 27 Confederate___ 18 Union, 2 Confederate..... 4 examples given___...... 40 histories selected......... 164 histories selected......... Abstracts of 93 given......... Abstracts of 26 given......... Abstracts of all given; 6 U., 3 C 1 Union, 1 Confederate....... * Two of these died from inter- current diseases. 95 128 141 159 161 167 190 206 212 304 The results of contusions have been fully considered on page 126, fractures of the outer table on page 140, of the inner table on page 150.- The large ratio of mortality of the " fractures of both tables without known depression," in comparison with the fatality of the cases, in which depressed fracture was unquestioned, must attract attention. The explanation of this apparent anomaly is that many speedily fatal cases, in which no accurate diagnoses were rendered, were included with the deaths without known depression. Of cases reported as " gunshot contusions of the skull," and of the so-called "frac- tures of the outer table alone" and of linear fissure of both tables, there must have been many in which symptoms were obscure and diagnosis difficult arid fallible. The fractures confined to the inner table could only be observed after death, except in such extraordinary cases as that recorded on page 149, where a segment of bone exfoliated and revealed the fracture of the inner table. Doubtless among the cases enumerated as contusions there were those in which the inner table may have been fractured. It wiH be observed that the mortality was slightly less, when the missile passed com- pletely through the cranial cavity, making an aperture of exit, than when it penetrated and lodged. Abstracting the one hundred and seven cases in which the results could not be ascer- tained, there remain four thousand two hundred and forty-three cases, with a general mortality of 59.2 per cent.* * In the Surgical report in Circular No. 6, S. G. O., 1865, p. 9, I have 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 the surgery of the British Army in the Crimea, already cited, Staff Surgeon T. P. Mattheav enumerates (op. cit., Vol. II, p. 28C) eight 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 Avere mortal, or 73.9 per cent. M. Ciienu, in his Crimean report (op. cit., p. 134) classifies two thousand seven hundred and seventy-four wounds of the head under the four divisions of: fractures, undetermined wounds, simple'wounds' 308 WOUNDS AND INJURIES OF THE HEAD. Recapitulation and Genera.l 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. Nature and Results of Twelve Thousand Nine Hundred and Eighty Injuries of the Head from all Causes as reported during the War. INJURIES. Incised Wounds of the Scalp..................... Incised Fractures of the Cranium.................. Incised Wounds of Scalp........................ Punctured Wounds of the Scalp................... Punctured Fractures of the Cranium............... Contusions and Lacerations of the Scalp............ Concussions from blows, falls, railway accidents, etc Fractures of Skull from similar causes............. Gunshot Wounds of the Scalp.................... Gunshot Contusions of the Bones of the Skull...... Gunshot Fractures of the Outer Table (?)........... Gunshot Fractures of the Inner Table.............. Linear Fissures caused by Gunshot............... Gunshot Fractures Avithout known Depression...... Depressed Gunshot Fractures of the Skull......... Penetrating Gunshot Fractures.................... Perforating Gunshot Fractures.................... Smash......................................... Contre-coup(?).................................. Aggregates.......................... 282 49 28 18 6 331 72 105 7,739 328 138 20 19 2,911 364 486 73 9 2 12,980 Deaths. 6 13 1 2 5 14 57 162 55 10 19 7 1,826 129 402 56 9 1 2,774 Discharges. 68 12 10 4 1 21 43 28 1,176 173 66 1 12 651 190 65 17 2,539 208 24 17 12 309 13 17 3,689 100 62 309 42 19 4,821 Result un knoavn. 1 2 3 2,712 125 3 2,846 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. CHENU gives seven hundred and thirty-one cases, with five hundred and forty-one deaths, or a mortality of 74 per cent. In the Austro-Franco-Italian war of 1859, M. CHENU (op. cit, T. II, p. 424) tabulates seven hundred and seventy-nine wounds of the head from all causes, with four hundred and fifty-six deaths, a mortality of 58.53. These are classified as contused, complicated, and undetermined wounds, contusions and unspecified (sans indications) injuries. There were two hundred and thirty-three contused wounds by musket balls, with two deaths, and twelve from shell 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-three undetermined wounds from small projectiles,»and ten from large missiles, 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, or altogether five hundred and ninety-five cases of gunshot injuries of the head, with one hundred and thirty-four deaths, or 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 the skull, with a mortality of one hundred and fourteen cases, or 48 per cent. Inspector General MOUAT reports, from the New Zealand War, thirty-six gunshot wounds of the head among the ofBcers and men of the British 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, with Abstract 1095, and ending with Abstract 1422, on page 126, memoranda of three hundred and twenty-eight 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 the the remaining cases of gunshot fracture before proceeding to a more general discussion of the head injuries referred to in the foregoing observations. Table VIII. Resutts of Hine Hundred Cases of Injuries of the Skull in which Operations were performed. OPERATIONS. > J> a | a . REMARKS. 3 « a © Q a "3 175 33 89 21 83 12 3 48.3 36.3 The missiles extracted from beneath the scalp or soft parts are not reck-oned in this table. Removal of bone splinters or elevation of de- ? pressed bone. J 454 275 176 3 39.0 220 95 124 1 56.6 29 7 22 75.8 M*\ 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: Nitschke, A., Sergeant, Co. A, 26th Wisconsin Volunteers, aged 23 years. Resaca, Georgia, May 15th, 1864. Treated at Bridgeport and Milwaukee. Duty, March 15th, 1865; discharged June 24th, 1865. Examiner James Diefendorf, M. D., reports, July 6th, 1865, 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. ' 310 WOUNDS. AND INJURIES OF THE HEAD. Ryan, P., Private, Co. F, 27th Indiana Volunteers. Gettysburg^ July 3d, 1863. Fracture of left parietal by fragment of shell. Treated at Camp Letterman, McDougall, and De Camp Hospitals. Duty, February 20th, 1864; discharged October 10th, 1864. Examiner J. T. Dodd reports, January 10th, 1865, that there is a sulcus, shoAving a loss of osseous tissue one inch and a half long and three-fourths of an inch Avide, and that the applicant stated that he suffered from vertigo and pain on stooping. Brown, Nathaniel, Private, Co. D, 154th NeAV York Volunteers, aged 29 years. Chancellorsville, May 3d, 1863. Treated at hospital of Eleventh Corps, Carver, and De Camp. Duty, May llth, 1864; discharged June llth, 1865. Examiner Thomas J. King, M. D., reports portion of frontal, about one inch in diameter, carried aAvay ; fistulous opening remains; several pieces of bone exfoliated; discharge still continues from opening; the pensioner suffers from vertigo. Sawyer, J. H., Private, Co. K, llth NeAV York Battery. Gettysburg, July 3d, 1863. Treated at Seminary, McDougal, and DeCamp Hospitals. Duty, February llth, 1864; 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 pieces of bone; paralysis of left side for four weeks, and headache; cannot bear heat of sun nor Avarming influence of exercise or labor Avithout severe headache, dizziness, and confusion of thought; was of opinion that the bullet was still in the head. Harris, George, Private, Co. D, 35th Indiana Volunteers, aged 20 years. Kenesaw Mountain, 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. R. HaAvn, M. D., reports, April 27th, 1869, mental faculties greatly impaired; is almost an idiot. Thompson, Hklim, Corporal, Co. E, 44th NeAV 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, 1868, 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, 18(15. Examiner William G. Perry, M. D., reports, January 12th, 1867, that about a square inch of the bone Avas gone; that he cannot stoop without 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 Keserve Corps, from the group of eight hundred and twenty-three cases, six were subsequently pensioned. Essklstine, L. W., Sergeant, Co. L, 1st NeAV York Cavalry, aged 26 years. New Market, Virginia, May 15th, 1864. Fracture of left mastoid process by musket ball. Treated at Frederick, Baltimore, and Elmira. Transferred to Veteran Reserve 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 the power 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: Krtjger, B., Private, Co. A, 8th New York Volunteers. Bull Run, 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 hearing of left ear is entirely destroyed, and that there is constant and profuse otorrhcea. Kaiiler, Lewis, Private, Co. I, 13th New Jersey Volunteers, aged 44 years. Chancellorsville, May 3d, 1863. Fracture of occipital bone by conoidal ball, which 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 6th, 1867, states that there is vertigo, dimness of vision, and pain in head, and that the poAver of locomotion is somewhat interfered with. Wainwright, James A., Private, Co. I, 15th New Jersey Volunteers, aged 34 years. Cedar Creek, October 19th, 1864. Fracture of frontal hone by conoidal ball. Treated in field, at Baltimore, and Philadelphia. Discharged June 16th, 1865. Examiner Alfred Edeline, M. D., reports that 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 wound, leaving the other fingers contracted. * One of these im-al ided men had suffered from erysipelas of the scalp ; another had survived a copious haemorrhage from the temporal artery, 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 INJURIKS OF THE CRANIUM. 311 Curtiss, Robert G., Private, Co. D, 34th Massachusetts Volunteers, aged 18 years. NeAV Market, May 15th, 1864. Fracture of frontal bone by conoidal musket ball. Treated at Cumberland and Worcester. Discharged June 2d, 1865. There is loss of bony structure and his disability is rated three-fourths and permanent. Countermine, Charlks F., Private, Co. C, 140th New York Volunteers, aged 20 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. Dunning, Eugene H., Private, Co. I, 140th NeAV York Volunteers, aged 21 years. Wilderness, May 5th, 1864. Treated in field, Washington, and Baltimore, and discharged July 9th, 1865. Examiner B. L. Horey, 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 llth, 1865. 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 dimnesss of vision. Ickerman, 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 destroyed. 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 because 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. Nearly 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 character of those of the series just adverted to, and call for no remark, except that in one instance (Private W. N. 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, 19th South Carolina Regiment, aged 38 years, wounded at Snake Creek Gap, October 15th, 1864. The next in age was Lieutenant J. N. Moore, 48th Virginia Infantry, wounded July 9th, 1864, at Monocacy, aged 30 years. The rest were from 20 to 25 years of age. 312 WOUNDS AND INJURIES OF THE HEAD. With few exceptions all of these patients suffered from very grave disabilities. Six of them were utterly disabled by complete hemiplegia, and others labored under partial paralyses. Two o'f 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 the stringency of the examinations for discharge from service in the Confederate armies* The series of thirty cases of deserters from hospitals 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, comprizes 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 by 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 hundred 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. "Nullum capitis vulnus contemnendum" was the warning of Hippocrates. "Nam veluti magna et gravia capitis vulnera non sequitur mors, sic et levia sospenumero mortis causce sint" amplified Galen. "No injury of the head is too slight to be despised, or too grave to be despaired of," paraphrased Liston, a text fully exemplified in the preceding pages. * For example, Surgeons F. N. Patterson, E. M. Waters, and J. B. Thomas, P. A. C S., constituting the retiring medical examining board, at Richmond, in 1865, have under consideration the case of Private James F. Blackwell, Co. E, 15th Virginia regiment, whom Captain Gover certifies to have been severely wounded in both thighs, at the battle of Sharpsburg. September 17th, 1862. This man was enlisted June 19th, 1861. to serve twelve months. His application and Captain GoA-er's certificate are approved by Major C H. Clarke, commanding regiment, Brigadier-General M. D. Corse, Major-General G. E. Picket, and Lieutenant-G eneral J. Longstreet, and the Board finds: That the patient is '' permanently disabled from any service in consequence of gunshot wound of the superior and posterior portion of 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. VII, 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 service, the Board will specify for what position he is best qualified, and, if he has heretofore been detailed upon any light duty, the Board will state how and when employed, and if his services are still desirable in such position. The medical examining board near Petersburg, consisting of Surgeons H. H. Hubbard, G. W. Langdon, L. P. Warren, B. F. Ward, aud C. B. McGuire, P. A. C. S., had before them in March, 1805, among others, Private James Aycock, of Captain D. T. Hardin's company (C), of the 15th North Carolina regiment, whose application being according to rule, and endorsed by the company, regimental, brigade, division, and corps commanders, is faA-orably 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 service of the Confederate States and 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 desirableness 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 are haemorrhage, concussion, compression, cerebral irritation, foreign bodies, extravasations, meningitis, encephalitis, and purulent infection. I need not speak of concussion ;l its signs are well known, and no light has been thrown on its obscure pathology by the observations here collected. External and intra-cranial haemorrhages 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.2 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 (p. 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, Avas wounded at the capture of Fort Donelson, February 14th, 1862, by a musket ball Avhich struck the left ear, carried aAvay the antitragus, perforated the temporal bone, and made its exit at the masseter muscle on the right side, dividing the duct of Steno. He was sent to Third Street Hospital, at Cincinnati, where, on March 2d, in an effort to remove fragments of the petrous bone, there Avas copious haemorrhage, Avhich was treated, but not arrested, by the free employment of persulphate of iron. Haemorrhage recurred on the 8th, and, on March 22d, chloroform was given, and Surgeon John Moore, U. S. A., tied the carotid. Ligature came away on the tAvelfth day. The patient rapidly regained his strength, and was discharged convalescent July 23d, 1862. He was last heard from in 1868. He had facial paralysis. Professor J. A. Murphy reports the case. Private John Brooks, Co. I, 57th Pennsylvania Volunteers, aged 17 years, Avas Avounded at the battle of the Wilderness, May 6, 1664. by a conoidal musket ball, which entered over the left ear, passed foryyards, 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. hoAvever, Avere not injured. He was treated in a field hospital, and, on May 15th, was sent to the Columbian Hospital at Washington. He Avas pale, emaciated, and complained of acute cephalalgia; otherwise, his bodily functions were normal. On the 17th, the headache had increased, and the pupils had become contracted. Expectant treatment was used, notwithstanding Avhich, delirium gradually came on, and, on May 20th, the patient was comatose and unable to swallow. The pulsations of the heart were rapid and feeble; the pulse at the Avrist, imperceptible. He remained in this condition sixty hours, when it was found that if fluids Avere placed in his mouth in small quantities, he would swallow them. From this time he sloAvly improved. On June 2d, the patient was able to sit up, but his bowels were constipated, he voided his urine unconsciously, and his mental faculties were much impaired. He Avas unable to articulate, had no recollection ofthe past or proper perception of present things, and stared vacantly round the tent. His appetite Avas ravenous. The pupil of the right eye did not respond to light; otherAvise, there was no paralysis. At this date, a haemorrhage occurred from the posterior Avound to the amount of about two ounces, followed by great improvement in all the symptoms. Haemorrhage recurred every two or three days, and Avas not altogether checked until the 18th of June, as it seemed to aid much in restoring 1 On this subject consult: COLQUHOUN, G.. De cerebri concussione, Edinburgh 1800; Haktman, A. H., De commotione cerebri, Gryphiae, 1846; Laorange, Delacomm. du. cerveau, These de Paris, 1819, No. 239 ; MOUNIBR, De la commotion cerebral, These de Paris, 1834, No. 119; Repiquet De la commotion du, cerveau, These de Paris, 1808, No. 36; Bruns, V., Die chirurgischen Krankheiten nnd Verletzungen des Gehirns and seiner Umhiillungen, Tubingen, 1859, Band I; Gama, Traite des plaies de tele et de Vencephalite, Paris, 1855, 2m« edition ; Laugier, S., Diet, de Med. ou Rep. Gin. des Sci. Med., Paris, 1834, T. VIII, p. 453; DuPUYTREN, Lecons Orates, Paris, 1839, T. VI, p 170; Mayer, C, De commotione cerebri, Berol., 1816; Maler, D., De commotione cerebri, Argent, 1777 ; FaNO, Memoire sur la commotion (Memoires de la Soeieti de chirurgie de Paris, 1852). 2 See Mr. PltESCOTT Heweti's remarks in Holme's System of Surgery, 2d ed., 1870, Vol. II, p. 258; Sir Benjamin C. Brodie (Med. Chir. Trans. Vol. XrV, p. 385) says: "blood is seldom poured out in any considerable quantity between the duramater 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 this accident to occur, except as a consequence of fracture. If, therefore, we find the patient lying in a state of stupor, and, on examining the head, we discover a fracture, with or without depression, extending in the direction of the middle meningeal artery, although the existence of an extravasation on the surface of the duramater is not thereby reduced to absolute certainty, it is rendered highly probable; and the surgeon, under these circumstances, would neglect his duty if he omitted to apply the trephine; and where no fracture is discoverable, yet, if there is other evidence of the injury having fallen on that part of the cranium in which the middle meningeal artery is situated, the use of the trephine may be resorted to on speculation, rather than that the patient should be left to die without an attempt being made for his preservation."- 4:0 314 WOUNDS AND INJURIES OF THE HEAD.- his mental faculties. On the latter date, an attempt was made to ligate the temporal artery; and this failing, the common carotid was ligated at its upper portion, on June 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 Avere removed; the wound Avas then plugged with lint, Avhich entirely arrested the haemorrhage. It Avas estimated that fifty ounces of blood had been lost during the last haemorrhage. Liberal diet was prescribed, and the patient gained rapidly in flesh. The ligature came away on the tenth day after the operation, and the Avound united, except at the point of ligation, Avhere a fistulous opening remained, which discharged daily a small amount of pus. On August 15th, blood Avas found to ooze from the place of ligation; and, the patient having lost about twenty ounces, the artery was cut doAATn upon by Surgeon Crosby and ligated below the omo-hyoid muscle. The vessel was found dilated to more than double its normal size, and firmly attached to it, on the inner side, Avas a well-formed clot. Low diet was ordered; tincture of aconite Avas given to keep the heart's action as much reduced as Avas consistent Avith the safety of the patient. On September 15th, the Avound had fully healed, and, on November 15th, the patient was furloughed, apparently entirely restored in his bodily functions. He Avas discharged from service on June 8th, 1665. The case is reported by Surgeon T. E. Crosby, U. S. V., and iB 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, June 3d, 1864, the ball entering at the right of the protuberance, and emerging at the right meatus auditorius. He Avas conveyed to Alexandria, and, on June 6th, on his admission to 3d division Hospital, in an anaemic state, the wound Avas swollen from extravasation under the scalp. On the 8th, Surgeon E. Bentley, U. S. V., gave chloroform and ligated the common carotid opposite the thyroid cartilage. The bleeding continued after the operation, and the Avound Avas filled with lint saturated Avith a solution of persulphate of iron. The patient lingered until June 13th, 1864, and died from syncope, Private Taylor Mcintosh, Co. H, 40th Indiana Volunteers, aged 18 years, was Avounded at Mission Eidge, November 25th, 1863, by a conoidal ball, Avhich entered 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 loAver maxilla. He was admitted on the next day to the field hospital of the 2d division, Fourth Corps. He Avas stupid and had partial concisions at first, but subsequently regained his senses, although he Avas 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 Avound. December 10th, evacuatiorj of abscess in eyelid. By December 15th, he Avas able to make his wants known 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- FlG. 1*.—Coagulum in distal portion of the left carotid six days after liga- tion. Spec. 3179, Sect. I, A. M. M. -, 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 onco conveyed to the hospital of the 1st division, Fifth Corps, and, on the 24th, was transferred to Lincoln Hospital, Washington. The Avound extended from Avithin a half inch of the outer canthus of the left eye to just posterior to the left mastoid process. Cold-Avater dressings were applied. On the 26th, arterial haemorrhage occurred, which was checked by filling the wound with lint soaked in a solution of persul- phate of iron. It, hoAvever, 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 beloAV 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 Avas found to be cut across. It Avas impos- sible to detect from Avhat artery or arteries the haemorrhage proceeded. Both lungs Avere 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 draAving 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 IoAva Volunteers, aged 19 years, Avas Avounded, by a fragment of shell, in the left temporal region, at Vicksburg, December 28th, 1862. He Avas treated in .a field hospital until January 17th, 1863, when he Avas admitted to LaAvson Hospital, St. Louis. On January 18th, haemorrhage amounting to twelve ounces occurred from the middle meningeal artery, Avhich, 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 Avas discharged from the service May "2~th, 1863. In March, 1868, 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 stooping, and partial anaesthesia of the left side of the face, being compelled to keep his room in the cold winters of Madison, IoAva, from liability of freezing the left ear and face. Andrews remained in tolerable health on June 4th, 1872, nearly ten years from the date of the operation. . LIGATIONS OF ARTERIES,—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-four cases,1 among wounds of the neck and spine, twenty-three cases, of ligations of the common carotid will be found, or a total of eighty-four operations, with sixty-three deaths, or a mortality of 76.8 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 Avounded at the battle of Cold Harbor, June 3d, 1664, by a conoidal ball, which fractured the external angle of the right orbit and the zygomatic arch, passed imvard and doAvnward, and lodged behind the right masseter muscle. He was admitted to the hospital of the 2d division, Ninth Corps, and on June 9th Avas 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 Avas applied to'the bleeding vessels, and the orifice plugged up Avith 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 ihe Superficial Temporal.—This 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.2 Two are here noted. Of the twenty-two, two were fatal from haemorrhage, three from other causes : Private Robert Faucett. Co. B, 8th Michigan Volunteers, aged 45 years, received a gunshot flesh wound of the scalp, on the right side, at Spottsylvania, May 6th, 1864. On May 19th, there Avas haemorrhage from 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 Avas transferred, convalescent, to Whitehall, Avhence he Avas transferred to the Veteran Reserve Corps, January 23, 1865. Private Josiah Forbes, Co. L, 1st Vermont Cavalry, aged 19 years, received a gunshot scalp Avound at Burke's Station, June 24, 1664. The wound became inflamed and irritable and arterial bleeding took place, to arrest which, the right superficial temporal artery Avas tied, at the Baxter Hospital, Burlington, Vermont, in July. The patient recovered and returned to duty, September 29, 1864. Assistant Surgeon S. L. Thayer, U. S. V., the operator, reported the case. Foreign Bodies.—Many remarkable instances of the removal of balls3 and other foreign bodies from under the scalp, or within the cranium, have been recorded. 1 Dr. Love's ligation of the carotid for bleeding in a wound of the face, fatal from distal hasmorrhage (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 Smith, and Corporal Taylor; on page 82, cases of Lieutenant Gilmore, Privates Hartley, Mullen, Reese, Corporals Talmadge, Kullman, and Private D. Jones; also cases of Privates L. Jones, page 83; Newcombe, page 101; Sergeant R. D-----, page IriO; Private Wheeler, page 225 ; Private Miller, page 241; Private Allen, page 244 ; Private Taylor, page 256 ; Private Bunnell, page 288 ; Corporal E. Jones, page 298; Private Brooks, page 313. 3 Since the case of Underwood, p. 281, was put in type, Dr. B. Howard has published (Am. Jour. Med. Sci., October, 1871, N. S. Vol. 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 reach and out of sight has been discovered and removed from the brain by trephining—a permanent recovery 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 the anterior lobe of the left cerebral hemisphere. — [After Howard.] 316 WOUNDS AND INJURIES OF THE HEAD. Of one hundred and eighty-six cases of balls 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.1 Trephining.—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, 46th Indiana Volunteers, receiA-ed, at Jackson, Mississippi, July 12th, 1863, a gunshot fracture of the cranium. He Avas taken to the field hospital, Avhere Surgeon J. L. Dicken, 47th Indiana, performed the operation of trephining. He was afterward treated in the Jefferson Barracks Hospital, and discharged on November 30th, 1863. He did not apply for a pension until February 7th, 1872. Pension Examiner J. M. Justice reports, August 7th, 1872, that Hamilton's disability is one-half 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 duramater exposed. The following2 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------Avas struck, at Petersburg, in 1864, by a shell fragment on the right parietal, near the middle of the sagittal suture. There Avas no marked depression, and the constitutional symptoms Avere slight and soon abated. Two years afterward he had an epileptic convulsion, Avhich recurred in three months, and then Avith increasing frequency, until the paroxyms were diurnal. In 1871, Dr. J. T. Gilmore, formerly chief medical officer of the 1st Division of General Longstreet's Corps, determined to trephine. The perforation measured nearly one inch in thickness. Meningitis followed, and was controlled by purgatives, mercurials, and veratruin viride. The patient regained perfect health, and at the end of 1871 epilepsy had not returned. John Berry, a stout and healthy civilian, at St. Louis, Missouri, on April 27th, 1864, fell from a horse, while in a state of drunkenness, striking his head against a curbstone. Soon after the accident, he Avas 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 bone, and the bare bone was detected with some depression. Five days after the injury a trephine was applied, and several pieces of bone were removed. Three days after the operation, erysipelas supervened; 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 May 30th, he was able to walk about town and take full diet. About one month later he Avas discharged from the hospital. Keported by Surgeon B. B. Breed, U. S. V. A soldier of the 4th U. S. Heavy Artillery (colored) was struck on the head with a spade, causing a compound fracture of the left parietal bone, Avith 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 Avas 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 Avas 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 Avas admitted to the Washington Infirmary. Assistant Surgeon J. W. S. Gouley, U. S. A., enlarged the Avound, Avhich 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 he regained conscious- ness, but again lapsed into a state of stupor. On the following morning, he answered questions coherently. Recovery took place without further untoward symptoms. Reported by the operator. Private John H. Miller, Co. I, 134th New York Volunteers, received a blow upon the head at the battle of Gettysburg, July 1st, 1863, 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, NeAV York, who reports some depression of the edges of the fractured bone, Avhich caused compression of the brain and hemiplegia ofthe right side. The patient had convulsions regularly once a Aveek, and these symptoms becoming more aggravated, on November 24th Drs. Wheeler and S. B. and H. Wells performed trephining. He was discharged from the serA'ice May 30th, 1834. 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 ofthe left parietal bone, and rated his disability as three-fourths and permanent. l Aran, Recherches sur les fractures de la base ducrdne, (Archives g&nirales de midecine, 1844, Tom. VI, 4me serie.); Bonetus, THEOFH., Sepulchretum. lib. IV, Sect. 3, observalio AT, Geneva;, 1700; Celsus, A. C, De re medica libri octo, Lugduni, 1592 ; Chopart, Memoire sur les lesions de la tete par contre-coup, Paris. 1771; GRIMA, Memoire sur le contre-coup, Paris, 1778; GOUPIL, Dissertation sur les contre-coups dans les Bletsures de la Tete, Paris, 1815; Mehee, Traite des lesions de la tete par contre-coup, Meaux, 1773; SABOURAUX, Mimoire sur les contre-coups dans Us lesions de la tete, 1778 ; AVagnek, R., De contra fissura, Jena, 1708, in HalUr's Disp. Chir., T. I, p. 15; Verite, De la guirison des fractures du rocher, These de Pari*. 1667, Xo. 59. "- GILMORE. Report of the Surgery of Mobile County for 1871, p. 31; Heavett, in Holmes's System of Surgery, 1870, Vol. LI, p. 248, Path. Cat. R. C S.. Vol. II, p. 168.. MSS. Surg. Cat. A. M. M., Spec. 5135, Sect. 2. TREPHINING OF THE CRANIUM. 317 Private William H. Edwards, Co. I), 3d Iowa Cavalry, aged 23 years, of good physical condition, was admitted into the hospital at Keokuk, IoAva, January 31st, 1864, Avith a fracture of the left parietal bone near its eminence, caused by a blow from a naA-y re\Tolver, at Memphis, January 23d, 1864. He was comatose and delirious ; the soft parts were greatly lacerated and contused; there Avas a slight discharge of pus and blood; there was a circular depression of the fractured bone less than one-half an inch in diameter. The operation of trephining being deemed advisable, Acting Assistant Surgeon D. S. McGuigan 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 Avere applied without success, and saturated solution of sulphate of iron was substituted; the hernia gradually declined, and he was discharged December 19th, 1864. He applied for a pension, but his claim Avas rejected. The case is reported by the operator. Private John McTye, Co. G, 6th Tennessee Volunteers, was struck on the head with a piece of steel, knocked insensible, and robbed, on February 7th, 1863. He Avas admitted into Hospital No. 1, Murfreesboro', on the same day. The propriety of trephining Avas considered, but the operation was not performed. He apparently recovered, and the wound gave him no trouble, and on March 23d he Avas transferred to Hospital No. 23, Nashville, where he was treated for diarrhoea; on April 7th, while applying for a pass, he Avas suddenly attacked with convulsions, and an examination revealed a depression over the fronto- parietal suture sufficiently large to insert the little finger; after consultation, a T-shaped incision was made, the trephine applied, and three pieces of bone removed. On the 8th, he rested Avell, pulse 124, tongue slightly colored, and appetite poor; on the 9t'i, he was very much depressed in spirit; on the 10th, he commenced sinking; the parts around the wound became much swollen, and he d;' d on April llth, 1863. 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 tAvo at its centre and depressed about three-fourths of an inch. Trephining was performed by Acting Assistant Surgeon John Morris. The compression Avas relieved. The patient 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, fifty-six fatal, or 56.6 per cent.; secondary, four fatal, or 23.5 per cent. If the thirty-four opera-r tions, 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.1 As to the degree of fatality according to the pait of the cranium perforated, the results of one hundred and fifty-two operations for the effects of shot fractures limited to one cranial bone, give the following results: trephining of parietal in eighty-five cases, l ARKEMAXN, D., Bemerkungen uber die Durchbohrung des processus masto'ideus in gewissen Fallen der Taubheit, Gdttingen, 1792 ; BREYER. F., De trepanatione cranii in morbis capitis, Tubingae, 1831; BILLROTH, Til., Historische Studien uber die Beurtheilung und Behandlung der Schusswunden vom 15, Jahrhundert bis avf die neuesle Zeit, Berlin, 1859, p. 29 ; Baret, P. G., Essay sur la necessity de Voperation du trepan dans Us plaies de tete par armes & feu, Paris, 1815; BERLIN, A., De cranii trepanatione qusedam, Berolini, 1828; Celinski, De trepanatione cranii, Diss., Berolini, 1833;- Cokstatt, R., Nonnulla de terebratione cranii leesionibus capitis adhibenda, Vratislaviae, 1865; DALE, T. F., Depressed Fracture of the Cranium successfully treated, North Am. Med. and Surg. Jour., Vol. X, p. 164; Dorsky, J. S., Fracture of the Skull and Wound of the Brain, Phila. Med. Museum, Vol. II, p. 282, 1806; FLOURENS, Considerations sur Vopiration du tripan, Paris, 1830; FISCHER, H., Klinisches und experimentelles zur Lehrevonder Trepanation, Berlin, 1865; GL'ILD, J., Case of Epilepsy cured by Trephining, Am. Jour. Med. Sci., Vol. IV, p. 96, 1829; Hceckert, C. A., De trepanatione adjectis observationibus hue spectantibus, Diss., Wirceburgi, 1826; Hayavood, G., Epilepsy successfully treated by Trephining, Am. Jour. Med. Sci., Vol. XXII, p. 517, 1838; HOLSTON, J. G. F., Trephining for Epilepsy, Am. Jour. Med. Sci., Vol. XVII, p. 541, 1849 ; Judkins, W., Chronic Injuries of the Brain relieved by an Operation with the Trephine, Transyl. Med. Jour., Vol. II, p. 135, 1829 ; Kauzmann, M. E., De novo trepanationis instrumento, Diss., Erlangen, 1802; Kerxer, Th., De perforalione capitis, \Tratislavia3, 1856; LEFORT, De Vutilite et des indications de la trepanation du crdne dans les lesions traumatiques de la tete (Gaz. Hebd., 1867, Nos. 19, 20, 24) ; LUDWIG, G. F., De novo trepano preecique pro orbitse vulneribus atque de indole morborum verndlium, Tubingae, 1811; LE BltUN'A, Biblioteka umiejetnosci lebarskich, Chirurgia Operacyjna, Warzsawa, 1868 ; Larrey, M. H., Etude sur la Trepanation du crdne dans les Lesions traumatiques de la tete, Paris, 1869 ; LOUVMER, J., Abhandlungen uber die Durchbohrung des Schadels, AVien, 1800; Lauffs, J., De variis trepanationis mcthodis, Berolini, 1826; LEISNIG, A. F., Uber Trepanation, NYiirzburg, 1844; Malaval, Precis d'obs. sur le trepan in Mem. de I'Ac. roy. de chir., 1743; MOTT, V., Memoir on the Subsequent Treatment of Injuries of the Head, Trans. Physico-Med. Soc of New York, Vol. I, p. 223, 1817; Nksemann, B., De terebratione cranii in leesionibus capitis adhibenda, Vratislaviae, 1858; Norris, G. W.4 Report of Cases of Injuries of the Head, Am. Jour. Med. Sci., Vol. IX, p. 304, 1831; PARK, A., Fractured Skull successfully trephined, Chapman's Phila. Med. Jour., Vol. VIII, 1824 ; Richter, C A., Uber Kopfverletzungen und die Trepanation, Tubingen, 1863; ROSER, AV., Zur Trepanationslehre, in pamphlets, v. 224; ROGERS, D. L., Epilepsy from Depressed Bone, cured by Trephining, N. T. Med. and Phys. Jour., Vol. V, p. 79, 1826; Rolanu, De trapanatione cranii, Berolini, 1844; TEXTOR, C, Uber die Nichtnothwendigkeit'der Trepanation bei Schadel- eindriicken, Wiirzburg, 1835; Velpeau, Plaies de tete, De Voperation du trepan, Paris, 1854 ; VROLICK, Bemerkungen uber die Wcisse, wie die Oeffnung in dem Schadel, nach der Trepanation, oderanderem Knochenverlust, ausgefiillt wird, Amsterdam, 1837 ; WAREINSHEIX, These de Paris, 1861, No. 58, Du trepan en AngUterre; Wirmanski, J., De cranii trepanatione, Berolini, 1831; Weeds, J. F., Case of Cerebral Abscess, NashvilU Jour, of Med. and Sci., April, 1872. 318 WOUNDS AND INJURIES OF THE HEAD. Fio. 4*.—Calvaria, showing a shell fracture near the vertex. Spec. 1013, Sect. I, A. M. M. 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.1 Hernia cerebri.—Sixty-one cases were reported, with eleven recoveries.2 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 be 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. 5*. 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. 4*) represents a calvaria contributed by Surgeon J. T. Hodgen, U. S. V.,—case of Private James M-------, 24th Texas Cavalry, wounded by a shell fragment at Arkansas Post, January 22d, 1863, with injury of dura-mater; died February 8th, 1863. Figure 6* represents a pistol ball 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 probably erroneous. There is great variety in the malleability of the lead-used for projectiles; but the momentum necessary to produce flattening in the softest will generally suffice to overcome the resist- ance of the hardest bone. The projectile represented in the cut (Fig. 7:::) weighed only thirty grains, but fractured and depressed the frontal bone. i In the surgical report in Circular No. 6, 8. G. O., 1865, page 16,1 stated that " Surgeon D. \V. Bliss, U. S. V., alone has reported eleven successes after the use of the elevator or trephine.'' 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 of trephining, with six recoveries, viz: 1. R-----, p. 59; 2. Morton, p. 125, fatal; 3. P-----, p. 266, fatal; 4. E-----, p. 2G8, 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 remoA-al of fragments, namely: 1. Wagner, p. 238; 2. N-----, p. 248, fatal; 3. McConnvifle, p. 255, fatal; 4. Kennedy, p. 294, or fifteen cases, with eight itc-overies. 2 Adernetht, Surgical Works, Vol. II, 1830, p. 51; Ali.ex, J. A., Fungus cerebri successfully treated by Excision. New England Med. Jour., Vol. VlII, p. 323, 1819; Kick. G., Researches on Hernia Cerebri following Injuries of the Head, X. T. Jour. Med. and Surg., A'ol. IV. p. 348, 1840; C'ouvixi>. J. F. C, De hernia cerebri, Argentorati, 1749 ; DETMOLD, W., Abscess in the Substance of the Brain; Hernia Cerebri, the Lateral Ventricle* opened by an Operation, Am. Jour. Med. Sci., Vol. XIX, p. 86, 1850; Hennen, op. cit, 3d ed., p. 316, Case XLVII; Helstis, J. AV., Case of Hernia cerebri cured, Am. Jour. Med. Set., Vol. Ill, p. 350, 1829; Hill, J., Cases in Surgery, Edinburgh, 1872, p. C4; LOI is, Sur U tumeur fongeust de la Dure Mere, Mem. del'Acad. Royal de Chirurgie, Nouv. ed., Paris, 1819, T. V, p. 9; SoLOMOXB, De cerebri tumoribus, Dias., Edinburgh, 1810; Stanley. Cases of hernia cerebri, in Med. Chir. Transactions, Vol. Ill; Held, De hernia cerebri, Diss., Giessas, 1777. Fig. 5*.-Skull of a Pampa Indian fractured by the bolas, a ball attached to a cord, a Pate- gonian weapmi. Spec. 972, Sect. I, A. M. M. Fig. 6*.—Internal view of segment of left parietal perforated by a pistol ball, the inner table beveled, but not fissured. Spec. 3220, fcect. I, A. M. M. Fig. 7*.—Buck- shot flattened on the frontal bone. Spec. 4473. 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 duramater 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. Klenke1 reports 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. H. W------, of Washington, a precocious lad of about twelve years, received, in 1842, a compound depressed fracture of the right side ofthe frontal bone, caused by a blow from a stone. The integuments were drawn together by adhesive strips, and absolute rest, Ioav diet, and confinement in a dark room were enjoined by his medical attendant, Dr. Thornton. He recovered apparently Avithout any untoward systoins; but a few Aveeks afterward, Dr. BorroAvs Avas called to see him on 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 Avas 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, Avhen epilepsy recurred, and he gradually became idiotic. He lived till 1863. Physically he was Avell devel- oped. These reminiscences of the case Avere furnished orally by Dr. Joseph Borrows. The specimen was contributed by Professor Johnson Elliot, of the Georgetown Medical College. The trephine 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 the mem- brane, which must have pressed upon the cerebral mass. No notes of the autopsy were preserved. Surgeon Andrews,2 1st Illinois Light Artillery, differs from Guthrie, and from 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. 'Wagner (Uber den Heilungsprozess nach Resection und Extirpation der Knochen, Berlin, 1853, »S. 23) refers to the paucity of notices of dissections of persons who have survived trephining for a long period. Consult Dubreuil (Presse Medicate, 1837) ; GUENSBURG (Deutsche Klinik, 1850, No. 8); Klexke (Physiologic der EntziXndung und Regeneration in Organischen Geweben, Leipzig, 1842, S. 197) ; ROKITAXSKI (Lehrbuch der Pathologischen Anatomic, AVien, 1855, B. I, S. 179); Jameson, Case in which the Osseous Disk, removed by trephine, was regenerated, Mary- land Medical Recorder, A'ol. I, p. 152, 1829 '• Hunauld, Sur les os du crdne de Ihomme in Mem, de VAcad. des Sciences, 1730; Verite, De la guerison des fractures du rocher, These de Paris, 18CJ7, No. 59; OLLIER, Traite experimental et clinique de la regeneration des os, Paris, 1867; Vioarol'x, Opuscule sur la rigineration des os, Paris, 1788. Opportunities of examining the repair of depressed fractures of the skull, after the lapse of many years, are not very common. Hence the interest attaching to the specimen represented by the wood-cuts (FIGS. 5* and 6*). The case is reported on page 165 ante, and the specimen is described at page 10 of the Catalogue of the Surgical Section of the Museum. 2 Andrews (Complete Record of the Surgery of the Battles fought near'Vicksburg, December 27th, 2Sth, 20th, and 30tt, 1862, Chicago, 1863, p. 32) relates five cases of cranial fracture with the following comments: " Of these five fractures two were from bullets penetrating the brain and three from pieces of shell or oblique bullets. They all died, without exception; only one was trepanned, and he without benefit. The general result in military Surgery is that gunshot fractures of the oranium are 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 brain, which, for some reason, seems to sustain injury with less mortality than any other part." Fig. 8*.—Exterior view of trephine orifice eighteen vears after operation. Spec. 5024, Sect. I, A*. M. M. Fig. 9*.—Interior view of same specimen, showing the fibroid septum, with its falci- form projection. Fig. 10*.—Exterior view of a segment ofthe right side of the frontal bone, deeply indented. Spec. 2619, Sect. I, A. M. M. * FIG. 11*.—Interior view of the foregoing speci- men. Spec. 2619, Sect. I, A. 31. M. 320 WOUNDS AND INJURIES OF THE HEAD--CONCLUDED. Brevet Lieutenant Colonel J. G. F. Holston, Surgeon U. S. V., Professor of Anatomy of the Georgetown Medical College, gives the folloAATing vieAvs of operative interference in Avounds of the head: " I will briefly state my vieAvs of trephining under the three heads of primary, intermediary, and subsequent operations. Primary operations are indicated: 1st. Where the scalp is Avounded and the subjacent bone broken in, so as to press upon a portion of the braiu that cannot be relieved in any other Avay; for, in this case, the brain has already suffered and Avill suffer still further injury, if not relieved: commonly, some portions may be picked away by the forceps, so as to f 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 difference. I have preferred the chisel for such removal, as the sharp edge of the chisel will cut cleaner and Avith less irritation than the saw, the teeth of which tear the tissues, and give almost as much shock for every tooth, as the chisel and mallet do at every Vj1oav. The chisel I have had made by Tiemann, is of the form indicated (Fig. 12*), the projecting blunt tooth of the cutting edge pressing aside the duramater and preventing 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 ofthe interior ofthe cranium, believing that the patient may be more severely hurt by the exploration than by the original injury. I should content myself in such cases by removing all extraneous spiculae of bone and other detrimental matter that may be about the orifice of the wound. 3d. Where there is no external Avound, but evidently a large compression of bone on the brain. If symptoms of com- pression are gradually deepening, there can be no doubt but Ave should relieve the brain of pressure; in this case, probably blood has been poured out from one of the meningeal arteries. I consider such operations intermediary as are performed on the patient before he has recovered 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. But there is one condition, which happens occasionally, where a certain part ofthe skull has been struck without external Avound, Holston's 0r without any sign of compression coming on immediately. After several days, coma begins to manifest itself, and here we have probably to deal Avith suppuration ; which, if not speedily provided Avith 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 have four times successfully operated on epileptics. The patients all recovered of the operation, and all were cured of the epilepsy. As regards 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 practice, but I found in my 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 Avithout trephining than Avith, so that it is an open question Avith me, whether trephining 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 other operative proceedings." Note.—The following authorities may be consulted on Wounds and Injuries of the Head: Andral, Clinique de la Charite, Tom. V; BaucheTi Des Usions traumatiques de Vencephate. These de concours pour Vagregation, Paris, 1860; Baudens, M. L., Clinique des plaies d'armes a feu, Paris, 1836; Begin, Elements de Chirurgie, Paris, 1858, Tom. II; Bell, B., System of Surgery, Vol. Ill, 1785; Berchon, Observations remarquables de fractures du crdne. (Bulletin de la Societe anatomique, 1865); Berenger de Carpi, Defractura cranii, 1529; Bichat, Memoire sur les plaies de la tete, Paris; BOHN, De renuntiatione vulnerum, Lipsiae, 1711; Boinet, Des signes immediate de la contusion du cerveau. (Archives generates de mide- cine, 5mes6rie, Tom. II et III, 1837); BoiREL, Traite des plaies de tete, Alencon, 1677; Botallus, L., Op. Omnia, de Vulner. sclop, 1582; Boyer, Maladies Chirurgicales, Tom. IV, 5me edition; Briot, Histoire de I'lStat et des Progres de la Chirurgie Militaire en France, Besancon, 1817; Brodie, Silt Benj., On Injuries of the Head ; Brownschweig, Dis ist dat Buch der Cirurgia Handwuerckung der Wundtartznei' Strassburg; Caspari, Die Kopfverletzungen, Leipzig, 1823; Chassaignac, Des lesions traumatiques de I'encephale, (These pour le concours d'agregation en chirurgie, Paris, 1842); Chauvel, Des fractures du crdne (These de Paris, 1864, 124) ; Colles, Practical Precepts on Injuries of the Head, Dublin, 1814; Cooper, Samuel, Diet, of Pract. Surg., 7th and 8th editions, 1838 and 1869; Cooper, Sir A., Lectures on the Principles of Surg., Vol. I, London, 1824 ; Dease, Observations on Wounds of the Head, 1776; LaJIotte, Traite complet de chirurgie, Tom. H, Paris, 1722; Denonvilliers, Compendium de chirurgie, Tom. II, Paris, 1864, These de concours pour Vagregation, Paris, 1859; Desault, CEuvres Chirurgicales, Tom.II; Despoutes, Plaies d'armes a feu, Par;?, 1749, p. 388; DE VIGO, JOHN, Practica in arte chirurgica copiosa, Rom, 1514;'DlONIS, Cours d'operations chirurgicales, 4mc edition, 1740; Duchesne, Joseph, Sclopetarius, Lugdun, 1576; Dupre de l'Isle, Traite des lesions de la tete, Paris, 1770; Eichorn, W., De capitis Isesionibus, Erlang, 1815; Eltze, Diss, defract. basii cranii, Berlin, 1826 ; Fabrice D'Aquapexdente, CEuvres chirurgicales, Lyon, 1674; Fabricius Hildanus, Observations Medico-chirurgicales, cent. 6 ; Ferri Alphonso, De Tormentariorum sive Archibusorum vulnerum et cura, Rom, 1552; Gama, Traite du plaies de tete et de Vencephalite, Paris, 1855, 2me edition; Garengeot, Operations chirurgicales, Tom. Ill, 1751, 2me Mition; Gerard, These de Slras bourg, 1802; Geesdorf. Feldbuch der Wundtartznei, Strassburg, 1517; GOOCH, B., Cases and Practical Remarks in Surgery, London, 1758; Guil- lejieau, CEuvres de chirurgie, 1649; Guthrie, On Injuries of the Head, London, 1842; Haller, Disputationcs chirurgicx select®, Tom. I, Venetiis, 1755; Hennen, Op. cit.?. 281; Heavett, P., Lectures on Injuries of the Head, Medical Times and Gazette, Vol. 11,1855, and Med. Chir. Trans. Vol. XXXA'I, 1853 ; HILDANUS, Ccnturia 2, Observat. 2, p. 77 ; HILLS, Cases in Surgery, 1762 ; HIPPOCRATES, De Vulneribus capitis, 1578 ; JOLIEU, Doctrine des anciens sur les plaies de tete (These de Paris, 1811); Larrey, Clinique chirurgicale, Tom. I et V; Lauriol, Considerations sur les fractures de la base du crdne (These de Montpellier, 1851, 99); Ledran, Observations de chirurgie, Tom. I, 1751; Lombard, Remarques sur les lesions de la tete, 1796; Losius, Observ. Medic. 1, lib. 1; Magatus, De rara medicatione vulnerum, Venetiis, 1676; MALGAIGNE, De la theorie et du traitement des plaies de tete (Gazette medicate, 1836); Maxne, Obs. dechir. au sujet d'une plaie a la tete, Avignon, 1729; Marchettis, Observationum medico- chirurgorum radofum sylloge, Amstelodam, 1665; Marchal de Calvi, Annates de la chirurgie, Paris, 1842, Tom. V; Marjolin, Diet, en 30 vol. (tete), 1844; Maslieurat-Lagemard, Ecchymoses palpebrales et orbitaires (Archiv. gener. de medecine, 1841, Tom. XI, 5me. serie) ; Matzger, De lasionibus capitis, 1774 ; Michel, These de Paris, 1854, No. 95, Quelques considerations sur le crdne surtout au point de vWe des fractures; MlNDERER, Medicina militaris seu libellus castrensis, Augsburg, 1620; Nouhault, Traitds des Plaies de Tete; OCHWADT, Kriegs-chirurgische Erfahrungen auf dem administrativen und technischen Gebiete wdhrend des Krieges gegen Dancmark, Berlin, 1865; Pare, CEuvres completes, Tom. II, Edition Malgaigne, 1840; Petit (J. L.), CEuvres chirurgicales, Tom. I, p. 43, 1774; Percy, Manuel de Chirurgien d'Armee; PLATNER, Institutions chirurgicx, Lipsi*, 1745; Pott, P., Obs. on the Nat. and Con. of Wounds and Cont. of the Head, London, 1760; Quesnay, Mem. de VAcdd. de chirur., 1743; Ranhy, Method of treating Gunshot Wound*, London, 1744; RlCHET, Anatomie medico-aliirurgicale, Paris, 1860; Rouhault, Traite des plaies de tete, Turin, 1720; Saucerotte, Mem. de VAcad. de chirur., Tom. Ill; Saviard, Nouveau recueil d'observationschirurgicales, Paris, 1702; Schmidt, Kopfverletzungen, Hamburg, ]?:!-: Scultetus, Armamentarium Chirurgicale, 1593; Schmucker, Chirurgische Wahrnehmungen, Berlin, 1759; Serres, Annuairc m4dico-chirurgical des hopitaux, 1849; SHARP, W., Practical Observations on Injuries of the Head, London, 1841; Teubeler, De vulneribus cerebri- non semper Uthalibus, Halle, 1760; Tulpius, N., Observationes Medicse, Lugduni, Bat., 1716; Van Swieten, Bocrhaavi aphorismi; WEPFER, J. J., Observationes de affect, capitis, Scaphusii, 1727; Yo.vge, Wounds of the Brain proved curable, London, 1682. CHAPTER II. WOUNDS AND INJURIES OF THE FACE. The number of cases reported of wounds and injuries of the face that came under treatment was nearly ten thousand, or a proportion of rather more than three-fourths, as compared with the lesions of the cranium and its soft parts. It will be unnecessary to discuss the wounds of the face in such detail as those affecting, or liable to affect, the brain, injuries of the head affecting the brain having been already fully considered. The chapter will be divided into three sections; the first devoted to the incised, punctured, lacerated, and miscellaneous wounds, the second to gunshot wounds, and the third to plastic operations for deformities resulting from wounds and injuries of the face. Section I. INCISED WOUNDS, CONTUSIONS, AND MISCELLANEOUS INJURIES. The cases grouped under this heading number several hundreds; but few are reported sufficiently in detail to possess much surgical interest. The most serious cases referable to this class were the burns and scalds, which will be separately considered in a future chapter. The instances of sabre and bayonet wounds will be enumerated, and a tabular statement of the other cases belonging to this Section will be given. Sabre-cuts.—Thirty-seven cases of sword wounds of the face were reported In four instances only were the facial bones incised or denuded, and but a single case had a fatal result. There was no example of grave injury to the vessels or nerves. Twenty-eight of the thirty-seven wounded men were returned to duty at intervals of from one to one hundred and eighty days. Three patients were discharged, one was sent to the provost marshal for exchange, one deserted, one died, and three are not accounted for. 41 o__ WOUNDS AND INJURIES OF THE FACE. Barnett, Robert, Private, Co. F. 6th United States CaA'alry, aged 34 years. MoAver Hospital. Duty, September 13th, isi;:i. Brand. Adam, Private, Co. C, 4th NeAV York Cavalry. Aldie Cap, June 17th, 1833. Alexandria Hospital. Duty, June 29th, 1863. Buowx, Charles. Sergeant, Co. F, 9th XeAV York CaA'alry. Rappahannock River, October llth, 1803. Regimental hospital. Duty, October llth, 1863. Bushmaxt, Hexry, PriATate, Co. B, 8th NeAV York, aged 22 years. Bull Run, July 21st, 1861. Duty six months after injury. Carter, Cornelius, Corporal, Co. C, 4th IoAva Cavalry. Hospital steamer, Jefferson Barracks, and Keokuk hospitals. Duty, March 9th, 1864. Comstock, Mark, Private, Co. L, 1st United States Cavalry. UpperATille, June 21st, 1863. Emory Hospital. Duty, July 3d, 1863. Drake, William IL, Private, Co. A, 6th Ohio Cavalry. Upperville, June 21st, 1863. Field and Emory hospitals. Duty, July 13th, 18(53. Fixk. Michael, Private, Co. B, 1st Potomac Home Brigade, aged 45 years. Frederick, March 24th, 1864. Frederick hospital. Duty, April 2d, 1864. Flynx, Axi)REAAr, Private, Co. A, 6th Michigan Cavalry, aged 32 years. Gettysburg, July 2d, 1863. York hospital. Duty, December 4th, 1863. Freeman, Moses H., Private, C.o. G, 6th Ohio Cavalry, Upperville, June 21st, 1863. Emory Hospital. Duty, November 27th, 1863. Haynes, William G., Private, Co. B, 13th Indiana. Dessert Mountain, Virginia, January 30th, 1863. Regimental hospital. Duty, April 23d, 1863. Jones, Saaiuel D., Private, Co. G, 2d Massachusetts Cavalry, aged 28 years. Gainesville, Virginia, May, 1864. Alex- andria hospital. Duty, August 1st, 1834. Kelly, Thomas J., Corporal, Co. K, 6th Michigan Cavalry, aged 21 years. Trevillian Station, June llth, 1864. Field and Mount Pleasant hospitals. Duty, September 13th, 1864. Maxdel, Frederick, Quartermaster Sergeant, Co. E, 2d Virginia Cavalry, aged 31 years. Harper's Farm, April 6th, 1865. Field and Annapolis hospitals. Duty, April 26th, 1865. McDoxald, William, Private, Co. H, 148th Pennsylvania. Wounded by an officer, October 19th, 1883. Regimental hospital. Duty, November 6th, 1863. Newhall, Walter J., Captain, Co. A, 3d Pennsylvania Cavalry. Gettysburg, July 1st, 1863. Duty. Northway, Delos R., Captain, Co. A, 6th Ohio Cavalry. Aldie, Virginia, June 17th, 1863. Duty. Ring:-:r, Jacob A., Sergeant, Co. A, 50th Ohio, aged 37 years. Chattanooga, October 8th, 1864. Nashville, Louisville, and Madison hospitals. Duty, February 17th, 1865. Bodgers, William C, Private. Baltimore Battery. Moorfield, August 7th, 1864. Sabre-cut of face, with injury of nasal bones. New Creek hospital. Transferred to post commander, August 25th, 1864. Simon, Lyon B., Private, Co. I, 18th Pennsylvania Cavalry, aged 25 years. Gettysburg, July 1st, 1863. York Hospital. Duty, December 15th, 1863. Snyder, M. B., Sergeant, Co. F, 6th Pennsylvania Cavalry, aged 26 years. Near Culpeper, August 1st, 1863. Wash- ington hospital. Duty, September 30th, 1863. Stokes, Francis. Sergeant, Co. A, 72d Indiana Mounted Infantry. Atlanta, 1834. Duty, five Aveeks after injury. Straus, Charles, Private, Co. H, 5th Ncav Jersey. Rappahannock, January, 1863. Also gunshot wound of leg. Returned to duty. Tempest, Marten, Private, Co. A, 8th Indiana Cavalry, aged 28 years. Cuyler Hospital. Duty, March 13th, 1865. Thorne, George H., Private, Co. H, 26th Massachusetts. June 30th, 1863. Barracks. New Orleans. Duty, October 17th, 1863. Tompkins, Aaron B., 1st Sergeant, Co. G, 1st NeAV Jersey Cavalry, aged 21 years. Amelia Springs, April 5th, 1865. Field and Annapolis hospitals. Duty, May 8th, 1865. Three Avounds. Welton, John A., Corporal, Co. D, 4th Pennsylvania Cavalry. Upperville, June 21st, 1863. Field and Emory hospitals. Dutv, August 13th, 1863. Williams, John, Private, Co. F, 3d Wisconsin Cavalry, aged 27 years. Madison, July 30th, 1834. Harvey Hospital. Duty. March 2d, 1835. Three patients appear to have been more seriously hurt, and were discharged : Todd, Richard, Private, Co. A, 59th New York. Cold Harbor, May 31st, 1864. Sabre-cut, taking off half of nose; also, shell Avound of mouth, and gunshot wound of thigh. Discharged from service August 15th, 1864. Waffle, Allen, Private, Co. M, 3d XeAV York Light Artillery, aged 20 years. Accidental. April 5th, 1865. Sabre- cut left eye. Field and Patterson Park hospitals. Mustered out May 27th, 18(55. Durbin, John, Private, Co. C, 18th Pennsylvania Cavalry, aged 36 years. Hanover Junction, June 30th, 1863. Sabre- cut of face, near outer canthus of right eye, causing loss of sight of right eye, and sympathetic affection of left eye. Field, McKim's Mansion, Cuyler, and Satterlee hospitals. Discharged from service June 6th. 1865. INCISED AND PUNCTURED WOUNDS OF THE FACE. 323 In the following case of a Confederate prisoner, the patient recovered and was released : Kissicl; Henry, Private, Co. C, 2d Kentucky Cavalry, aged 31 years. Cynthiana, June 12th, 1864. Covington hospital. Military prison, June 27th, 1864. In two other cases of this category, one patient deserted and one died: Watson, William, Private, 9th Indiana Cavalry, aged 49 years. April 9th, 1864. Indianapolis hospital. Deserted May 7th, 1864. Martin, J. W., Private, Co. D, 6th Virginia. Sabre-cut of cheek, through zygoma. Richmond hospital. Died June 30th, 1862. In the three following cases, the terminations cannot be ascertained : Laavson, John C, Private, Co. E, 6th Ohio Cavalry. Raid in Virginia, May, 1864. Field hospital. Termination unknown. Pike, Philip C. Private, Co. A, 1st Alabama Cavalry. Campaign in North and South Carolina, between January 28th and March 22d, 1865. Severe sabre-cut of face. Field hospital. Tei-mination unknown. Clark, Nelson, Private, Co. F, 122d Ohio. Manchester, Virginia. Sabre-cut of left side of face, about one-half inch external to angle of mouth. Termination unknown. Bayonet Wounds.—Twenty-seven cases of bayonet wounds of the face were reported. Eleven returned to duty, eleven were discharged, one died, and four of the wounded were not accounted for: Ala'IS, John, Corporal, Co. B, 28th United States Colored Troops, aged 21 years. Petersburg, October 27th, 1864. Punctured wound; loss of right eye. Field and Alexandria hospitals. Discharged June 10th, 1865. Dim, Frederick, Private, Co. C, 188th Pennsylvania. Drury's Bluff, June 14th, 1864. Fracture of lower jaw. New York and Phildelphia hospitals. Discharged May 4th, 1865. Gorman, Michael, Corporal, Co. I, Second Veteran Reserve Corps. January 18th, 1865. Punctured wound under right eye. Elmira hospital. Duty February llth, 1865. Willard, Henry C, Corporal, Co. B, 13th New Hampshire. Petersburg, June 13th, 1864. Mustered out of service June 21st, 1865. Corbett, Michael, Private, Co. C, 13th New Hampshire. Petersburg, June 25th, 1864. Mustered out of service December 19th, 1865. Gaycorn, John, Private, Co. —, Vermont Volunteers. Lee's Mills. April 16th, 1862. Bayonet Avound of face> accident- ally. Returned to duty. Roark, John, Private, Co. A, 30th Massachusetts. Baton Rouge, February, 1862. Discharged June 5th, 1863. Merdeer, Millorn, Private, Co. B, 21st United States Colored Troops, aged 26 years. October 28th, 1865; Hilton Head hospital. Duty Xovember 22d, 1865. Barr, Joseph, Private, Co. C, 97th Pennsylvania. Deep Bottom, August 16th, 1864. Virginia and Philadelphia hospitals. Discharged June 20th, 1865. Whittaker, Matthew, Private, Co. F, 32d Ohio. Bayonet Avound. McDowell, May 8th, 1862. Mohan, Thomas, Private, Co. F, 13th Missouri. Bayonet wound of face. Fair Oaks, May 31st, 1862. Sullivan, Daniel, Private, Co. I, 69th New York. November, 1864. Field hospital. Duty November llth, 1864. Gould, Charles G., Captain, Co. H, 5th Vermont, aged 18 years. Petersburg, April 2d, 1865. Field hospital. Mustered out of service June 19th, 1865. White, Charles, Private, Co. E, 23d United States Colored Troops. Petersburg, July 30th, 1864. Field hospital. Duty September 17th, 1864. Beldon, H., Corporal, Co. B, 41st Ohio. Murfreesboro', December, 1862. Field hospital. Burnham, G. W., Lieutenant, Co. G, 6th Maine. Fredericksburg, May 3d, 1863. Washington hospital. Resigned March 20th, 1864. Houston, Richard, Private, Co. C, 31st Illinois. Belmont, November 7th, 1861. Punctured wound under eye. Died April 22d, 1862. Leonard, Solomon, Private, Co. G, 179th New York. Petersburg, June 30th, 1864. Field hospital. Duty August 9th, 1864. Lang, Mason, Private, Co. G, 14th New York, aged 37 years. Petersburg, July 30th, 1864. Punctured wound of left eye; also gunshot Avound of scalp. Field, Washington, and NeAV York hospitals. Transferred to Veteran Reserve Corps, March 20th, 1865. 324 WOUNDS AND INJURIES OF THE FACE. Beerschntder, John, PriA'ate, Co. A, 4th NeAV York Cavalry. Punctured Avound, Avith loss of right eye. Georgetown hospital. Discharged February 2d. 1863. Saiitii. John, PriA-ate, Co. II, 17th New York, aged 25 years. NeAV York City, July, 1^33. Punctured wound ofthe left pvc. Desmarres Hospital, Washington. Simple dressings applied. Sight of eye greatly diminished. Frequent and protracted attacks of asthma. Condition of eye unimproved. Discharged February 26th, 1834. Brady, Peter S., Private, Co. K, 3d Kentucky. Chickamauga, September 20th, 1833. Nashville hospital. Duty September 26th, 1864. Hank, David, Private, Co. B, 17th Ohio Volunteers, Cumberland hospital, Nashville. Returned to duty January 18th, 1864. Sagee, Andrew, Private, Co. D, 73d Pennsylvania, aged 49 years. Bird's Ferry, Virginia. Punctured wound, causing evacuation of humors of left eye. Rhode Island and Philadelphia hospitals. Returned to duty May 27th, 1834. Edele, F., Private, Co. E, 98th Pennsylvania Volunteers, aged 44 years. Maryland hospital. Returned to duty January 29th, 1864. Henderson, Randsor, Private, Co. B, 4th Maryland Volunteers. Belle Island, February 22d, 1864. Washington, Maryland, and Pennsylvania hospitals. Discharged June 9th, 1865. Fox, Joseph, Sergeant, Co. G, 148th Pennsylvania, aged 20 years. August 25th, 1864. Lincoln hospital. Duty September 24th, 1864. Besides these sabre and bayonet wounds, there were incised, punctured, contused, and lacerated wounds of the face, from stabs, blows, kicks, railway accidents, and other causes, which may be summed up as follow: Table IX. Results of Sixty-four Casts of Fractures of the Rones of the Face from Various Causes. REGION. Cases. DuTr. 1 Discharged. Died. 1 1 Unknown. 11 39 3 10 1 4 25 2 5 1 4 8 1 4 2 5 1 Malar............................................................ 3 64 37 17 7 There were also reported two hundred and seventy-one flesh wounds of the face from similar causes, as follow: Table X. Remits of Two Hundred and Seventy-one Cases of Injuries of the Face from Miscellaneous Causes. character. Lacerations..................... Contusions..................... Punctured Wounds (not bayonet),. Incised Wounds (not sabre),..... Unspecified..................... Aggregates. Cases. Duty. 35 29 154 96 24 7 34 27 24 8 271 167 Discharged. Died, unknown. 5 45 15 5 13 83 1 11 2 1 3 18 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 hemorrhage, or suppuration and necrosis following the lodgement of bails in the spongy bones of the nasal and supra-maxillary regions, are among ihe 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 w;ill 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 llth, 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 Avas 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 Avas conveyed to the hospital transport steamer D. A. January, and conveyed to St. Louis and placed in the City Hospital. On admission it Avas 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 Avere separated and dislocated backAvard. 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. 155), with a memorandum of the case, to the Army Medical Museum. A fracture traverses the body of the sphenoid and petrous portion of the left temporal hone, and a second fissure divides, longitudinally, the palatine process of the right superior maxillary. The Fl0.15S._Degtruction of tlw eyes and frontal sinuses, which are very large, are freely exposed, and the cranial cavity is opened orbital region. Spec. 1016, Sect. I, A. through the ethmoid, the opening measuring three-fourths by one-half inch. M. M. 326 WOUNDS AND INJURIES OF THE FACE. C\sk.—Sergeant Jefferson Coates. Co. H, 7th Wisconsin Volunteers, aged 20 years, Avas Avounded at Gettysburg, 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 junction of the malar and frontal bones, through the great wing of the sphenoid, and emerged at a point corresponding to the place of entrance, producing a wound not less than an inch and a half in diameter, and tearing away nearly the whole ofthe orbital plate. The Avound of entrance was about half an inch in diameter. He was admitted to the Seminary Hospital, (Gettys- burg, and, on July 8th, transferred to the Satterlee Hospital, Philadelphia. When admitted, the tunics of the right eye were hanging out and much tumefied, about as large as a black walnut, and covered with a mass of slough; there was complete evasion ofthe 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 hy the lower. In other respects, with the exception of a slight inflammation, the tunics of this eve were healthy in appearance. In its passage, the ball had apparently passed immediately beneath the cribnform 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 sli-htly 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 spiculae from the right side. On the llth, 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 improved 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 July 21st, a thin plate of bone was discharged from the nose, apparently a piece of the perpendicular plate of the ethmoid. CEdema of the upper lip 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 the 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, avIio reports the case, states that after the insertion of the artificial eyes there will be very little deformity. CASE.-Private William BroAvn, Co. D, 119th Pennsylvania Volunteers, aged 24 years, Avas Avounded at Cold Harbor, Virginia, June, 1864, by a conoidal ball, Avhich entered the right temple tAvo inches from the orbit, and emerged through the right eyeball.' He was admitted to hospital 1st division, Sixth Corps ; on June llth, transferred to Campbell Hospital, Washington, and on July 23d, sent to Satterlee Hospital, Avhence he was discharged June 28th, 1865. The right eye Avas totally destroyed, and the sight ofthe left eye Avas lost. In March, 1888, he was a pensioner at $25 per month, his disability being rated total and permanent. Dr. J. A. McArthur reports that BroAvn Avas under his care at Soldiers' Home, Philadelphia, until January 27th, 1869, Avhen he died of phthisis pulmonalis. At the time of his death, he suffered from total blindness. CASE.-Private Charles C------, Co. H, 30th North Carolina Regiment, aged 30 years, received, at the battle of the Wilderness, May 7, 1864, a gunshot wound of the face. The missile entered the left temple, passing obliquely anteriorly, and emerging one inch below the left eye, severely fracturing and comminuting the superior maxilla, and completely destroying the nasal bones He Avas among the captured Avounded sent on hospital transports to Washington, and on May 14th Avas admitted to Carver Hospital. He was very low, and in a comatose state, requiring considerable exertion to arouse him sufliciently to partake of food and stimulants, which Avere freely administered. He took a quart of milk punch daily. Detergent lotions were applied to the Avound. The contents of the left orbit were eA'acuated, and the vision Avas destroyed in the right eye. Inflammation gradually extended to the brain; hut without any very violent symptoms. The patient survived tAventy days, death resulting May 27th, 1864. Acting Assistant Surgeon J. E. Winants reported the case 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, Avith 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 carried aAvay. The left parietal is fissured from the anterior inferior angle to the parietal eminence. The left palate bone is fractured across, the sphenoid cells are exposed, and the cranial cavity is freely opened. The edges ofthe fractured bones are slightly necrosed and show traces of an attempt at repair. FiG. 1511.—Cranium showing a gunshot fracture of the orbital region. Spec. 2899, Sect. I, A. M. M. Caaierox, Joseph, Sergeant, Co. A, 13th Ohio Cavalry, aged 25 years. Gunshot fracture of facial hones. Conoidal ball entered one-half inch beloAV external canthus of right eye, passed under the nose, and emerged at the outer angle of left eye, carrying away a considerable portion of orbital plate. Petersburg, Viiginia, July 30th, 1864. Complete loss of sight in both eyes. Discharged January 2d, 1865, and pensioned. GUNSHOT WOUNDS OF THE EYES. 327 Case.—Private John T. Cole, Co. A, 10th Vermont Volunteers, aged 24 years, Avas Avounded at Petersburg, April 2d,. 1805, by a conoidal ball, Avhich entered just above the left zygoma, passed through the orbit, and emerged through the outer and upper portion ofthe right orbital structure, destroying both eyes, lie Avas, on the following day, admitted to the depot field hospital at City Point; on April 7th, sent to the Lincoln Hospital, Washington, and, on May 20th, transferred to the Sloan Hospital, Montpelier, A'ermont. At this time the wound of entrance had healed and the general health of the patient was good, but lying on the left side Avould cause headache; the sense of smell Avas entirely destroyed. Cold water dressings were applied; during the treatment, small pieces of bone were taken from the Avound of entrance. Otherwise the case progressed well, and, on June 12th, 1865, Cole Avas discharged from service and pensioned at $25 per month Case.—Private William H. Davis, Co. C, 51st Ohio Volunteers, aged 22 years, Avas wounded near KenesaAV 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 Avas admitted to the hospital of the 2d brigade, 3d division, Fourth Corps; on June 25th, sent to field hospital at Chattanooga, Tennessee; on July llth, 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, 74th New York Volunteers, received, at the battle of Gettysburg, July 2d, 1863, a gunshot Avound of the left temple, the missile destroying in its course both eyes. He also received, in the same engagement, tAvo AATounds 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, where he Avas discharged the service December 15th, 1863. The Avounds had all healed, but the patient Avas totally blind. He Avas, in March, 1868, a pensioner at $25 per month. Case.—Private 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 inches from the angle ofthe right eye, and emerged near the outer angle ofthe left eye. He was, on June 29th, left in the hands of the enemy, but was afterAvard exchanged, and on October 5th, 1864, discharged from the service. Examiner Cyrus Porter, M. D., reports. October 5th, 1864, 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, Avhich entered the anterior part of the right temporal region, traversed both orbits, and emerged at a corresponding point on the opposite side of the head. He Avas 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 Avas totally blind, and the orbits Avere filled with profuse granulations of a flabby, spongy character. There was slight ectropion of both eyelids, the lashes resting 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 aAvay 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 Avere applied to the Avound. The patient died November 22d, 1863. The post mortem examination shoAATed an abscess in the right anterior lobe ofthe cerebrum. The lesions about the orbit are represented in the adjacent Avood-cut (Fig. 157). The orbital portions of the right malar and upper maxilla are Avanting, 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 Avere FlG ]57._GUnShot fracture of the right contributed by Assistant Surgeon P. S. Conner, U. S. A. orbitai region. Spec 2U89, Sect. I, A. M. M. Case.—Private Daniel Stansbury, Co. I, 3d Maryland Volunteers, aged 36 years, Avas wounded near Petersburg, Virginia' June 17th, 1864, by a conoidal ball, AA'hich injured the skull and destroyed both eyes. He was admitted to field hospital, Ninth Corps; on June 25th, sent to DeCamp Hospital, Ncav York Harbor, and, on August llth, transferred to NeAvton University Hospital, Baltimore. He Avas discharged from the service on May 16th, 1865, and pensioned. CASE.-Private John W. Williams, Co. F, 16th United States Infantry, was Avounded at Chickamauga, Georgia, September 20th, 1863, by a fragment of shell, Avhich caused a Avound of the right side of scalp, destroyed the right eye, and grazed the orbital ridge. He was admitted to the 1st division hospital at Annapolis, and discharged from service December 21st, 1863, and pensioned. Examiner H. Lenox Hodge, M. D., reports, February 15th, 1864, that the humors of the right eye have been evacuated and that the left eye was probably torn from its proper position by the blow. The pensioner suffers from total blindness. Case.—Private Henry Zimmerman, Co. I, 42d NeAV York Volunteers, Avas wounded at Antietam, September 17th, 1862, the missile having passed through the head from temple to temple. He was conveyed to the hospital of the Second Corps at the Hoffman House, and on October 1st, Avas admitted to Camp A Hospital, Frederick. Total loss of vision resulted, and the patient Avas discharged the service on December 19th, 1862, and pensioned. Subsequent information avers that the patient's lower jaw was anchylosed. His disability is rated total and permanent. Case.—Sergeant William H. Ferdon, Co. A, 40th NeAV York Volunteers, aged 25 years, Avas Avounded.in the engagement at Hatcher's Run, Virginia, March 25th, 1865, by a conoidal ball, which entered the right temporal region near outer angle of right eye, and passing through the orbital portion of the sphenoid bones on both sides, severed in its course the optic nerves of both 328 WOUNDS AND INJURIES OF THE FACE. eves. The point of exit Avas directly opposite the point of entrance. He was, on the following day, admitted to the depot field hospital of the Second Corps, at City Point, and on March 29th, transferred to the Armory Square Hospital, complaining of much pain in the head. He could not tolerate opium or morphine. Nervines were given every hour, till quiet Avas procured, and good Avine, in small quantities, allowed. On April 26th, the wound Avas nearly healed, but the patient Avas entirely blind. On May 15th, 1865, he was transferred to New York, AA'here he Avas discharged June 13th, 1865, and pensioned. Case.—Private Marion F. Johnston, Co. F, 116th NeAV York Volunteers, aged 20 years, Avas Avounded at Winchester, Virginia, September 19th, 1864, by a musket ball, which struck the left orbital ridge, and emerged just above the malar process of the right superior maxillary bone, destroying both eyeballs. He was admitted to the depot field hospital, and thence transferred, on October llth, to Hospital No. 1, at Frederick. He had almost lost his sight, but did not present any cerebral symptoms, and the Avounds of entrance and exit discharged laudable pus. Several spiculae of bone were removed from the wound of exit. On October 14th epistaxis, amounting to two ounces, took place, and the conjunctivitis partially subsided, but the vision was not yet restored. The patient made now a rapid recovery, and was furloughed on the 1st of November, 1864. At the expiration of his leave, he was, on January 3d, 1865, admitted into the hospital at Buffalo, NeAV York, and discharged from service on April 3,1865. He has been pensioned at the rate of twenty-five dollars per month, his disability being rated total and permanent. The case is reported by Acting Assistant Surgeon R. W. Mansfield. BiGGS, Jacob, Private, Co. F, 81st Indiana Volunteers, aged 23 years. Gunshot wound of face; loss of both eyes. Marietta, Georgia, June, 1864. Admitted to Hospital No. 14, Nashville, Tennessee, July 8th, 1864. Sent to hospital at New Albany, Indiana, July 25th, 1864. Discharged May 2d, 1865, and pensioned. Barrett, Sylvester, Private, Co. E, 2d Connecticut Artillery, aged 19 years. Cold Harb&r, June 1st, 1864. Destruc- tion of both orbits by conoidal ball. Alexandria hospital. Died July 22d, 1864. Benjamin, John P., Corporal, Co. H, 170th NeAV York Volunteers, aged 19 years. North Anna River, May 27th, 1864. Fracture of temporal, with injury to both eyes. Field, Washington, and New York hospitals. Died October 4th, 1864. Collins, Edavin F., Private, Co. F, 6th Connnecticut Volunteers. Near Richmond, October 7th, 1864. Loss of both eyes. Field hospitals. Died October 16th, 1864. Davenport, C. C, Private, Co. H, 2d Louisiana Regiment. Gunshot wound, destroying both eyes. Chancellorsville, Virginia, May 3d, 1863. Admitted to Louisiana Hospital, Richmond, Virginia. Furloughed, for sixty days, June 13th, 1863. Griselle, Balthasar, Private, Co. E, 44th Illinois Volunteers. Gunshot wound of forehead, with loss of both eyes. Franklin, Tennessee, December 17th, 1864. Admitted to Hospital No. 3, Nashville, Tennessee. Died January 6th, 1865. Garvan, J. L., Private, Co. K, 17th South Carolina Regiment. Gunshot wound of face, destroying both eyes. Admitted to hospital at Petersburg, Virginia, November 10th, 1864. Died November 12th, 1864. Haase, Henry, Sergeant, Co. H, 29th Alabama Regiment, aged 25 years. Nashville, December 15th, 1864. Fracture of frontal, with destruction of eyes. Field and Nashville hospitals. Died December 18th, 1864. Henson, Jonathan, Private, Co. G, 6th United States Colored Troops. New Market, September 19th, 1864. Fracture of frontal, malar, and nasal bones, resulting in the loss of both eyes; also perforating Avound of abdomen. Portsmouth hospital. Died October 1st, 1864. Hendrickson, William C, Sergeant, Co. F, 3d Kentucky Volunteers. Gunshot wound of face. Ball entered half an inch beloAV outer angle of right eye, and emerged at outer angle of left eye, destroying both eyes and impairing sense of smell. Chickamauga, Tennessee, September 20th, 1863. Discharged December 5th, 1863, and pensioned. Hodgdon, John M., Sergeant Major, 13th NeAV Hampshire Volunteers. Gunshot wound of face, ball destroying the sight and fracturing the loAver jaw. Discharged June 14th, 1865, and pensioned. Kooken, Jefferson, Private, Co. I, 123d Ohio Volunteers, aged 44 years. Missile entered at external angle of left eye and emerged at external angle of right eye, producing blindness. Discharged May 26th, 1865, and pensioned. Merritt, J. J., Private, Co. C, 24th Georgia Regiment, aged 30 years. Gunshot Avound of face; ball passing through and destroying both eyes. Gettysburg, July 2d, 1863. Paroleti. September 5th, 1863. Mudge, William R., Private, Co. H, 2d Massachusetts Volunteers. Gunshot wound of face. Both eyes lost. Chan- cellorsville, Virginia, May 3d, 1863. Discharged and pensioned. McBaniels, John, Co. C, 2d North Carolina Regiment, aged 25 years. Gunshot Avound of face. Missile passed through both orbits, from side to side, destroying both eyeballs. South Mountain, Maryland, September 14th, 1862. Eyesight entirely lost. Sent to Fort Me Henry, probably for exchange. Ruoher, James, Private, Co. A, 2d United States Cavalry, aged 20 years. Winchester, September 19th, 1864. Fracture of parietal and frontal bones; both eyes destroyed. Field and Baltimore hospitals. Died December 6th, 1864. Roose, Simon J., Private, Co. F, 145th Pennsylvania Volunteers, aged 28 years. Gunshot wound of face. Missile entered outer canthus of right eye, passed under the nasal bones, and emerged at the external canthus of left eye, completely destroying both eyes. Gettysburg, Pennsylvania, July 2d, 1853. Mental aberration supervened, but in September his condition gradually improved. Discharged October 28th, 1883. Not a pensioner. Shoemaker, Thomas W., Private, Co. K, 40th NeAV York Volunteers, aged 21 years. Conoidal ball entered at external angle of right eye, passed through the nose and lodged, destroying the right eyeball entirely. Inflammation and loss of sight of loft eye. Discharged February 18th. 1865, and pensioned. GUNSHOT WOUNDS OF THE EYE. 329 Shelon. John M.. Private, Co. A, 110th Pennsylvania Volunteers, aged 30 years. Gunshot wound of face. Conoidal ball entered external canthus of left eye. and emerged at outer angle of right eye, destroying both. Artificial eyes inserted. Discharged January 24th, 1865, and pensioned. Sanderson, George W., PriA-ate, Co. G, 186th Ncav York Volunteers, aged 36 years. Shell wound of superior maxillla. Petersburg, Virginia. April 2d, 1865. Discharged June 5th, 1885. Both eyes involved; total blindness. lie is a pensioner. Ungerer, Jacob, Private, Co. B, 1'th New York Artillery, aged 31 years. Gunshot Avound of face; missile destroying both eyes. Petersburg, June 19th, 1864. Discharged April 25th, 1865. Not a pensioner. Wintress, David IL, Private, Co. C, 139th Ncav York Volunteers. Gunshot wound of face. Conoidal ball entered left cheek one inch beloAV the eye, passed through and emerged near the temporal bone, destroying in its course both eyes. Discharged July 28th, 1863. It is stated that sixty-five pieces of bone Avere removed from the Avound. He is a pensioner. Yengi.ing, John. Private, Co. C, 24th Indiana Volunteers, aged 35 years. Fracture of right nasal bone and orbital process of same side; both eyes destroyed. Champion Hills, Mississippi, May 16th, 1863. Discharged July 7th, 1863. Not a pensioner. Of the foregoing thirty-nine cases of destruction of both eyes by gunshot injury, eleven were fatal. Twenty-two of the survivors were pensioned. Several of the fatal cases were complicated by other serious wounds. The next category comprises cases in which only one eye was destroyed. Case.—Private Peter Bice, Co. B, 57th NeAV York Volunteers, aged 30 years, was wounded at Gettysburg, July 2d, 1863, by a conoidal musket ball, Avhich entered at the upper margin of the zygoma of the right side, passed through the apex of the right orbit, and emerged at about the centre of the loAver margin of the left orbit. He was admitted to the regimental hospital on the same day, and thence conveyed to the Turner's Lane Hospital, at Philadelphia, on July llth. Ordinary dressings Avere applied to the wound, and cathartics, stimulants, and tonics administered. By July 30th, the wound had healed, and the patient complained only of stiffness of the jaw. The vision ofthe left eye was good, while that of the right Avas entirely destroyed. On November 3d, 1863. he Avas transferred to the Veteran Reserve Corps. The case is reported by Assistant Surgeon C. H. Alden, U. S. A. Pension Examiner Lathrop, M. D., reports, December 19th, 1866, that the lens of the right eye is opaque, and that the lachrymal duct of the left eye is obliterated, and the visual power much impaired. Case.—Sergeant George Prince, Co. I, 3d New Jersey Cavalry, aged 28 years, Avas wounded at Winchester, September 19th, 1854, by a conoidal ball, which fractured the bones of the face. The missile entered just below the zygomatic process, on the right side, passed through, carrying away the inferior and superior turbinated bones, emerged about one inch beloAV the left eye, and destroyed the right eye. He was conveyed to the field hospital, cavalry corps; transferred to Baltimore, October 28th, and on the following day Avas admitted into the NeAvton University Hospital. On November 28th, he Avas transferred to Haddington Hospital, Philadelphia. Anodyne dressings Avere applied to the wound, and spiculae of bone removed from time to time. On May llth, 1865, he Avas admitted into the Satterlee Hospital, and on July 22d transferred to Ward Hospital, Newark, Ncav Jersey, whence he was discharged the service August 30th, 1865. A. M. M., Surgical Photographic Series No. 312. He was pensioned and Avas, for a long time, a messenger of the Treasury Department at Washington. His general health was good in June, 1871, when he came to the Surgeon General's Office for examination. There Avere frequent exfoliations from the ethmoid and turbinated bones, and a constant suppuration from a cloaca in the site of the left lacrymal sac. Case.—Private William Bittinger, Co. G, 12th Pennsylvania Volunteers, was wounded before Richmond, June 28th, 1862, by a conoidal ball, Avhich destroyed the left eye, and passing obliquely outward, fractured the orbit, and emerged at a point tAvo inches above and behind the left eye. He was conveyed to Baltimore July 25th, and placed in McKim's Mansion ; transferred on September 19th to West's Buildings, and on April 29th, 1863, to the York Hospital in Pennsylvania. On October 21st, he was returned to Baltimore, and admitted into the Patterson Park Hospital, and in July, 1864, transferred to Harrisburgh, to be mustered out of service. Pension Examiner Rabter, M. D., reports, April 23, 1869, that the bones ofthe left orbit are all broken away, leaving great deformity. What remains ofthe eyelid is everted, exposing the sensitive conjunctiva. Case.—Private Thomas Breen, Battery L, 1st Illinois Artillery, aged 29 years, Avas Avounded near Cumberland, Maryland, on August 1st, 1864, by a conoidal musket ball, Avhich entered at the inner canthus of the right eye, passed doAvinvard and backward, through the bones of the face, and lodged in the fauces, Avhence it Avas ejected in coughing. He was admitted to the hospital at Cumberland, much depressed from the shock, as Avell as from the loss of blood. Upon examination of the wound, it was found that the missile had carried away a portion of the inner Avail of the orbit, the superior maxillary, the nasal bones, and the vomer. The eye seemed to have escaped injury. The detached fragments of bone were removed, cold-Avater dressings applied, and expectant treatment Avas used. On the following day, there was a sanious discharge from the Avound, some of Avhich passing into the stomach, induced more or less vomiting. The tumefaction increased until suppuration was established, on the 6th, when there was marked subsidence of the febrile symptoms. The right eye Avas disorganized. The patient Avas discharged February 20th, 1865, his Avound having healed. In July, 1868, the pension examiner reports him in good health, Avith the loss of his eye as his disability. CASE.-Private William H. Nims, Co. D, 61st New York Volunteers, Avas wounded June 17th, 1864, in front of Petersburg, and Avas admitted into the hospital of the 1st division, Second Corps, and thence sent to Columbian College Hospital, at W ashington, June 22d, 1864. He Avas struck by a fragment ot shell, Avhich evacuated the humors of the right eye, and fractured the nasal bones and right superior maxilla. The treatment consisted in the removal of fragments of bone, and adiust- 42 330 WOUNDS AND INJURIES OF THE FACE. mont of the lacerated soft parts. On April 25th, 1865, there was a small fistula, communicating, probably, Avith a necrosed fragment of the spongy bones. Surgeon Thomas R. Crosby. U. S. V.. Avho had directed the patient's treatment, had removed all accessible dead bone, had continued to keep the nasal canal pervious, and so coaptated the lacerated parts about the orbits as to secure a cicatrix, sliOAving as little deformity as the gravity of the injury would permit one to hope for. A photograph ol the patient Avas made at the Army Medical Museum (Vol. 1, p. 32, Surg. Scries). The patient Avas discharged from service and pensioned April 26th, 1865. In 1867, Pension Examiner G. W. Avery, reported that this.pensioner continued to suffer greatly; and that the very unpleasant deformity induced by his Avound, made it impracticable for him to obtain employment. Thus his mutilation Avas a doubly cruel one. Case.—Private Jonas Erray, Co. H, 10th New York Cavalry, aged 23 years, Avas Avounded near Shepherdstown, July 16th, 1863. by a conoidal musket ball, Avhich entered the frontal bone one inch above the right superciliary ridge, near the median line, passed doAvmvard and outAvard, and lodged in the superior maxillary bone. Insensibility, of four or fiATe hours duration, folloAved the injury. The patient remained at the field hospital until the 30th, and was then conveyed to Hospital No. 1, at Frederick. The Avound had nearly cicatrized, but the pulsations ofthe brain Avere plainly visible; the sight of the right eye Avas destroyed, and sensibility on that side ofthe 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 Avhich, moreover, the sound eye sympathized. The pain continuing unabated, Acting Assistant Surgeon John H. Bartholf extirpated, on August llth, the right organ of vision. The headache still continued until the 20th, and giddiness Avas produced by the least exertion; the poAver of feeling and of smell in the light nostril had, by this time, somewhat improved. On the 28th of the month, the socket of the right eye Avas granulating healthily, and there Avas only little discharge from the original Avxrand. On October 1st. the Avound had so far healed that the pulsations of the brain ceased to be visible. On November 3d, the missile was detected behind the last molar tooth and extracted by the dressing forceps. The sensibility of the fifth pair of nerves was noAV restored but the mobility of the jaw remained limited. The patient Avas discharged from service on November 16th, 1863. The pathological specimen, No. 3970, Sect. I, A. M. M., exhibits the cornea and lens ofthe right eye. The vitreous humor in great part remains opaque and of a yelloAvish Avhite color. A collection of clotted blood fills the anterior portion of the cavity, protruding through the iris. The cas,e is reported by the operator, Acting Assistant Surgeon John H. Bartholf. 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 R. Guiney, 9th Massachusetts Volunteers, Avas Avounded at the battle of the Wilderness, May 5th, 1864, by a conoidal musket ball, AA'hich entered just above the inner angle of the left eye and passed across the orbit and behind the malar bone and zygoma to near the ear, Avhere 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 Avas destroyed, and, in removing the ball, St eno's duct Avas severed. He Avas admitted to the hospital of the 1st division, Fifth Corps, and, on May 12th, sent to Wash- ington, Avhere he received a leave of absence on May 14th, 1864. He was mustered out of service on June 21st, 1864, and pensioned. For a year after the reception of the injury a salivary 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 reneAved Avhenever, in shaving, the razor touches the cicatrix. Although the Avound Avas not immediately connected Avhh the brain it has affected it in its functions. He is unable to concentrate his thoughts for any length of time Avithout suffering from dizziness and confusion of ideas, the dizziness becoming so decided at times, as to necessitate the grasping of objects near him for support. Since the Avar, Avhile serving as Assistant District Attorney at Boston, he has been obliged to bathe his head, during the session ofthe court, to enable him to attend to his duty. He is noAV, February 1st, 1870, vriiolly 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 Maine Cavalry, aged 24 years, Avas wounded at the battle of the Wilderness, May 6th, 1864, by a conoidal musket ball, which entered the left eye and lodged at the left temple. He Avas at once admitted to the hospital of the 2d division, Cavalry Corps, thence conveyed to Washington, and admitted, on the llth, into the Emory Hospital, Avhere the missile Avas extracted and the Avound dressed in the usual manner. On May 16th, he Avas transferred to the De Camp Hospital, New York, and thence, on June 2d, sent to the Cony Hospital at Augusta, Maine. On February 16th, 1865, he Avas discharged from service and pensioned. 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 can but just drag himself about. Case.—Private Jack Kemp, Texas Partisan Rangers, aged 35 years, was Avounded at La Fourche Crossings, Louisiana, June 21st, 1863, by a conoidal ball passing from right to left obliquely and backAvard, carrying aAvay 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 water dressings Avere applied, and opiates and stimulants given. Six weeks after the reception of the injury he Avas returned to the hands of the Confederates. He had been able to walk about the ward for two weeks; the Avound Avas doing Avell, giA'ing promise of entire recovery. The case is reported by Surgeon W. N. TroAvbridge, 23d Connecticut Volunteers. CASE.-Private George Guptill, Co. K, 29th Maine Volunteers, aged 24 years, Avas Avounded at the battle ot Cedar Creek, October 19th, 1864, by a ball which passed through the upper lid of the left eye, penetrated the orbital plate and lodged, evacu- ating the humors of the globe. He was sent, on October 23d, to Satterlee Hospital, Philadelphia. Strict attention was paid to his diet, and his room Avas darkened. Several loose pieces of bone Ave re removed. No attempt Avas made to find the ball. The patient's pulse Avas decidedly cerebral, slow and irregular. Erysipelas supervened. In the beginning of November, he com- plained of pain and twitchings of the muscles of the feet and occasional headache. ToAvard the end of November, he began to improve, and was discharged from the service on January 7th, 1865. The wound. Avhiehhad been kept open as long as discharge issued, had closed, and he Avas, to all appearances, Avell. In July, 1868, the pension commissioner stated that Guptill A\ras a pensioner at $8 per month, his disability being rated total and permanent. The case is reported by Surgeon I. I. Hayes, V. S. V. GUNSHOT WOUNDS OF THE EYE. 001 Case.—Private James Neilson, Co. H, 118th Pennsylvania Volunteers, aged 28 years, Avas Avounded in an engagement at ShepherdstoAvn Ford, Maryland, September 20th, 1862, by a conoidal musket ball, which 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 loAver lid so that it hung doAvn over the face, even Avith the tip of the nose. He lay on the field in an insensible condition from morning until night, when he Avas taken to the Fifth Corps hospital. Thence he Avas 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 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 feAV Aveeks the fits ceased to occur. He Avas transferred to the Veteran Reserve Corps on May 12th, 1864. In November, 1867, Neilson Avas able to folloAV bis usual vocation of carpet Aveaving. There was a sero-purulent discharge from the eye, especially in damp Aveather, and he was still subject to fainting spells, Avhen under any undue emotion, or Avhen exposed to great heat. The 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. H, 21st Connecticut Volunteers, aged 24 years, Avas wounded at Petersburg, July 30th, 1864, by a conoidal musket ball, Avhich entered the left temporal region, passed through the left orbit, and emerged through the right nostril. The left eye Avas entirely destroyed. He Avas taken to the hospital ofthe 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, Ncav York, where he remained under treatment until November 30th, AA'hen he Avas transferred to the Knight Hospital, at New Haven. He was discharged from service February 10th, 1865. In 1869 he Avas a pensioner, his disability being rated as total. Mastica- tion AA-as difficult, his sense of smell Avas affected, and, beside the loss of his left eye, vision in the right eye Avas impaired. His mind had become so affected as to unfit him for mental application, and he complained of a dull pain in the head. / 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 doAATrward and lodged at the angle of the left inferior maxilla. He Avas admitted to the Mansion House Hospital, Alexandria, Avhere the ball Avas removed. The patient recovered and was discharged December 24th, 1862. The specimen and history of the case Avere contributed to the Army Medical Museum by Surgeon J. E. Summers, U. S. A. The ball, figured in the wood-cut (Fig. 158), is roughened and jagged, and there are bony particles embedded in the furrows. No application from this soldier appears upon the Pension Records, hence it may be hoped that his recovery was so complete that he did not require assistance. Case.—Private George Thompson, Co. F, 6th Missouri Volunteers, was wounded at Arkansas Post, January llth, 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 dowmvard, fractured the orbital plate, and lodged in the frontal sinus. He was conA-eyed by steamer to Memphis, and placed in Hospital No. 3, on January 23d. At the dressing of the wound, the course of the missile Avas traced along the fracture as far as the bottom of the orbit, beyond Avhich it was not considered prudent to explore. The globe of the eye Avas disorganized and destroyed. For a considerable time inflammation ran very high, and the pain was exceedingly severe. The swelling, however, after tAvo or three weeks, gradually subsided. The wound remained very painful afterward, and renewed treatment Avas necessary to allay the pain. Extirpation of the disorganized eye-ball was considered at this time, but the operation Avas rejected. Acting Assistant Surgeon Thomas F. Smiley, in his comments upon the case, declares his conviction that this should have been done, as thereby the missile, and probably splinters of bone at the bottom of the orbit as well, might have been remo\Ted. The patient Avas discharged from service on April 3d, 1863, though not entirely cured, yet still able to travel. In March, 1869, Examining Surgeon W. W. Potter reports this pensioner's disability as three-fourths and permanent. Case.:—Colonel James Washburn, 116th Ohio Volunteers, was wounded near Snicker's Ferry, July 18th, 1864, by a conoidal ball, which entered the corner of the left eye and emerged from below the right ear. The right side became paralyzed and the face grew distorted from contraction of the facial muscles. The left eye Avas entirely destroyed. He Avas mustered out on July 5th, 1865, and pensioned, his disability being rated total and permanent. Case.—Private John A. Lasell, Co. C, 60th New" Y'ork Volunteers, aged 24 years, received, at the battle of Gettysburg, July, 1863, a gunshot Avound of the eye and head. He Avas conveyed to the field hospital, Avhere he remained until July 10th, when he Avas transferred to New York, entering McDougall Hospital on the 12th. He died August 23d, 1864. Assistant Surgeon H. W. Sprague, U. S. A., reports the case. Case.—Private S. C. Kenningham, Co. K, 12th Virginia Regiment, received, on July 15th, 1863, a gunshot Avound ofthe eye. He Avas admitted to No. 1 Hospital at Richmond, soon after the reception of the injury, and died the day of his admission. Case.—Private M. W. Sexton, Co. C, 13th South Carolina Regiment, received a gunshot wound of the left eye by a conoidal ball. He was admitted to the Jackson Hospital at Richmond, on July 29th, 1864, Avhere he died on September 30th, 1864. Case.—Private A. B. Wilson, Co. F, 10th Tennessee Volunteers, aged 29 years, Avhile being taken, in a state of intoxica- tion, to the guard-house at Fort Gillam, near Nashville, on September 20th, 1864, Avas accidentally wounded by a conoidal musket ball, at the angle of the nasal and malar bones, three-fourths of an inch beloAV the inner canthus of the left eye, passed deeply beneath the nasal bones, upward, outward, and backAvard, and emerged at the junction of the frontal and the right parietal bones, two inches from the median line. He Avas immediately conveyed to Hospital No. 8, Nashville, in an unconscious state. The brain substance and bloody serum issued from the wound of exit, as Avell as entrance. The right eye Avas destroyed ; its upper lid being nearly severed from its connections. The usual dressings Avere applied, and the treatment in the main was expectant. FiG. 158.—Round musket ball, with bits of facial bones impacted. Spec. 4408. Sect I, A. M. 31. 332 WOUNDS AND INJURIES OF THE FACE. During the day the pulse rose from 76 to 80, the respirations numbered 16, and consciousness was partially restored. On the 22d he had become fully conscious, and complained of pain in the head. The next morning the pulse was 96, and the respirations 2<). He Avas still conscious, though mental effort Avas dull; but shortly afterward he sank into a state of coma. The brain substance iioav 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 fi-ontal bones were found badly fractured, and several large fragments of the frontal were detached. Further examination disclosed extensiA-e disorganization of the encephalon. Case.—Private Louis W----, Co. K, 10th Vermont Volunteers, aged 33 years, Avas wounded at the battle of Cold Harbor, A'irginia, June 1st, 1864, by a conoidal musket ball, which entered the frontal bone above the nasal eminence, carried aAvay both sinuses and a portion of the left orbital plate, destroyed the left eye, and escaped near the angle of the left ramus of the lower jaw. He Avas conveyed to Washington, and admitted, on the 9th, into the Lincoln Hospital. Death occurred June 16th, 1864. At the autopsy, an opening Avas 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, Avas observed. Upon the removal of the frontal portion of the calvarium to a level Avith the orbital region, a fragment of the Avail of the sinus Avas found, adherent to the dura mater, beneath which membrane extravasation of venous blood existed. There Avas also a general enlargement of the A7eins of the cerebrum. The optic commissure and nerve Avere found lacerated, and the tuber cinereum in a sloughing condition. Some tAvelve ounces of venous blood exuded from the meningeal vein, especially from several points along the falx cerebri and falx cerebelli. The heart Avas fatty on the right side, but the lungs and other organs Avere perfectly sound. The pathological specimen is No. 2574, Sect. I, A. M. M., and Avas contributed, with its history, by Surgeon J. C. McKee, U. S. A. Abbott, Harlin, Private, Co. F, 77th NeAV 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, NeAV York, and Albany hospitals; transferred to Veteran Reserve Corps. Discharged August 4th, 1865; pensioned. Ackerly, Darius, 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 aAvay by a conoidal ball; also Avound of left thigh. Taken prisoner, exchanged, and treated at Annapolis and Camp Chase. Discharged October 23d, 1863. Adams, 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. Discharged July 14th, 1865, and pensioned. Austin, L., Private, Co. A, 24th NeAV 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 hospitals. Left eye destroyed. Discharged June 14th, 1865, and pensioned. Adams, George, Private, Co. I, 9th New Hampshire Volunteers. Petersburg, July 25th, 1864. Gunshot wound of face. Admitted to Emory Hospital, Washington, August 1st, 1864. Removal of spicula of bone. Discharged November 20th, 1864, Avith loss of right eye and partial loss of sight of left eye, and pensioned. Adams, Thomas, Private, Co. K, 13th Arkansas Regiment, aged 24 years. Franklin, Tennessee, November 30th, 1864. Gunshot fracture of superior maxilla; eye destroyed. Sent to Provost Marshal for exchange June 9th, 1865. Amos, John F., Private, Co. G, NeAV 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, 12th NeAV Jersey Volunteers. Chancellorsville, May 3d, 1863. Gunshot wound, fractur- ing orbital plate and destroying left eye. Sight of right eye sympathetically impaired. Washington, DelaAvare, and New Jersey hospitals. Discharged December llth, 1863, and pensioned. Boardman, Morand, Private, Co. B, 9th Illinois Volunteers, aged 41 years. Shiloh, April 6th, 1862. Fracture of malar and frontal bones and destruction of eye. City hospital, St. Louis. Great disfiguration. Discharged September 23d, 1862. 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. Britt, J. J., Sergeant, Co. D, 43d North Carolina Regiment, aged 27 years. Winchester, September 19th, 1864. Destruc- tion of vision of left eye by a fragment of shell. Taken prisoner and treated in field and Baltimore hospitals. Sent to Provost Marshal for exchange April 8th, 1865. 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 NeAV York hospitals. Deafness of right ear. Discharged March 1st, 1865, and pensioned. Burmeister, Henry, Sergeant, Co. A, 9th Illinois Volunteers. Shiloh, April 6th, 1862. Fracture of right orbital arch and destruction of left eye. Quincy, Illinois, hospital. Exfoliation of bone. Repulsive deformity. Discharged September 22d, 1862, and pensioned. Butler, W. C, Sergeant, Co. C, 15th Virginia Regiment. Gunshot wound through right orbit; also wound of thigh. HoAvard Grove Hospital, Richmond. Furloughed June 29th, 1864. Byrxe, Dudley, Private, Co. A, 88th New York Volunteers. Antietam, September 17th, 1862. Loss of right eye. Philadelphia hospital. Discharged January 5th, 1863, and pensioned. There was great deformity, and the sense of smelling Avas gone. Neuralgic trouble also existed. Barlcsdale, Hezchiah D., Private, Co. E, 6th Arkansas Regiment. Fracture of right orbital ridge; eye destroyed. Admitted to Confederate hospital, Dalton, Georgia. The result of the ease is not recorded. GUNSHOT WOUNDS OF THE EYE. 333 Balders, Charles, Corporal, Co. K, 134th New Y'ork Volunteers, aged 31 years. Gettysburg, July 1st, 1863. Fracture of frontal bone over left eye by conoidal ball; eye destroyed; also Wound of right arm. Pennsylvania and New York hospitals. Discharged January 31st, 1865. and pensioned. Belcheb, Charles, Private, Co. K. 6th Pennsylvania Volunteers. Antietam, September 17th, 1863. Fracture of frontal bone. Corps and Washington hospitals. Destruction of left eye and partial deafness of left ear. Discharged November 3d, 1863, and pensioned. Bixby, Philip, PriA-ate, Co. E. 92d New Y'ork Volunteers. Fair Oaks, May 31st, 1862. Fracture of frontal bone above left orbit; missile lodged, destroying sight. Field and New Y'ork hospitals. Discharged October 29th, 1862. Bradden, Isaac II., Private, Co. B, 24th Indiana Volunteers, aged 21 years. Champion Hills, Mississippi, May 16th, 1863. Gunshot Avound; 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. Broavx. Johx, PriA-ate, Co. G, 2d Dehvware 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, W. 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. Becket, 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 Y'ork, January 12th, 1865. Discharged June 26th, 1865, and pensioned. Barnes, 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, tAvo inches above knee. Admitted to Post Office Hospital, Washington, December llth, 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, W. H., Private, Co. K, 3d Tennessee Cavalry, aged 18 years. Conoidal ball entered and destroyed left eye, and emerged at inner 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. Boltox, Samuel M., Private, Co. D, llth Maine Volunteers, aged 32 years. Missile, a buckshot, penetrated and destroyed the right eyeball. Bermuda Hundred, June 2d, 1861. Ball removed. Discharged April 21st, 1865, and pensioned. Berg, Johx, Private, Co. A, 117th New York Volunteers, aged 25 years. Gunshot Avound of face. Missile carried away right eye. Fort Fisher, North Carolina, January 15th, 1835. Discharged June 22d, 1865, and pensioned. Carpenter, J. D., Private, Co. M, 16th North Carolina Regiment. Chancellorsville, May 3d, 1883. Fracture of cranium, Avith 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 hospitals. Vision of right 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 Philadelphia 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, 1832, 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. Col3, Charles, Corporal, Co. A, 103d Ohio Volunteers, aged 22 years. Resaca, 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. Bentonville, March 21st, 1885. Fracture of right temporal and destruction of right eye by conoidal ball. Field, New Berne, New Y'ork, and Madison hospitals. Dis- charged May 26th, 1865, and pensioned. Copexspire, Charles, Private, Co. K, 60th NeAV York Volunteers, aged 20 years. Winchester, September 19th, 1864. Fracture of left temporal and upper jaAV; left eye destroyed. Field and Philadelphia hospitals. Several pieces of upper jaw remoA-ed. Discharged June 2d, 1865, and pensioned. ->>4 WOUNDS AND INJURIES OF THE FACE. Chase. Reuben. PriA-ate, Co. A, 37th Massachusetts Volunteers, aged 24 years. Shell wound, fracturing maxillary and malar bones, causing total loss of right eye. Hatcher's 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 Avound of face. Ball entered near external angle of left eye, destroying the eye. passed through superior maxilla, and emerged beloAV outer corner of right eye, impairing its usefulness. Seven Pines, Virginia, July, 1862. Retired from the service. Chisholm, Johx W., PriA-ate, 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 beloAV the eye. Peach Tree Creek, July 20th, 1864. Discharged July 27th, 1865. He is not a pensioner. Crawley. David, Private, Co. C, 107th NeAV Y'ork Volunteers, aged 23 years. Conoidal ball struck nasal hone, and passed through left eye. Chancellorsville, Virginia, May 3d, 1863. Discharged August 29th, 1864. Total loss of left eye, and partial loss of sight of right eye. He is not a pensioner. Carter, John AV., 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 Petersburg, Virginia, July 30th, 1864. Discharged February 6th, 1865, and pensioned. Connolly, Bernard, Private, Co. B, 65th New York Volunteers, aged 22 years. Gunshot fracture of malar bone, Avith loss of use of right eye, and sympathetic affection ofthe left eye. Cedar Creek, Virginia, October 19th, 1864. Can but partially open the mouth. Discharged July 24th, 1865, and pensioned. CARUTnERS, William L., Private, Co. G, 2d West Virginia Volunteers, aged 25 years. Conoidal ball entered left antrum, and emerged through the left orbit, disorganizing the eye. Farmville, Virginia, April 6th, 1865. Discharged July 26th, 1865, and pensioned. Chary, Prosper, 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, Rafaele, Sergeant, Co. A, 39th Ncav York Volunteers. Gunshot fracture of superior maxilla. Sight of right eye destroyed. BristoAV Station, Virginia, October 15th, 1863. Recovered, and was discharged and pensioned. Dance, Charles 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. Hatcher's 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, Cyrus, Private, Co. G, 9th NeAV 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, 1805, and pensioned. Will probably become totally blind. Dennis, George 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. Dinger, Nathan, Private, Co. D, 107th Pennsylvania Volunteers, aged 21 years. Gettysburg, July 1st, 1863. Loss of left eye. Camp Letterman and Philadelphia hospitals. Discharged March 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 Avounds of right leg, left heel, chest, right arm, and shoulder and right forearm. Taken prisoner, exchanged, and treated in Washington and NeAV York hospitals. Vision of left eye and hearing of right ear entirely lost. Headache, giddiness, and weakness. Discharged October 19th, 1862, and pensioned. Doyle, Barnard, Private, Co. C, 38th Indiana Volunteers, aged 25 years. Kenesaw Mountain, June '6th, 1864. Fracture of cranium. Loss of left eye. Savannah, New Y'ork, and Madison hospitals. Discharged June llth, 1865, and pensioned. Drake, Ethan A., Private, Co. G, 7th Illinois Volunteers. Farmington, Mississippi, May 9th, 1862. Loss of left eye. Field hospital. Discharged November 3d, 1862. Daniel, J. R, Private, Co. B, 1st Virginia Regiment. Gunshot Avound 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. Dimmary, JOSEPH, Private, Co. E, 29th Connecticut Volunteers, aged 47 years. Gunshot AA-ound of left side of face; destruction of left eye. Bermuda Hundred, September 8th, 1864. Discharged October 28th, 1865, and pensioned. Daniel, Hoses, 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, 6th Wisconsin Volunteers, aged 25 years. Gunshot AA-ound 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, lilth Blinois 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 ofthe eye. Atlanta, Georgia, July 22d, 1864. Discharged March 8th, 18C5. He is not a pensioner. GUNSHOT WOUNDS OF THE EYE. 335 Drxx, James W., Private. Co. A, 8th Illinois Volunteers. Gunshot Avound of face. Missile entered left zygomatic process, passed slightly upAvard and backward and emerged on opposite side just above the zygoma. Tlie optic nerve of the ri»ht eve Avas carried aAvay and the eye forced forward. A'icksburg, Mississippi, June 22d, 1863. Insensible for three days. Fragments of bone thrown off. Gangrene. Mustered out July 30th, 1864, and pensioned. Dklamatkr, Joseph W., Private, Co. H, 124th New Y'ork Volunteers. Gunshot wound of face; left eye lost; also wound of right hand. Chancellorsville, A'irginia, May 3d, 1863. Died May 25th, 1863. Ecke, Hexry, Private, Co. H, 6th AA'isconsin A'olunteers. Gunshot fracture of nasal bone and extirpation of left eye. Antietam, Alaryland, September 17th, 1852. Transt'errcd to Invalid Corps, November 15th, 1883; afterward discharged and pensioned. Eaton, OliA'ER P., Private, Co. G, 86th Illinois Volunteers. Jonesboro', September 1st, 1884. Fracture of frontal and destruction of right eye by conoidal ball. Field, Chattanooga, and Nashville hospitals. Discharged May 30th, 1865, and pensioned. Egan, Barney, Private, Co. F, 91st New York Volunteers. Port Hudson, June 14th, 1863. Loss of sight of left eye. Port Hudson and Baton Rouge hospitals. Right eye sympathetically affected. Discharged November 21st, 1863, and pensioned. Egan, John, PriA'ate, Co. M, 13th New Yrork Cavalry, aged 20 years. Piedmont, October 19th, 1864. Left eye torn out by ball; also Avound of left arm. Field hospital. Right eye and nervous system generally affected. Discharged August 2d, 1865, and pensioned. Ellis, W., Private, Co. F, 19th A'irginia Regiment. Fracture of frontal and loss of left eye. Confederate hospital, Rich- mond. Deserted October 29th, 1862. Evkrly, Frederick, Pri\rate, Co. F, 15th Alissouri Regiment, aged 20 years. Springhill, December 26th, 1862. Fracture of left malar, temporal, and palate bones, and injury of right eye and left ear. Nashville, Jeffersonville, and Evans- A'ille hospitals. Hearing of left ear lost. Discharged Alay llth, 1885. Elder, AA'illiam, Private, Co. F, 63d Pennsylvania, aged 21 years. AA7ilderness, May 5th, 1864. Fracture of frontal and temporal bones, eye destroyed; also Avound 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 Avound of right eye. Field, Alexandria, and York hospitals. Died August 24th, 1864, from inflammation of brain. Free, Jaaies, Private, Co. K, 55th NeAV Vork ATolunteers, aged 19 years. Fair Oaks, May 31st, 1882. Loss of right eye. Washington hospital. Died July 8th, 1862, of typhoid fever. Fitzgerald, Charles H, Sergeant, Co. C, 138th Pennsylvania Volunteers, aged 32 years. Winchester, September 19th, 1864. Loss of right eye. Regimental, Sandy Hook, and Philadelphia hospitals. Left eye sympathetically affected. Discharged February 14th, 1865, and pensioned, Fitzgerald, James, Private, Co. G, 5th Louisiana Regiment, aged 18 years. Rappahannock Station, November 7th, 1863. Fracture of frontal and orbital bones, loss of vision of left eye. Taken prisoner, and treated at Washington hospital. Transferred to Old Capital Prison for exchange April 14th, 1864. Fixch, Robert, Sergeant, Co. B, 1st Michigan Sharpshooters, aged 22 years. North Anna River, 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, 1362. Loss of left eye. Perryville and Louisville hospitals. A'ision of right eye impaired. Discharged December 20th, 1862, and pensioned. Funk, David, Corporal, Co. I, 5th Pennsylvania Reserves. Fredericksburg, December 13, 1862. Fracture of cranium, and sight of left eye destroyed. Field, AA'ashington, and Philadelphia hospitals. Amaurosis of right eye. Discharged March 3d, 1863, and pensioned. Goff, John, Private, Co. E, llth Ohio Cavalry. Fracture of frontal bone, and destruction of right eye. Regimental hospital. Left eye sympathetically affected. Discharged December 4th, 1865. Pension claim pending. Greenleaf, Jaaies M., Private, Co. C, 145th Pennsylvania A'olunteers. Fredericksburg, December 13th, 1862. Frac- ture of frontal bone, and loss of right eye; also fracture of loAver jaw. Field and Washington hospitals. Discharged April 6th, 1863, and pensioned. Grier, Sylyanus, Private, Co. K, 124th New York Volunteers. Chancellorsville, May 3d, 1863. Loss of right eye. Field hospital. Discharged November 1st, 1834. Left eye subsequently became A-ery defective. Pensioned. Gunst, Peter, Private, Co. I, 2d Alichigan Volunteers, aged 21 years. Petersburg, June 17th, 1«64. Loss of right eye. Also fracture of rinsr finger of right hand, necessitating amputation. Field and Washington hospitals. Discharged July 28th, 1865, and pensioned. Godwin, H. 77'., Sergeant, Co. C, 5th North Carolina Regiment, aged 26 years. Gunshot Avound 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. Grovi.r, John, Private, Co C, llth Connecticut Volunteers, aged 23 years. Gunshot Avound of left side of face; loss of left eye. Drury's Bluff, Virginia, May 16th, 1884. Returned to duty December 15th, 1864. He is not a pensioner. Gintiikr, John, Private, Co. A, 16th Alichigan Volunteers, aged 27 years. Rappahannock Station, Virginia, November 7th, 1863. Shell wound, destroying globe of left eye. Washington hospital. Discharged March 20th, 1864, and pensioned. 336 WOUNDS AND INJURIES OF THE FACE. Gaii.ey, Andrew, Private, Co. G. 104th Ohio Volunteers, aged 44 years. Gunshot fracture of left malar bone; eye destroyed. Franklin, Tennessee, November 30th, 1864. Discharged May 18th, 1865. (ii.NUXG, Calvin, Private, Co. A, 109th NeAV York A'olunteers. aged 44 years. Gunshot fracture of malar bone and destruction of right eye. AA'eldon Railroad, Alrginia, August 19th, 1864. Spiculae of bone removed at various times. 1 'scharged 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 jaAv; destruction of right eye. Fair Oaks, Virginia, October 13th, 1864. Transferred to Veteran Reserve Corps, and discharged July 28th, 1865. He is not a pensioner. Galley, William R., Sergeant, Co. C, 40th Indiana Volunteers. Chattanooga, November 25th, 1863. Fracture ot frontal and left malar bones, Avith loss of left eye. Field hospital. Died December 23d, 1863. 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 NeAV 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, 1885. Harper, Robert, Private, Co. M, 102d Pennsylvania Volunteers, aged 22 years. Wilderness, Alay 5th, 1864. Fracture of right frontal with depression, and destruction of right eye, by conoidal ball. Washington and Pittsburg hospitals. Discharged November 14th, 1864, and pensioned. Haven, Francis AI., Private, Co. H, 17th Kentucky Volunteers, aged 20 years. Shiloh, April 6th, 1862. Fracture of frontal bone, Avith 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, Edavix. Private, Co. A, 2d United States Artillery, aged 32 years. City Point, July 23d, 1864. Fracture ot frontal bone and loss of right eye. Field and NeAV 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 AV., 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. Jefferson 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, Avith loss of left eye. Petersburg, Virginia, June 16th, 1864. Transferred to Veteran Reserve Corps November llth, 1864; discharged and pensioned. Huffman, J. D., Private, Co. E, 7th Pennsylvania Volunteers. Gunshot wound through nose and loss of one eye. Admitted to GeorgetoAvn College Hospital September 6th, 1862. Discharged December 3d, 1862. He is not a pensioner. Huntsinger, Henry J., Private, Co. A, 48th Indiana Volunteers. Gunshot Avound of right eye and fracture of loAver jaAV. 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 Illinois Volunteers. Gunshot fracture of nasal bones and injury ot 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 Pennsylvania A'olunteers, aged 16 years. Gunshot Avound of face. Missile entered just beloAV 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-Tourths 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, Avounds had healed. Transferred to Invalid Corps, December 31st, 1863. Not a pensioner. Hewitt, Edward G., PriA-ate, 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. Raskins, John C, Private, Co. B, 24th Texas Cavalry, aged 24 years. Fragment of shell struck left side of face, carry- ing away the entire malar bone and destroying left eye. Arkansas Post, January llth, 1863. Recovered and sent to prison May 4th, 1863. Helper, John, PriA-ate, 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 dowmvard 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 A'eteran Reserve Corps. Not a pensioner. GUNSHOT WOUNDS OF THE EYE. 33? Hill, George, Sergeant, Co. G, 64th Ohio A'olunteers. Chattanooga, November 25th, 1863. Alusket ball entered left eve, destroying it, and emerged on right side of face, near angle of jaAV, fracturing the superior maxilla. Vision of right eye impaired. Cumberland hospital. Discharged August 17th, 1864, and pensioned. Ii.sley, Nathaniel, Private, Co. I, 35th Alassachusetts, aged 27 years. Cold Harbor, June 5th, 1864. Fracture ot frontal bone and loss of left eye. Field, AA'ashington, and Portsmouth hospitals. Secondary haemorrhage. Returned to duty October 13th, 1864; discharged June 9th, 1865, and pensioned. Jesse, T. S., Private, Co. A, 29th A'irginia Regiment. Fracture of spine of scapula and orbital process of frontal bone, right side; right eye involved. Richmond hospital; no result recorded. Johnson, John, PriA'ate, Co II, 49th Ohio A'olunteers, aged 19 years. Buzzard Roost, Alay 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, Edavix R., PriA-ate, Co. E, 7th Illinois A'olunteers, aged 23 years. Allatoona, October 5th, 1864. Fracture ot outer edge of right supra-orbital ridge, Avith loss of eye, by conoidal ball. Field, Nashville, Jeffersonville, and Springfield hospitals. Removal of fragments. Keturned to duty February 28th, 1865 ; discharged Alay 13th, 1865, and pensioned. Joyce, Patrick, Private, Co. A., 115th New Y'ork Volunteers, aged 25 years. Petersburg, June 29th, 1865. Fracture 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 W., Private, Co. F, 54th North Carolina Regiment, aged 30 years. Gunshot Avound of face. Missile 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 the right 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 Blinois A'olunteers. Atlanta, August, 1864. Fracture of left'supra-orbital ridge and nasal bones; eye destroyed. Field hospital. Died August 16th, 1864. Kenyon, Elias AA'., 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 oi frontal bone, with loss of left eye. Field and AA'ashington hospitals. Vision of right eye very imperfect. Discharged from service February 5th, 1863, and pensioned. Klles, Jacob B., Private, Co. F, 110th Ohio Volunteers, aged 20 years. Cold Harbor, June 3d, 1864. Loss of left eye. Field, AA'ashington, Y'ork, and Philadelphia hospitals. Discharged June 14th, 1865, and pensioned. Kimberlin, John, Private, Co. E, 9th Illinois Volunteers, aged 20 years. Fort Donelson, February 15th, 1862. Loss of left eye. Cincinnati hospital. Discharged August 14th, 1882, 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, AA'ashington, and Philadelphia hospitals. Discharged June 28th, 1865, and pensioned. Killingsworth, P. D., Private, Co. I, 51st Georgia Regiment. Gunshot Avound of face. Missile destroyed the right eye and fractured upper and loAver jaAV. Chancellorsville, A^irginia, 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 Arolunteers. Gunshot Avound 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. Ke.aip, Charles, Private, Co. B, llth 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 1st, 1865. Fracture of temporal bone with loss of left eye. Washington hospital. Discharged May 6th, 1865, and pensioned. Lindsay, Joseph, Private, Co. C, 72d Pennsylvania Volunteers, aged 27 years. Malvern Hill, July 1st, 1862. Frac- ture of temporal and loss of right eye. Baltimore hospital. Discharged November 16th, 1862, and pensioned. Lynde, James H, Lieutenant, Co. 1,14th New York Heavy Artillery. Fort Steadmanj February 25th, 1865. Fracture of frontal bone, Avith loss of right eye. Field and City Point hospitals. Discharged August 26th, 1865, and pensioned. Lewis, H. B., Private, Co. A, 121st NeAV York Volunteers, aged 18 years. Gunshot Avound of face, Avith loss of right eye. Ball entered middle of right eyebroAV and exit through mouth. Chancellorsville, Virginia, May 3d, 1863. Returned to duty September 9th, 1883. Discharged and pensioned. Lomas, AAtilliam, Private, Co. H, 2d Pennsylvania Heavy Artillery, aged 30 years. Gunshot Avound of face, left eye destroyed. Petersburg, Virginia, June 18th, 1864. Removal of several spicula? of bone. The loAver eyelid is drawn to a V shape and attached to the malar bone. Dischaiged May Kith, 1865. Not a pensioner. 43 338 WOUNDS AND INJURIES OF THE FACE. Lynch, Patrick, Private, Co. F, 6th 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, A'irginia, August 21st, 186)4. Left eye completely gone; right eye very Aveak. Discharged Alay 5th, 1865, and pensioned. Leech, Albert G., Private, Co. H, 2d A'ermont A'olunteers, aged 25 years. Gunshot Avound of face. Conoidal ball entered at right supra-orbital arch, destroyed eye and passed into mouth. Cedar Creek, A'irginia, October 19th, 1864. Paralysis of right side of face; mastication and speech difficult. Discharged May 12th, 1865, and pensioned. Lackf.y, AA'illiam J., Private, Co. H, 102d Pennsylvania A'olunteers, aged 35 years. Gunshot wound of face. Conoidal ball entered just anterior to inner angle of right eye, fractured the nasal bones, passed directly through left eye and emerged just posterior to its outer angle. Cedar Creek, A'irginia, October 19th, 1864. November 22d, the wound has nearly healed. Discharged February 27th, 1865, and pensioned. Larimer, Isaac, Sergeant, Co. K, 35th Illinois Volunteers. Missile entered the right malar bone, close under orbit, fractured and destroyed a portion of orbital process, passed through palate bone into the mouth, grazed ramus of left inferior maxilla, and emerged through left side of neck. Discharged September 27th, 1864. Loss of vision of left eye. He is a pensioner. Lippixcott, Dexis, Private, Co. D, 5th United States Infantry. Gunshot fracture of superior maxillary and nasal bones; loss of right eye. A'alverde, Ncav Mexico, February 21st, 1862. Discharged June 25th, 1862, and pensioned. McCoy, John P., Private, Co. H, 77th Illinois, A'olunteers, aged 22 years. May 16th, 1863. Loss of right eye. Mem- phis hospital. June 15th, secondary haemorrhage from temporal artery. Returned to duty July 20th, 1863. Partial blindness of left eye. Discharged March 7th, 1865, and pensioned. M( Having, Henry, Private, Co. D, 2d Michigan Volunteers. Petersburg, December llth, 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. 1,108th Ohio Volunteers, aged 25 years. Kenesaw Mountain, June 20th, 1864. Fracture of frontal bone, and loss of left eye. Field, Nashville, Louisville, and Camp Dennison hospitals. Discharged May 31st, 1865, and pensioned. Masters, Aquilla, Sergeant, Co. E, 14th Ohio Volunteers, aged 23 years. Chickamauga, September 20th, 1863. Fracture of right temporal bone, Avith loss of vision of right eye. Field, Chattanooga, Nash\dlle, and Columbus hospitals. Discharged July llth, 1864, and pensioned. Miller, John W., Private, Co. K, 55th Pennsylvania A'olunteers. Pocotaligo, Virginia, October 22d, 1862. Fracture of frontal and temporal bones, with loss of right eye. Hilton Head hospital. Hearing of right ear impaired. Discharged December 14th, 1862, and pensioned. • • Miller, William H, Private, Co. B, 3d NeAV York, Artillery, aged 23 years. Honey Hill, November 30th, 1864. Injury of frontal and temporal bones, and destruction of right eye. Hilton Head hospital. Discharged May 9th, 1865, and pensioned. Morgan, James E., Corporal, Co. K, 15th IoAva 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. MOORE, William, Private, Co. F, 119th Pennsylvania Volunteers, aged 36 years. Rappahannock Station, Virginia, November 7th, 1863. Loss of left eye. Washington and Philadelphia hospitals. Incipient and progressive amaurosis of right eye. Discharged March 22d, 1865, and pensioned. Murphy, Huqh, Private, Co. D, 17th AA'isconsin Volunteers, aged 30 years. Bentonville, North Carolina, March 21st, 1865. Fracture of angle of left orbit, and destruction of left eye. Field, NeAV Berne, NeAV Y'ork, and Madison hospitals. Discharged May 23d., 1865, and pensioned. McMiller, Johx, Private, Co. A, 32d Iowa Volunteers, aged 28 years, Gunshot wound of face. Missile struck the right maxillary bone, and splitting, passed through the right eye and right frontal sinus. Pleasant Hill, Louisiana, April 9th, 1864. The tAvo pieces of ball Avere extracted. Discharged February 14th, 1865. Pension of eight dollars per month granted February 14th, 1865. Softening of the brain supervened. Constant headache and other cerebral symptoms. Meckel, AVilllam, Private, Co. H, 3d NeAV York A'olunteers, aged 21 years. Gunshot wound of left side of face, destruction of eye. Petersburg, Virginia, July 30th, 1864. Transferred to A'eteran Reserve Corps, Alay 4th, 1865. Discharged and pensioned. Myers, 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 6th, 1865, and pensioned. Marcy, Edward, Private, Co. D, 91st Ohio A'olunteers, aged 41 years. Gunshot Avound of face. Conoidal ball entered left malar bone and emerged through right malar bone, destroying sight of left eye. Winchester, Virginia, September 19th, 1864. Transferred to A'eteran Reserve Corps, P'ebruary 10th, 1865. He is not a pensioner. Minkler, George W., Private, Co. C, 128th New York A'olunteers, aged 21 years. Gunshot fracture of superior maxilla and nasal bones. Cedar Creek, Virginia, October 19th, 1864. Blepharoconjunctivitis of left eye. Loss of use of light eye. Discharged May 20th, 1865, and pensioned. Miner, Henry, Private, Co. C, 10th A'ermont A'olunteers, aged 36 years. Gunshot fracture of nasal bones; missile passed through ball of left eye. AVinchester, Virginia, September 19th, 1^64. Ball extracted from cavity of eye. Left eye completely gone, right eye very Aveak. Discharged April 6th, 1865, and pensioned. GUNSHOT AVOUNDS OF THE EYE. 339 Mengham, W. T., Private, Co. K, 21st North Carolina Regiment, aged 21 years. Gunshot wound of orbit; missile carried aAvay the eye and emerged from the nose. Fort Fisher, North Carolina, January 13th, 1865. Released June 28th, 1865. Millard, Isidore, Private, Co. H, 10th Alissouri Cavalry, aged 29 years. Missile entered anterior to meatus auditorius externus, passed forward and dowmvard and emerged at right orifice of anterior nares, destroying sight of right eye. Selma, Alabama, April 2d, 1865. Discharged May 31st, 1865. Not a pensioner. Morrison, Hugh, 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. Martin, Thomas B., Private, 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, Tennessee, September 20th, 1863. Several haemorrhages occurred, Avhich Avere 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 AVisconsin Volunteers, aged 26 years. Gunshot fracture of nasal bones; conoidal ball passed transversely and destroyed the right eye. Spanish Fort, Alabama, March 30th, 1865. Mustered out September 23d, 1805, and pensioned. Nichols, Norman J., Private, Co. G, 2d Arermont 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, 1863. Loss of right eye. Farmville hospital. Retired from service June 3d, 1864. Neale, Fielding, Adjutant, 96th NeAV 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, 1864. Returned to duty February 9th, 1865. Discharged and pensioned. Oakball, Ned, Private, Co. D, 2d Indian Home Guard, 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, 1864. Loss of right eye. Returned to duty May 31st, 1865. Not a pensioner. Packard, Albert H., Captain, Co. G, 31st Maine Volunteers. Wilderness, May 6th, 1864. Penetrating fracture of cranium by musket ball, which lodged in brain substance; eye destroyed. Field and AVashington hospitals. Died May 16th, 1864. Peeler, John, Private, Co. K, 134th New York Volunteers. Gunshot wound of face. Missile struck the margin of the 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. Percifield, 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, 1864. Discharged June 14th, 1865, and pensioned. Pcrdy, Elum, Private, Co. H, 84th Blinois Arolunteers, aged 22 years. Gunshot fracture of zygoma; right eye destroyed. Buzzards Roost, May 9th, 1884. 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, 1863. Fracture of frontal bone and loss of sight of left eye. Field and Washington hospitals. Discharged December 19th, 1863, and pensioned. Pradt, John C, Private, Co. A, 3d Wisconsin Cavalry. Baxter Springs, Kansas, October 6th, 1863. Fracture of cranium and entire destruction of left eye. Post hospital, Fort Scott. Returned to duty December llth, 1863; discharged August 17th, 1867, and pensioned. Pearce, James M., Private, Co. M, llth 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, 26th 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 llth, 1884, and pensioned. Ransom, Sutton, Private, Co. E, 1st United States Colored Cavalry, aged 20 years. Bermuda Hundred, June 17th, 1864. Fracture of temporal and destruction of left eye. Point Lookout hospital. Returned to duty November 14th, 1864. 340 WOUNDS AND INJURIES OF THE FACE. Redding. William A., Private, Co. A, 6th NeAV Hampshire Volunteers. Bull Run, August 30th, 1862. Loss of left eye and derangement of intellect. AVashington hospital. Vision of right eye impaired. Discharged June 27th, 1H63, and pensioned. Reese, Charles, Captain, Co. D, 20th Indiana Volunteers. Gettysburg, July 2d, 1863. Loss of right eye. (iettys- burg and AVashington hospitals. Discharged October 22d, 1863. Regling, Christopher, Private, Co. G, 3d Michigan A'olunteers, aged 35 years. Wilderness, May 6th, 1864. Fracture of temporal bone, with loss of right eye. Field, Washington, and Detroit hospitals. Headache, vertigo, and mental aberration. Discharged August 29th, 1864, and pensioned. Reynolds, Daniel M., Corporal, Co. F, 49th Pennsylvania Volunteers, aged 21 years. Spottsylvania, May 10th, 1864. Fracture of frontal and nasal bones and destruction of right eye. Field, Washington, and New York hospitals. Imperfect vision of left eye. Returned to duty July 28th, 1884; discharged December 22d, 1864, and pensioned. Riley, AIichael, Co. K, 35th Massachusetts Volunteers. Antietam, September 17th, 1862. Loss of left eye. Frederick hospitals. Discharged December, 1862, and pensioned. Roe, Joseph, Corporal, Co. C, 91st NeAV York Volunteers, aged 28 years. South Side Railroad, April 2d, 1865. Fracture of nasal and malar bones and loss of left eye. Field and Washington hospitals. Discharged August 3d, 1865, and pensioned. Rogerson, Andrew B., Lieutenant, Co. A, 20th Illinois Volunteers, aged 27 years. Chattanooga, July 16th, 1864. Fracture of temporal and nasal bones and destruction of right eye. Chattanooga and Nashville hospitals. Senses of taste and smell nearly destroyed. Discharged Alay 15th, 1865, and pensioned. Ross, J. A., Private, Co. C, 38th North Carolina Regiment, aged 23 years. Destruction of left eye. Point Lookout hospital. Transferred to provost marshal April 8th, 1865. Rutter, E., Private, Co. E, 2d Maryland Arolunteers, aged 19 years. August 19th, 1864. Wound of left temple, involving eye and nose. Richmond hospital. Returned to duty October 19th, 1864. Rogers, Alvin, Private, Co. C, 77th Illinois Volunteers. Gunshot fracture of facial bones. Conoidal ball struck just over the left eyebrow, passed doAvmvard, destroying the eye, and lodged in the superior maxilla. Vicksburg, Alississippi, May 22d, 1863. A'ision of right eye also impaired. Discharged July 10th, 1863, and pensioned. Reynolds, D. AI., Lieutenant, Co. E, 184th Pennsylvania Volunteers, aged 21 years. Conoidal hall 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, 1864. Not a pensioner. Rothenberger, H, Sergeant Co. D, 48th Pennsylvania Volunteers, aged 21 years. Gunshot Avound of face. Conoidal ball entered at the inner canthus of left eye, passed downward and backward, and lodged outside of angle of inferior maxilla. Petersburg, April 2d, 1865. Missile removed. Left eye was entirely destroyed. Returned to duty July 6th, 1865. Discharged and pensioned. Ross, John M., Private, Co. H, 8th Pennsylvania Volunteers. Gunshot wound of face. Missile entered the left eye, passed obliquely through superior maxilla, and emerged opposite and near the mastoid process. Fredericksburg, December 13th, 1862. Discharged January 24th, 1863. Left eye destroyed. Pensioned. Richardson, John, Private, Co. B, 14th Hlinois Volunteers. Gunshot Avound 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 6th, 1862. Ball removed six Aveeks after reception of injury. Discharged September 29th, 1862. Loss of vision of left eye, and difficulty of hearing. He is a pensioner. Shaeffer, Peter, Private, Co. M, 12th Ohio Cavalry, aged 18 years. Accidentally, near Lexington, June llth, 1864. Perforating fracture of cranium; loss of left eye. Lexington hospital. Died June 12th, 1864. Sanders, Henry C, Private, Co. B, 20th Maine Volunteers, aged 20 years. 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 Alay 26th, 1865, and pensioned. Schuler, Joseph A., Sergeant, Co. C, 3d Michigan. Mine Run, Virginia, November 27th, 1863. Fracture of angular process of temporal hone, and destruction of left eye. Regimental and Fairfax hospitals. Transferred to A^eteran Reserve Corps, March 25th, 1864. Incipient cataract of right eye. Discharged June 17th, 1864, and pensioned. Sharp, Matthew, Private, Co. I, 82d Pennsylvania Arolunteers, aged 36years. Sailor's Creek, Virginia, April 6th, 1865. Fracture of frontal bone, with loss of left eye. Field, City Point, and Washington hospitals. Discharged June 14th, 1865, and pensioned. Shaver, William H., Private, Co. H, 3d NeAV York Artillery. Petersburg, September 13th, 1864. Fracture of frontal bone, and destruction of right eye. Fort Monroe, and New York hospitals. Discharged June 27th, 1865. Sheley, George A., Lieutenant, Co. M, 1st Michigan Light Artillery. Cumberland Gap, Virginia, June 18th, 1864. Fracture of frontal bone, Avith 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 Pennsylvania 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 upper extremity. GUNSHOT WOUNDS OF THE EYE. 341 Sickles, AVilliam, Private, Co. G, 73d Ohio A'olunteers, aged 20 years. Resaca, May 15th, 1864. Fracture of cranium, with loss of left eve. Field, Chattanooga, Nashville, Louisville, Camp Dennison, and Columbus hospitals. Discharged June 13th, 1885, and pensioned. Slack, Alden S., Corporal, Co. I, 3d A'ermont A'olunteers, aged 26 years. AVinchester, September 19th, 1864. Fracture of frontal bone, Avith loss of right eye; also fracture of right leg. Field, Baltimore, Brattleboro', and Montpelier hospitals. Discharged June 12th, 1865. and pensioned. SLOCUM, AA'arren, Private, Co. G, lilth New York Volunteers, aged 21 years. Wilderness, May 5th, 1864. Fracture of frontal, orbital, and maxillary bones, and destruction of left eye. Field, AVashington, Chester, and New Y'ork hospitals. Discharged September 5th, 1864, and pensioned. Has constant pain in head, with frequent attacks of vertigo. Statler, Rudolph, Private, Co. I, 33d Alissouri A'olunteers, aged 20 years. Pleasant Hill, April 9th, 1884. Fracture of orbital bones, Avith loss of left eye. Field and Memphis hospitals. Returned to duty November 17th, 1864. Stewart, W. X., Private, Co. G, 43d North Carolina Regiment. Spottsylvania, May 10th, 1864. Loss of left eye. Retired Alarch 6th, 1835. Had constant pain, headache, and vertigo, and loss of sense of taste and smell. Had also occasional attacks of epilepsy. Stokes, Patrick. Private, Co. F, 28th Massachusetts Volunteers, aged 28 years. Spottsylvania, May 12th, 1864. Fracture of frontal bone and loss of left eye. Had previously received Avounds of abdomen and foot. Field, AVashington, Readville, and Worcester hospitals. Discharged July 21st, 1865, and pensioned. Stratton, Isaac, Sergeant, Co. F, 7th Ohio A'olunteers. Gettysburg, July 3d, 1883. Fracture of left supra-orbital arch, Avith loss of left eye. Seminary and Y'ork hospitals. October 1st, removal of fragments of ball. Returned to duty October 21st, 1863. Killed near Dallas, Georgia, May 25th, 1864. Smith, Elias, Private, 2d Iowa Battery. Gunshot Avound of left orbit; loss of sight. Vicksburg, Mississippi, May 22d, 1863. Returned to duty September 23th, 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. Cold Harbor, A'irginia, June 1st, 1864. Discharged October 14th, 1864. Not a*pensioner. Saiith, Andreav J., Private, Co. C, 7th AA'isconsin A'olunteers. Conoidal ball struck right eye, passed downward, and lodged in left side of neck. Gettysburg, Pennsylvania, July 1st, 1863. Ball extracted by an incision in left side of neck. Eight eye destroyed. Transferred to A'eteran Reserve Corps September 9th, 1863. Not a pensioner. Shannon, Jaaies J., Corporal, Co. B, 83d Ohio Volunteers. Gunshot Avound of left eye. Arkansas Post, January llth, 1863. Died Janunry 19th, 1863. Seal, Zachap.iah, Private, Co. B, 15th New Jersey Volunteers. Gunshot wound through eye and fracture of jaw. Discharged Alarch 9th, 1863, and pensioned. Slocum, John A., Private, Co. H, 150th 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. Returned to duty December 12th, 1864. Discharged and pensioned. Stiner, Joseph, Private, Co: H, 203d Pennsylvania Aroluntcers, aged 21 years. Gunshot injury of jaw; right eye destroyed. Fort Fisher, North Carolina, January 15th, 1865. Discharged April 23d, 1865, and pensioned. Shepler, Peter, Sergeant, Co. B, 6th Pennsylvania Reserve Corps. Gunshot fracture of right orbit; eye torn out; under lid carried away. Spottsylvania, Virginia, May 10th, 1865. Discharged July 17th, 1865. Appearance repulsive. Not a pensioner. Semich, Julius, Private, Co. A, 26th Wisconsin Volunteers, aged 25 years. Missile entered outer angle of right orbit, destroyed right eye, passed through both superior maxillary bones and lodged at second upper molar, left side. Atlanta, Georgia, July 20th, 1864. Transferred to A'eteran Reserve Corps, December 20th, 1864. Discharged and pensioned. Sexior, Johx, Private, Co. B, 35th Massachusetts Volunteers. Antietam, September 17th, 1862. Gunshot fracture of superciliary ridge and frontal bone. Baltimore hospital. Discharged November 26th, 1862, and pensioned. A'ertigo and impaired vision of the right eye. Stuckley, D. H., Private, Co. H, 59th Alabama Regiment, aged 25 years. Gunshot wound of face. Conoidal ball entered over outer angle of orbit, passed doAvnward and backward, and emerged at angle of inferior maxilla of opposite side. Right eye destroyed Spottsylvania, Alay 16th, 1864. Furloughed June 7th, 1864, nearly recovered. Syntes, Sylvester,- Private, Co. A, 18th Georgia Regiment, aged 19 years. Missile, conoidal ball, entered right eye, and passed out of left. Burksville, Virginia, April 6th, 1865. Released Alay 7th, 1865, on taking the oath of allegiance. Sutton, Sylvester, Private, Co. A, 14th Alichigan Volunteers, aged 21 years. Atlanta, Georgia, August 7th, 1864. Fracture of temporal, frontal, and malar bones, Avith loss of vision of right eye. Field, Chattanooga, Jeffersonville, 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 SmoketoAvn hospitals. Great disfiguration. Dis- charged December 6th, 1862, and pensioned. Thompkins, Thoaias, Corporal, Co. B, llth AVisconsin Volunteers. Gunshot fracture of facial bones. Alissile entered left side of nose, one-half inch below inner canthus, and emerged one-half inch in front of right ear. Right eye destroyed- Corinth, Alississippi, October 3, 1882. Discharged Alarch 31st, 1863. Not a pensioner. 342 WOUNDS AND INJURIES OF THE FACE. Tate, Samuel G., Private, Co. I, 4th United States Cavalry. Fracture of frontal bone, with loss of right eye. Louis- ville hospital. Returned to duty Alarch llth, 1863. Discharged April 22d, 1863, and pensioned. Uzelmeyer, JohnY Private, Co. I, 1st DelaAvare Volunteers, aged 20 years. AVilderness, May 5th, 1864. Fracture of external table of frontal hone, Avith loss of left eye. Field, AA'ashington, and Chester hospitals. Transferred to the A'eteran Reserve Corps, May 6th, 1865. Discharged September 15th, 1865, and pensioned. An unknoAvn 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. Vosburg, Stephen H., Sergeant, Co. F, 63d NeAv 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 Reserve Corps April 5th, 1865. Discharged and pensioned. Welton, G. W., Private, Co. F, 12th Virginia Regiment. Loss of eye. Richmond hospital. Furloughed September 7th, 1864. White, Charles F., Private, Co. F, 114th NeAV Y'ork Volunteers, aged 21 years. Cedar Creek, A'irginia, October 19th, 1864. Fracture of skull, and destruction, also, of right eye. Great disfiguration. Baltimore and Philadelphia hospitals. Transferred to the Veteran Reserve Corps. Discharged June 15th, 1865, and pensioned. Whitlock, John, Private, Co. A, 1st New Jersey A'olunteers, aged 21 years. Spottsylvania, Virginia, May llth, 1864. Fracture of orbital and temporal bones, Avith loss of right eye. Field, Washington, and Philadelphia hospitals. Discharged Alay 19th, 1865, and pensioned. AA'ill, George F., Private, Co. I, 77th New York Volunteers, aged 22 years. Wilderness, May 6th, 1864. Fracture of orbital and temporal bones, Avith loss of left eye. AA'ashington, Philadelphia, New York, and Albany hospitals. Sympathetic affection of right 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 Reserve Corps December 21st, 1864. Withey, Lemon B., Private, Co. C, 136th New York, aged 25 years. Gettysburg, July 2d, 1863. Fracture of malar bone, and loss of left eye. Gettysburg, York, and Alexandria hospitals. Spiculae extracted. Discharged May 25th, 1865, and pensioned. Williams, Asbury, Private, Co. D, 23d Indiana Volunteers. Vicksburg, May 19th, 1863. Fracture of cranium at base of brain, Avith 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, destroying the sight, crossed the face under the nose, and lodged in antrum of left side. Vicksburg, Mississippi, 1863. Trans- ferred to Veteran Reserve Corps, and returned to duty December 7th, 1863. Not a pensioner. Works, Wright, Private, Co. B, 60th New York Volunteers, aged 20 years. Gettysburg, Pennsylvania, July 3d, 1863. Gunshot Avound of facial bones, with loss of eye. Removal of spiculae of bone and lead at various times. Returned to duty June 28th, 1864. Discharged and pensioned. Walker, A., Private, Co. K, Palmettto 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, Georgia, July 20th, 1864. Left eye impaired. Discharged Alarch 20th, 1865, and pensioned. AA'illlvms, Ormando M., Private, Co. E, 5th Vermont Volunteers, aged 21 years. Gunshot fracture of bones of face; left eye destroyed. AVilderness, Virginia, May 6th, 1864. Ball remained in wound for three or four years, Avhen it was finally removed from the throat by the patient during a choking fit. Discharged November 16th, 1864, and pensioned. Wilford, James M., Sergeant, Co. D, 4th Tennessee Regiment. Gunshot fracture of nasal bone; right eye destroyed. Franklin, Tennessee, November 30th, 1864. Sent to provost marshal January 7th, 1865. 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, A'irginia, September 30th, 1864. Loss of right eye. Returned 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 doAvmvard, and emerged from cheek, near left angle of mouth, knocking out several teeth; also fracture of right ulna in lower third. Rocky Face, May 9th, 1864. Discharged October 7 th, 1864. A'ision of right eye destroyed; that of left slightly impaired, as also mastication and speech. Flexion of fingers imperfect. He 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 Avas ultimately lost. The GUNSHOT WOUNDS OF THE EYE. 343 aggregate of gunshot injuries of the 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 Gunshot Wounds of the Eye. extent of injury. Destroying sight of both eyes...... Destroying sight of right eye....... Destroying sight of left eye........ Destroying sight; side not given--- Injuring sight of right eye......... Injuring sight of left eye........... Injuring sight; side not stated...... Undetermined cases; right eye---. Undetermined cases; left eye....... Undetermined cases; side not stated Aggregate............... Cases. 63 393 387 45 25 20 6 106 116 29 17 12 24 11 1,190 64 Duty. Discharged. Unknown. 2 44 87 286 8 95 258 10 9 17 8 9 13 3 8 8 4 1 2 3 71 24 11 83 20 13 16 7 6 379 679 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 by 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 opacity, 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 ."j* The intrusion of fragments 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 ofthe 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 with the Merrimac, and it used to be said in the army that he should blush with a pardonable pride whenever he looked in the mirror. tLord Nelson lost an eye from this cause at the siege of Calvi, as related in a letter to his wife, August 18th, 1794. Tyrrell (Vol. I, p. 367), Ammon (Zeitschrift, B. Ill, S. 103), Dr. J. Hays (3d Am. ed. of Lawkence On the Eye, p. 182), and Matthews (Surg. Hist, of Brit. Army in the Crimea, p. 310), record similar cases. 344 WOUNDS AND INJURIES OF THE FACE. anterior chamber were those in Avhich the copper fragment was immediately extracted.* The injuries of the eye from pistol and musket balls and from fragments of large projectiles were very A-aried in their nature. Commonly 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 tlie 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 lodgement of a ball in the orbit, without injury to the globe, unless the case of Richardson (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 A'ery distressing march that night." The eyelids rarely escaped injury in gunshot wounds of the contents of the orbit; but in a feAV instances the glodbe 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 few instances are illustrated by photographs in the Museum ;f 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, Figs. 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, recoArery took place, or the fatal result was long deferred unless complicated Avith cerebral mischief; the fractures of the external walls of the frontal and maxillary sinuses Avere 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 Crompton'S account of seven cases treated by BARTON', of Manchester (London Med. Gazette, Vol. XXI, p. 171); Am. Jour, of Med. Sciences, for a case of successful removal of a fragment from the iris by Dr. X. R. SMITH; Dr. J. II ays (loc. cit., p. IK); Sttv.vexakt (Ann. d'Oc, T. I, p. 439), Clniek (ibid., p. 440); LAAVSON (Injuries of the Eye, p. 289) gives six cases. STOEBEK (in A\T. AV. Cooper's Wounds and Injuries of the Eye. London, 1869, p. 391). tSee Photographs of Surg. Cases and Specimens, A. M. 51., A'ol. I, p. 32; Ibid. A'ol. II. p. 2; Ibid. VoL II, p. 18; Ibid. Vol. VI, p. 9; Ibid. A'ol. VII, p. 8; Card Photographs of Surgical Cases, A. M. M., Vol. I, p. 4; Ibid. Vol. I, p. 4; Ibid. A'ol. I, p. 10; Ibid. Vol. I, p. 3; Ibid. Vol. I, p. 3; Ibid. Vol. I. p. 3; Ibid. Vol. I, p. 4. GUNSHOT WOUNDS OF THE EYE. 345 Gunshot contusions of the globe of the eye were not unfrequently followed by traumatic cataract. I have searched in vain in the records for such instances of recovery from this leison as Larrey recorded (Clin. Chir. T. le, 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 A-ery generally employed. In cases attended by destruction of the puncta or of the lacrymal canals, some of them having been under the observation of pension examiners or army surgeons for six or seA'en 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 Avere 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-five abstracts relate mainly to cases involving the upper and lower maxillse 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 Avound 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 spiculae of bone were removed on the * Consult Lakrey, Scarpa, Hey, Hennen, Vicq-d'Azyr on this disputed point. f Observations on gunshot wounds of the eye may be found in BEER, Lehre der Augenkrankeiten, AA'ien, 1792, B. 1, S. 95; in Hennen, Prin- ciples of Military Surgery, 3d ed., London, 1829, p. 344; GUTHRIE, Commentaries, etc., p. 523 ; W. W. COOPER, On Wounds and Injuries of the Eye, London, 1869, 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. 65; MACLEOD (op cit.), p. 223; DlXON, in Holmes's System of Surgery, Vol. Ill, p. 89, 2d ed.; LEGOUEST (op. cit.), p. 365; Annates d'Oculistique, T. Ill, p. 73, Bruxelles, 1840 ; WALKER, Oculists' Vade-mecum, London, 1843, p. 323; McRae, Medical Report of the Campaign in the Punjaub, p. 48; DEMOURS, Traite des Maladies des Yeux, Paris, 1818, PI. 52, fig. 1; Fenin, Ann. d'Oc, T. XX, p. 105; IsCHENSCHNIED, ibid., T. XXX, p, 107; CARRON DU VlLLARDS, Gazette Med. de Paris, T. VI, c. 1; Playne, Ophthalmic Hospital Reports, London, Vol. I, p. 216; Meniere, L'Hotel-Dieu de Paris, en juillet 1830, Paris, 1830; MACKENZIE, A Practical Treatise on the Diseases of the Eye, Am. ed. 1855, p. 412; Stellwag and SOELBERG Wells, in their recent treatises, add nothing to our information on the subject; Stoeber, Ann. d'Oc, T. Ill, p. 70 ; CROMPTON, London Medical Gazette, Vol. XXI, p. 175; Castelnau, Archives General de Medicine; LAWSON, Injuries of the Eye, Orbit, and Eyelid, London, 1867, p. 282; Gama, Traite des plaies de tete et de V enciphalite, 2d ed., Paris, 1835, p. 340; LAWRENCE, On the Diseases of the Eye, Am. ed., Phila., 1854, p. 182; Deval, Chirurgie Oculaire, Paris, 1844, p. 500; Desmarres, Traite des Maladies des Yeux, Paris, 1854, 2d ed. T. I, p. 152; AValton, Operative Ophthalmic Surgery, London, 1853, p. 95; Matthews, Surg. Hist, of the War in the Crimea, Vol. II, p. 309; Fardeau, Jour. Gin. de Mid. et de Chir., T. 24, Paris, 1809, p. 287, Denonvilliers ET Gosselin, Compendium (op. cit.), T. Ill, p. 413, Paris, 1861; Platner, Institutiones Chirurgix, Lipsia;, 1758, p. 322; Baudens, Cliniques de Plaies d'Armes a Feu, p. 167; Lohmeyer, Die Schusswunden, Zweite Ausgabe, 1869, S. 99 ; Beck, Die Schusswunden. S. 139 ; OCHWADT, Kriegschirurchische Erfahrungen, S. 351; ROSAS, Handbuch der theoretischen und practischen Augenheilkunde, Wien, 1830, B. I, S. 421; Dieterich, Archives GiniraUs de Midicine, October, 1826, p. 295; Hill, Cases in Surgery, Case V; Garengeot, Traiti des Operations de Chirurgie- T. 3«, p. 155. 44 346 WOUNDS AND INJURIES OF THE FACE. field. Hi' avus, on December 4th, admitted to 2d division hospital, Alexandria. On admission, the light side of the jaw had fallen in considerably, and the patient Avas Aveak and anaemic. Opiates, stimulants, and tonics were administered, and chicken broth, beef tea, and farina ordered. Secondary haemorrhage from one of the external carotid arteries occurred December 10th, amounting to ten ounces of blood, Avhich avus controlled by the application of persulphate of iron. The patient stated that he had recurrent haemorrhages. The horizontal ramus of the lower jaw is gone, and he can eat fluid food only. lie was discharged the service March 7th, 1864, and pensioned on March 15th. Examining Surgeon H. L. Hodge reports that he has great difficulty in SAvalloAving and very imperfect speech. His mind is Aveakened; disability total, probably permanent. The case is reported by Acting Assistant Surgeon J. G McKee. Case.—Private William H. Batchelder, Co. I, 16th Maine Arolunteers, aged 22 years, was Avounded at the battle of Gettysburg. July 1st. 18>>3, 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 Aving of the nose, passing doAvnward and backAvard, shattering the body of the right superior maxilla and the first and second molars, Avith the alveolar process of the inferior maxilla, grazing the side of the tongue in its passage. He Avas sent to the 2d division hospital, First Corps. The ball was removed at the lower side of the mouth. Secondary haemorrhage from the dental or facial artery occurred July 8th, amounting to about twenty ounces of blood, Avhich Avas arrested by the application of styptics, and pressure. On July 19th. he Avas transferred to York Hospital, Pennsylvania. The patient was put under chloroform, and seven teeth, consisting of five upper and two loAver, Avere removed, besides many pieces of the superior maxilla. Cold Avater dressings were applied to the wound. He Avas restless, and much pained, and had bad appetite. There was considerable discharge of pus in the mouth, the granulations filling the gaps in the jaAvs. On August 21st, the wound of entrance had closed, Avith some depression of its cicatrix. He could open the mouth one-half of an inch, but Avas unable to close it Avith force; spoke rather plainly, but could not speak when first Avounded. He looked rather pale, had good appetite, and Blept under morphia. He complained of paroxysms of pain at the root of the neck and shoulders, which yielded to Avet cups and morphia; these paroxysms continued Avith variable intensity, and extending to the back of the head, until about the 21st of September, at Avhich time it refused to yield to treatment. On the 22d, his face hushed, pulse frequent, irregular, and severe headache. Cups were applied to the back of the neck and cold applications to the head, which gave temporary relief. On the 23d, his condition Avas unchanged, save slight drowsiness. On the 24th, droAvsiness increased, and blisters AA'ere applied to the back of the neck. On the 25th, coma, snoring, and death. Necrotomy shoAved 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 Avas deeply red, softened, and at one point presented a spot of badly organized lymph, and possibly some pus. The ventricles Avere distended by several ounces of very clear serum. The case is reported by Surgeon Henry Palmer, U. S. X. Cask.—Sergeant George K. Burroughs, Co. G, 12th NeAV Jersey Arolunteers, aged 23 years, Avas Avounded at the battle of Cold Harbor, June 3d, 18o4. by a conoidal ball, which fractured the ramus of the inferior maxilla. The missile entered at the middle of the ramus on the right side, and emerged beloAV the angle on the left side, wounding the lingual and facial arteries. He Avas, on June 15th, admitted to HareAvood Hospital, AVashington. Secondary haemorrhage from the lingual and facial arteries occurred June 17th, amounting to eighteen ounces of blood. Haemorrhage recurred on the 20th. Free incisions Avere made in the course ofthe wound, and coagulated blood and pus cleaned out thoroughly; the haemorrhage thereupon ceased. The consti- tutional treatment throughout Avas supporting. Died June 22d, 1804. Patient seemed to have died from exhaustion superinduced by profuse and protracted suppuration, rather than from the immediate effects of the haemorrhage. The case is reported by Surgeon K. B. Bontecou, U. S. Ar. CASE.-Private James P. Benham, Co. D, 5th New York Volunteers, aged 22 years, of a nervo-sanguine temperament, and Avho had ahvays enjoyed perfect health, Avas wounded at the second battle of Bull Run, ATrginia, August 30th, 18112. by a conoidal ball, Avhich entered the left cheek midway on a line draAvn from the middle of the margin of upper lip to that ofthe 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 superior maxilla, and then striking the palate bone at its posterior edge, glanced off in an oblique direction doAvmvard and forward to the right, and lodged in the lingual muscles. He Avas admitted, on the next day, to the Armory Scjuare Hospital, AVashington, in an exhausted condition. Stimulants and nourishing diet were given. The ball could not be found. Spiculae of bone Avere removed, and cold water dressings applied. On September 6th, the wound Avas suppurating freely. On September 12th, secondary haemorrhage occurred, probably from the tonsillar or palatine arteries, which Avas restrained by cold applications. On October 17th, an incision Avas made one inch in front of the angle of the inferior maxilla, at the lower posterior edge of the gland, and the bullet extracted. It Avas found to be much flattened and bent, and thickly set with minute spiculae of bone. Fomentations Avere applied to promote suppuration. On October 26th, the wounds in the cheek and fauces Avere closed, and on the 31st, the parts had assumed nearly their normal condition. He Avas discharged from service March 31st, 1863. Surgeon D. AV. Bliss, U. S. Ar., reports the case. He is a pensioner, his disability being rated one-third and permanent. Cask.— Private Henry Baine, Co. C, 188th Pennsylvania Volunteers, aged 19 years, received, at the battle of Cold Harbor, A'irginia, June 3d, 1864, a gunshot Avound of head and face, conoidal ball entering in front ofthe 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, AVashington, on June 10th, 1864. Face much swollen; vision destroyed. Cold Avater dressings were applied and tonics administered. Patient did Avell until the evening of June 15th, when secondary haemorrhage took place. He lost from four to six pounds of blood, necessitating operation. On June 16th, at ten a. m., Surgeon N. R. Mosely, U. S. V., ligated the common carotid artery, in superior carotid triangle, just below origin of internal maxillary artery. He died on June 26th, 1664, from exhaustion and debility. The case is reported by the operator. GUNSHOT FRACTURES OF THE FACIAL BONES 347 Cask.—PriA-ate Cyrus AV. Beamenderfer, Co. A, 84th Pennsylvania Volunteers, aged 20 years, Avas wounded at the battle of the AA'ilderness, A'irginia, Alay Cth, 1864, by a conoidal ball, Avhich entered the left side of the face about half an inch above the angle of the mouth, taking a doAvnward and backward course, and emerged from the left side ofthe neck, about three inches beloAV the ear, and lodged in the left shoulder. The upper jaw sustained no injury, except the breaking off the first bicuspid. The left side of the under jaAV Avas very much broken, and Avas resected on the field, from the joint to a point betAveen the two bicuspids. On Alay 12th, 1864, haemorrhage occurring, the primitive carotid artery was ligated just above the clavicle by Henry McClain, formerly surgeon 2d New York A'olunteers. 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 Avere almost entirely healed. Cerate dressings Avere applied. He was discharged from service November 29th, 1864 On October 5th, 181)15, Pension Examiner George 1*. LineaAveaver 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. Hays, U. S. V., reports the case. Cask.—Private George BroAA-n, Co. I, 25th Alassachusetts A'olunteers, aged 41 years, received a gunshot wound of the face at the battle of Goldsboro', North Carolina, December llth, 1862. lie was on December 20th admitted to Stanley Hospital, New Berne, North Carolina. Secondary haemorrhage occurred January 7th, and recurred on the 9th; the loss of blood amounted to about thirty-two ounces. Cold water dressings Avere applied to the Avound, 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 ofthe temporal bone; also laceration of the external carotid artery. The case is reported by Acting Assistant Surgeon J. B. Upham. Case.—Private Daniel Cox, Co. F, 15th Indiana Arolunteers, aged 25 years, was Avounded at the battle of Missionary Ridge, November 25th. 186;?, by a musket ball, Avhich entered anterior to left angle of jaw, fracturing lower maxilla, passing under tongue, and out a little beloAV and to the right of the great horn of the hyoid bone; also injuring the sublingual artery He Avas admitted to the field hospital, Chattanooga, Tennessee. Profuse bleeding fi-om sublingual artery; Avound rugged ; lost four pints of blood. November 29th, Surgeon A. McMahon, U. S. V., made an incision from point of exit of ball down the neck on inside of sterno-mastoid, exposed sheath, with descendens noni nerve, and ligated right common carotid artery just above omo- hyoid. All bleeding instantly ceased. On December 1st, slight haemorrhage; controlled by persulphate of iron. December 2d, haemorrhage. December 3d, haemorrhage; ligation of left external carotid; no anaesthetic was used. December 6th, weak; musca? volitantes. December 9th, from this time did well. January 28th, 1864, feels as well as ever; maxilla not united. Left Chattanooga as Avell as ever, save from 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 Avound was still discharging pus. His disability is rated three-fourths and permanent. Case.—Brazilla S. Cobb, Co. C, 10th Maine Volunteers, aged 41 years, Avas Avounded at the battle of Gedar Mountain, Virginia, August 9th, 18G2, as he Avas kneeling on his right knee to discharge his gun. The missile, a small rifle or revolver ball, struck him in the mouth, driving in eight teeth, passed to base and outer side of right tonsil, and lodged apparently in the deeper muscles of the neck, in the region of the great vessels. He Avas admitted into the 2d division hospital at Alex- andria, Virginia, August 12th, 1862, and transferred to Satterlee Hospital, Philadelphia. The treatment consisted of Dover's poAvders, and local applications of equal parts of chloroform and tincture of aconite, to the ear, filling the outer ear Avith loose cotton, bathing the surface of the face and head with croton oil. He at first had profuse haemorrhage 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, extending back to the anterior edge of the trapezius. He suffered intensely from pain of the right side of the face and ear, occasioning high fever and arterial action, with intense pain in the head. He was discharged from service December 30th, 1862, and pensioned, his disability being rated one-half, and perhaps not permanent. Acting Assistant Surgeon AV. P. Morgan reports the case. Case.—Private V. F. Clark, Co. G, 98th Virginia Regiment, received, June 23d, 1864, a gunshot wound, which fractured the inferior maxilla. A considerable portion of bone was lost. He Avas admitted to the Confederate hospital at Farmville, Virginia. Secondary haemorrhage occurred, and on October 4th he was furloughed for sixty days. Case.—Private W. R. Copeland, Co. B, 61st Alabama Regiment, aged 34 years, was wounded at the battle of Winchester, Arirginia, September 19th, 1864, by a conoidal ball, Avhich entered just beloAV the angle of the left eye and lodged in the neck, two inches to the right of the fifth cervical vertebra. He was admitted to the depot field hospital at AVinchester on the same day. On October 1st, the ball was removed. On the 7th, the common carotid artery was ligated by Surgeon AV. S. Love, C. S. A. Haemorrhage recurred, five hours 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, Dauce'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. Secondary haemorrhage occurred, which was arrested by compression. October 30th, 1864, good prospect of speedy recovery. Case.—Corporal Charles A. Chapman, Co. E, llth 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. The ball was extracted near the clavicle. On January 5th, secondary haemorrhage occcurred from the branches of the internal maxillary artery, amounting to sixteen ounces of blood, which was controlled by compression. He was discharged February llth, 1863. He was pensioned, his disability being rated total. 343 WOUNDS AND INJURIES OF THE FACE. Case.—Sergeant Barclay Cooper, Co. B, 126th Ohio Volunteers, Avas Avounded at the battle of the AVilderness, May nth, 1^64, bv a musket ball, Avhich entered close to the mastoid process of the right temporal 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 ofthe scrotum. He Avas taken prisoner, and receiving but little attention, the wound of the scrotum became very unhealthy ; vermin gathered in it, and one testicle became exposed. He states that he Avas operated upon by a rebel surgeon for the wound of scrotum, after Avhich 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 Avas 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 Avas discharged from the, service June 25th, 1865. His speech was somewhat defective, and he had difficulty in SAvalloAving. Pension Examiner A. H. Hewetson, M. D., reports the case. CASE.-Private Elisha K. DeForest, Co. K, 88th 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 Avas, 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 haemorrhage occurred suddenly, after walking across the ward, and the patient died in a feAV 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 fi-om the tragus of the left ear, one and a halt inches from the base of the occipital bone. He Avas taken to a field hospital, Avhere 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 llth, 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 Avas foul. Simple dressings Avere continued, with injections of Labarraque's solution into the wound. On the night of August 6th, profuse haemorrhage from the external wound occurred, Avhich 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 llth, he was transferred to Christian Street Hospital in an improving condition. The dressing was removed from the external wound, Avhich presented a clean, healthy surface. The discharge was free. The treatment was continued, Avith the free use of stimu- lants. By October 1st, the Avound and general health of patient were improving. A small spicula 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 patient 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. The 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 haemorrhage occurred from the facial artery, amounting to about two ounces of blood, Avhich Avas controlled by pressure. On June 1st, he was transferred to Philadelphia, and admitted into the Satterlee Hospital, Avhence 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-fourths and permanent. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case.—Private Dennis Edwards, Co. A, llth Massachusetts Volunteers, aged 30 years, Avas wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a gunshot missile, which fractured 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 9th, 1863. There was haemorrhage from the facial artery, which recurred. The treatment consisted of compress and cold applications. He died on Alay 9th, 1863, of haemorrhage. Case.—Private James Edgar, Co. G, 81st Pennsylvania Volunteers, aged 23 years, was wounded at the battle of Gettys- burg, July 2d, 1863, by a conoidal ball, which fractured the inferior maxilla. The missile entered the left side of the neck one-half of an inch beloAV the ear, fracturing the lower maxilla in tAvo 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 Avere administered. Several spiculae of bone were removed, and Barton's bandages applied to the fractured jaw. Secondary haemorrhage from the left lingual artery occurred July 10th, and recurred on the llth 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, Avith 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 AA'illiam 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 and deranges vision. The tongue is partially paralyzed and has grown fast to the jaw, rendering mastication impossible and deglutition difficult. He uses soft food and liquids entirely. Speech imperfect. The wound in the jaw still continues to discharge internally. He rates his disability as permanent. GUNSHOT FRACTURES OF THE FACIAL BONES. 349 Case.—Private Hiram Fitzgera'd, Co. E, 3d A'irginia Cavalry, aged 24 years, was wounded at Old Church, Virginia, May 29th, 1864, by a conoidal ball, Avhich fractured the inferior maxilla. The missile passed from a point midway between the angle of the mouth on the left side, to the neck below, and behind the angle of the jaw on the right side. He was, on June 5th, admitted to Lincoln Hospital, Washington. Secondary haemorrhage from the branches of the facial and internal maxillary arteries occurred June 5th, and recurred on the 6th, amounting to three pints of blood, which was controlled by approaching syncope and injections of ice water into the mouth. The patient lived seven hours after the last visible haemorrhage, but never rallied, although stimulants Avere freely administered. The case is reported by Assistant Surgeon J. C. McKee, U. S. A. Case.—Corporal R. J. F------, Co. F, 60th New York A'olun- teers, aged 22 years, was Avounded at the battle of Fredericksburg, May 3d, 1863, by a conoidal ball, Avhich fractured the superior and inferior , maxilla. The ball entered the ala of the nostril, and passed doAvnward and backward, splitting the ramus of the inferior maxilla, and emerged by two openings in front and beloAV the pinna of the right ear. The superior maxilla of right sideAvas destroyed, and the right portion of the inferior fractured and comminuted, and fissures running into the orbital process. He was, on Alay 7th, admitted to Carver Hospital, Washington. Oold Avater dressings and bandages Avere applied. Slight haemorrhage from the internal maxillary artery occurred at ten and eleven o'clock p. M.. Alay 9th, Avhich yielded to compression; it again recurred pro- fusely at tA\-elve o'clock, amounting to about fifty fluid ounces of blood; attempts at compression of the carotid artery Avere unsuccessful, the patient being unmanageable from fear; during the remainder of the night and the day folloAving, he Avas kept in a sitting posture, and ice retained in his mouth, and strictly forbidden to speak. At two o'clock p. M. on the llth, his pulse being on the increase, six drops of the tinc- ture of aconite Avas ordered. The haemorrhage returned in the eA'ening, the patient became frantic Avith alarm, and prevented all attempts at com- pression. He died immediately. The autopsy revealed great comminu- tion of the superior and inferior maxilla, and that the haemorrhage proceeded from the trunk of the internal maxillary artery. The specimen is figured hi the wood-cut. The case is reported by Acting Assistant Surgeon E. F. Bates. Case.—Corporal Ebenezer Gallagher, Co. F, 52d Ohio Volunteers, aged 25 years, received a gunshot Avound of the face, by a conoidal ball. He Avas admitted to the field hospital at Chattanooga, Tennessee, July 2d, 1864, and died July 4th, from secondary haemorrhage. The case is reported by Assistant Surgeon C. C. Byrne, U. S. A. Case.—Private J. Greyer, Co. K, 50th Georgia Regiment, received, June 1st, 1864, a gunshot fracture of the inferior maxilla. The ball entered at the left angle and escaped from the mouth. He Avas admitted to the Receiving and AVayside Hospital, Richmond. Secondary haemorrhage occurred June 13th, Avhich Avas controlled by persulphate of iron. The patient recovered. Case.—Private Robert M. Gilson, Co. M, 6th Ohio Cavalry, aged 18 years, was wounded in the engagement at Hatcher's Run, Virginia, December 9th, 1834, by a conoidal ball, which perforated both jaws, near the angles. He Avas conveyed to the hospital of the cavalry corps, at City Point, Virginia, and on December 16th was admitted to the Armory Square Hospital, AVashington. Secondary haemorrhage took place, and patient died on the day of admission. Surgeon D. W. Bliss, U. S. V., reports the case. Case.—Private Jared Goodrich, 19th NeAV York Battery, aged 43 years, was wounded at Spottsylvania, Virginia, Alay 12th, 1864, by a conoidal ball, which fractured the lower jaAV, right side. He was admitted to the Stanton Hospital, AA'ashing- ton, on the 20th. Simple dressings Avere applied, and tonics and stimulants administered. He died May 27th, 1864, from exhaustion and secondary haemorrhage. The case is reported by Surgeon John A. Lidell, U. S. V. Case.—Corporal John Heiser, Co. I, 53d Pennsylvania Volunteers, aged 27 years, received, at the battle of Deep Bottom, Virginia, August 14th, 1864, a gunshot Avound of the face. Conoidal ball entered at superciliary ridge of right orbit, passing inwards, and emerged from neck, behind angle of inferior maxilla. AVhen admitted to the Emory Hospital, Washington, on August 17th, 1864, he Avas feeble, and much exhausted from exposure on the field, and during transportation. On August 25th, bleeding profusely, chloroform and ether were administered, and the right common carotid artery, through an incision about tAvo inches in length, was ligated by Surgeon N. R. Moseley, U. S. V. Cold water dressings were applied, and tonics and stimu- lants were administered. He died on August 30th, 1864, from exhaustion and constitutional irritability. The case is reported by the operator. Case.—Private J. H. Hancock, Co. K, 30th Georgia Regiment, was wounded at the battle of Cold Harbor, Virginia, June 1st, 1864, by a conoidal ball, which entered over the second right lower molar tooth, passed downward and forward, cutting the end of the tongue and fracturing the inferior maxilla, at its symphysis, and emerged one-half inch below the angle of the mouth. He Avas conveyed to Receiving and Wayside Hospital, at Richmond, Virginia, the same day, where spicula of bone were removed on the following day. On June 8th and 10th capillary haemorrhage occurred, which Avas controlled by the appli- cation of ice and persulphate of iron. On June 12th he Avas transferred. No further information can be obtained. FiG. 159.—Gunshot fracture of the inferior maxilla. Spec. 1216, Sect. I, A. M. M. 350 WOUNDS AND INJURIES OF THE FACE. Case.—Private R. Dayton Harvey, Co. K, 157th NeAV York A'olunteers, Avas Avounded at the battle of Gettysburg, renn- svlvania, July 1, 1863, by a round ball, AA'hich entered in front of the left ear and passed out of the right cheek. He was conveyed to the Seminary Hospital the same day, and on July llth Avas admitted to the McClellan Hospital, Philadelphia. Secondary haemorrhage occurred on the 16th, which Avas arrested by means of persulphate of iron and pressure. He was discharged from service December 2d, 1863. There was total deafness in the left ear, and the mental functions were impaired. Surgeon LeAvis Taylor, U. S. V., reports the case. The man Avas pensioned, but died October 31st, 1864, from inflammation of the brain. Case.—Private William M. Hersha, Co. K, 8th Alichigan A'olunteers, aged 20 years, Avas wounded at the battle of Cold Harbor, June 3d, 1864, by a conoidal ball, which fractured the inferior maxilla, right side. He was conveyed to the hospital of the 3d division, Ninth Corps, and transferred to AA'ashington, and on the 9th admitted into Lincoln Hospital. On the 13th, he was transferred to York Hospital, Pennsylvania, where he Avas admitted on the 14th. Simple dressings Avere applied to the Avound. Sloughing of the artery occurred June 28th, and secondary haemorrhage folloAved, amounting to thirty-five ounces of blood, Avhich 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 A'olunteers, aged 28 years, was Avounded at the battle of Cold Harbor, June 3d, 1864, by a conoidal ball, Avhich entered beloAV the left eye, aud passed out betAveen the shoulders. He Avas on June 7th admitted to Lincoln Hospital, Washington. Secondary haemorrhage occurred June 13th. Tonics and stimulants were administered. Patient died June llth, 1854. The case is reported by Assistant Surgeon J. C. McKee, U. S. A. Case.—Private Samuel Jacoby, Co. C, 48th Indiana Volunteers, Avas wounded at the battle of Corinth, Mississippi, October 3d, 1862, by a gunshot missile, Avhich entered the left cheek, passed through the inferior maxilla, and emerged above the clavicle, wounding the carotid artery. He was treated in the regimental hospital until October 13th, 1862, when he was admitted to the Alound City Hospital, Illinois. Secondary haemorrhage occurred from the common carotid artery October 13th. The patient died October 13th, 1832. The autopsy shoAved that the cellular tissue about the Avound of exit Avas infiltrated so as to form a firm fibrous ring about the orifice. The mouth Avas full of clotted blood, and there was an opening in the carotid, just beloAV its bifurcation, one-half of an inch in length. The ball- passed through the"pharynx and the root of tongue. The case is reported by Surgeon E. C. Franklin, U. S, V. Case.—Private George AAr. Lundy, Co. F, 7th Alichigan Cavalry, aged 25 years, received, at the battle of Gettysburg, July 3d, 1863, a pistol-shot Avound. The missile entered the superior maxilla beloAV 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 beloAV the ear. He Avas on the same day conveyed to the field hospital, Seminary, Gettysburg. Secondary haemorrhage occurred July 15th, Avhich caused death immediately. On post-mortem examination, the ball Avas 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 Lozier, Co. K, 1st Maine Cavalry, aged 24 years, Avas wounded at the battle of South Side Railroad, March 31,1865, by a fragment of shell, which fractured the inferior maxilla. He Avas on April 4th admitted to Judiciary Square Hospital, AA'ashington. 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, llth New Hampshire Volunteers, aged 32 years, Avas wounded at the battle before Petersburg, September 30th, 1864, by a conoidal ball, Avhich entered above the arch of the zygoma, fracturing the superior maxilla, and cutting aAvay a portion of the malar bones, all on the left side. He Avas on the same day conveyed to the hospital of the 2d division, Ninth Corps. On October 2d, he Avas admitted into the field hospital, Ninth Corps, and transferred to the 2d division hospital, Alexandria, where he was admitted October 12th. Cold Avater 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, 1884. The post-mortem examination revealed the ball embedded in the posterior nares. The case is reported by Surgeon EdAvin Bentley, U. S. V. Case.—Private D. W. Kilburn, Co. I, 1st Maine Volunteers, aged 22 years, Avas Avounded at the battle of Spottsylvania, A'irginia, Alay 19th, 1864, by a conoidal ball, which entered angle of mouth, making its exit near posterior border of sterno- cleido-mastoideus muscle, wounding facial and external carotid arteries. He Avas admitted to the Finley Hospital, AA'ashington, on Alay 28th, 1864. On Alay 29th, chloroform was administered, and the right carotid artery Avas 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, Avhen he complained of severe pain in region of head and chest; also great dyspnoea. He died on June 2d, 1864, from asphyxia. Case.—Private John Lynn, Co. F. 37th Wisconsin A'olunteers, aged 23 years, was Avounded at the battle of South Side Railroad, April 2d, 1865. by a conoidal ball, Avhich 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 AA'ashington, and admitted into Harewood Hospital April 5th. The treatment of the patient Avas rendered someAvhat difficult from the fact that the passage of the ball through the buccal cavity had produced intense pharyngitis and oedema ofthe adjacent tissues, so that the food, though carefully selected, could only be Avith difficulty administered; Avhile the particles of food and salivary secretions could only effectually be removed by syringing through both Avounds of entrance and exit Second- ary haemorrhage from the internal maxillary and facial arteries occurred April 9th, amounting to thirty ounces of blood. The sinking of the patient Avas so decided as to be beyond the control of any operative measures or medicinal treatment. The patient 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 open. The case is reported by Surgeon R. B. Bontecou, U. S. A'. GUNSHOT FRACTURES OF THE FACIAL BONES. 351 CASE.-Private Charles G. Lincoln, Co. C, 22d Alassachusetts Volunteers, received at the battle of Fredericksburg, Virginia December 13th, 1862, a gunshot fracture of the superior maxillary. He Avas conveyed to the hospital of the 1st divis- ion Fifth Corps, the same day, and on December 17th was admitted to the Eckington Hospital, AVashington. Secondary haemorrhage occurred, and the patient died on December 24th. Assistant Surgeon S. A. Storrow, U. S. A., reports the case. Case.—Private Adam Alyers, Co. C, 130th Pennsylvania A'olunteers, aged 23 years, received at the battle of Antietam, September 17th, 1862. a gunshot comminuted fracture of the upper and lower jaAvs, 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 Harris- bur"- Pennsylvania, Avhere he Avas admitted into the AValnut Street Hospital. Stimulants and tonics were administered, and stvptics applied to control the haemorrhage. Pyaemia supervened September 24th. The condition of the patient was bad, and no apparent effect Avas produced by treatment. The patient died September 29th, 1862. Case.—Sergeant George B. Merchant, Co. K. 4th Ohio A'olunteers, aged 33 years, received at the battle of Spottsylvania, A'iro-inia, Alay 10, 1864, a gunshot wound of neck, AA'ith fracture of inferior maxilla. He Avas admitted to Douglas Hospital, Washington, on Alay 13th, 1861. General health good. Secondary haemorrhage occurred, to the amount of eighteen fluid ounces, probably from internal maxilla. On Alay 15th the right common carotid Avas ligated by Assistant Surgeon William Thomson, U. S. A. On Alay 30th, it was again ligated. On Alay 31st, ligature came aAvay. He recovered, and was returned to dutv on June 19th, 1834. The case is reported by the operator. The patient is a pensioner. Examiner L. M. Whiting reports, September 20th, 1864, that more than half of the ramus of the right side ofthe loAver jaw is gone, and that there is very limited use of the right arm, OAving to some injury during the ligation. Case.—Private J. Morris, Co. I, 50th Georgia Regiment, Avas Avounded at the battle of Cold Harbor, June 1st, 1864, by a conoided ball, which entered at the left angle of the inferior maxilla, and emerged from the mouth, producing extensive comminution of the inferior maxilla. He Avas admitted to the Receiving and Wayside Hospital, at Richmond, Virginia, the same day. Avhere spicula of bone Avere removed by incision along the ramus of the jaAV. The wound was closed by wire sutures. On June 13th, haemorrhage occurred, Avhich Avas controlled by the application of persulphate of iron. Food Avas given him through a tube up to the 14th, and on the 15th he Avas furloughed for sixty days. No further information can be obtained. Case.—Private John B. Alcllroy, Co. C, 45th Pennsylvania Volunteers, was wounded at the battle of Cold Harbor, Virginia, June 3d, 1834, by a conoidal ball, Avhich 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 process of the scapula. He was admitted to the Fairfax Seminary Hospital, near Alexandria, Virginia, on June 7th, 1864. His constitutional condition was good. Cold Avater dressings Avere applied. Haemorrhage occurred, and on June 18th the common carotid artery, just above omo hyoid, was ligated by Acting Assistant Surgeon J. H. A'ork. He died on June 19th, 1864, in consequence of haemorrhage, caused by sloughing of posterior scapular artery, from second ball lodging upon it. The case is reported by Assistant Surgeon H. Allen, U. S. A. Case.—Corporal Henry McDowell, Co. G, 60th New A'ork Volunteers, aged 30 years, was Avounded at the battle of Gettysburg, July 2d, 1863, by a piece of shell, carrying aAvay the inferior maxilla. He Avas on the same day admitted to the field hospital, TAvelfth Corps. Secondary haemorrhage 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, Avas wounded in the engagement at BristoAV Station, A'irginia, October 14th, 1833, by a conoidal ball, Avhich entered posteriorly to right of spinous process of fifth cervical vertebra, passed anteriorly through middle third of inferior maxillary, producing compound fracture, and emerged opposite the canine teeth of same side; the injured parts were badly SAVollen and inflamed. He was admitted to the third divis- ion hospital. Alexandria, Virginia, on October 17th, 1863. On October 25th, chloroform Avas administered, and the common carotid artery, right side, Avas ligated, and a partial resection of the loAver jaw performed by Surgeon EdAvin Bentley, U. S. V. The ligatures came aAvay November llth, 1863. He was discharged from the service on February 13th, 1864. The case is reported by the operator. His name does not appear on the pension list. Case.—Private Samuel Mclnnis, Co. A, llth Illinois Volunteers, aged 27 years, Avas wounded at the battle of Vicks- burg, Alississippi, Alay 22d, 1863, by a musket ball, which entered immediately above and posterior to angle of left jaw, passed through pharynx and posterior nares, and made its exit at angle (right) of lower jaw, fracturing the bone. He Avas admitted to the Jackson Hospital, Alemphis, Tennessee, on Alay 27th, 1863; wound suppurating, profuse haemorrhage from external carotid and branches. On Alay 31st, the common carotid artery was ligated by Surgeon E. AI. 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, patient Avas doing well. He died on June 7th, 1863. The case is reported by the operator. Case.—Sergeant Francis Alaas, Co. E, 6th Kentucky Volunteers, aged 40 years, was Avounded at the battle of Resaca, Georgia, May 15th, 1864, by a conoidal musket ball, Avhich entered the mouth, fracturing the inferior maxilla, and emerged through the neck. On May 21st, he Avas conveyed to the field hospital at Bridgeport, Alabama. Secondary haemorrhage occurred, on the following day, from the inferior maxilla or some of its ramifications, amounting to eighteen ounces, Avhich Avas arrested by the application of ice. Simple dressings Avere applied, and the Avound healed kindly. He Avas furloughed July 9th On August 8th, he Avas admitted to the Crittenden Hospital, Louisville, Kentucky, and is charged with desertion December 31st, 1864. He is a pensioner. Assistant Surgeon H. T. Legler, U. S. V., reports the case. Case.—Private Patrick McCormick, Co. A, 4th NeAV York Volunteers,. Avas Avounded at the battle of Antietam, Alaryland, September 17th, 1862, by a conoidal ball, which entered the face, fracturing the upper jaw, passed backward and downward a:>2 WOUNDS AND INJURIES OF THE FACE. through the neck, wounding the carotid artery. He Avas conveyed to the hospital ot the Third Corps, and, on September 22d, was admitted to No. 5 Hospital, Frederick, Maryland. September 24th, abscess opened over the thyroid cartilage, and bone extracted. The opening from abscess communicates from above Avith the mouth, a sinus leading doAvinvard toward sternum. He died September 29th, from secondary haemorrhage from the carotid artery. Autopsy: the missile entered the mouth opposite symphisis of loAver jaAV, right side, injuring the tongue and soft parts, comminuting the bone up to its ramus, and producing a dislocation outAvard, 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 symphisis. The whole inner surface of sterno-mastoid Avas dissected. Surgeon H. S. Hewitt, U. S. V., reports the case. Case.—Private A. Alooney, Co. H, 1st New A'ork Artillery, aged 34 years, Avas Avounded 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 Avas, on June 3d, 1862, admitted to the hospital at Annapolis, Mary- land. June 5th, successive secondary haemorrhages from the internal 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 haemorrhage. Patient died comatose June 27th, 1862. The case is reported by Surgeon Thomas A. McParlin, U. S. A. Case.—Private William H. AIcL------, 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 fonvard, traversing the parotid gland, and carried away the condyle and a part of the ascending ramus of the lower maxilla, and lodged in the zygomatic fossa, severing v in its course the temporal and the internal maxillary branches of the carotid artery. He Avas, 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, Avhich Avas controlled by compression. Haemorrhage recurred on the 21st and 22d. Patient died October 24th, 1862. The pathological specimen is No. 632, Sect. I, A. AI. AI. The case is reported by Surgeon 0. A. Judson, U. S. V. Case.—Corporal Charles Moitoav, Co. I, 4th New Jersey Arolunteers, received, at the battle of Fredericksburg, Virginia, December 13th, 1862, a gunshot fracture ofthe inferior maxilla, right side. He was conveyed to the hospital ofthe 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, Avas controlled by compression and lint saturated with persulphate of iron. He Avas 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, AI. D. Case.—1st Lieutenant Thomas E. Maley, 5th United States Cavalry, aged 29 years, Avas wounded at the engagement at Deep Bottom, Virginia, July 28th, 1864. An explosive ball entered the face beneath the right zygoma, and passing through, exploded in the left antrum of Highmore. He Avas admitted to the Ladies' Home Hospital, New York City, on August 1st, 1864. Secondary haemorrhages occurred on August 18th, 22d, 23d, and 24th. He Avas 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, patient doing well under generous diet and tonics; pulse 84. On September 10th, ligature came aAvay. No recurrence of haemorrhage. He was granted leave of absence on October 4th, 1864, and Avas dropped from the rolls Avhile on leave. On July 28th, 1888, Lieutenant Maley called on Assistant Surgeon George A. Otis, U. S. A., in reference to a plastic 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, was wounded at the battle before Petersburg, July 30th, 1864, by a conoidal ball, Avhich passed through the superior maxilla. He Avas, on August 2d, admitted to Fort Alonroe Hospital. Simple dressings were applied to the Avound. On August 6th, he Avas transferred to New A'ork, where he Avas admitted into the DeCamp Hospital, David's Island. Secondary haemorrhage from the jugular vein occurred August 14th, amounting to forty ounces of blood. Stimulants and tonics Avere 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 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 apposition of fractured portions of the jaw were made by means of pasteboard splints and Barton's bandages. The patient was suffering with profuse salivation, which Avas attended with great thirst and a constantly increasing difficulty of deglutition. The dressings interfered with his efforts to quench his thirst, and Avere removed by him at the first opportunity after their application. As the tnroat symptoms became more and more prominent, all treatment of the fractured jaAV 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 shoAved 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 loAver jaw, on the left side. CASE.-Private Albert XX. Perry, Co. C, 1st Vermont Artillery, aged 24 years, was wounded at the battle of Cold Harbor, June 1st, 1864, by a conoidal ball, Avhich fractured the facial bones. He was conveyed to the hospital ofthe 2d division, Sixth Corps, and transferred by steamer from White House Landing to New York, where, on the 15th, he was admitted to DeCamp Hospital, David's Island. Simple dressings were applied to the wound. Secondary haemorrhage from the superior maxillary artery occurred June 18th, and recurred on the 26th, amounting to sixty-four ounces of blood. Patient died June 21st, 1864. The case is reported by Assistant Surgeon Warren AA'ebster, U. S. A. GUNSHOT FRACTURES OF THE FACIAL BONES. 353 Cask.—Corporal John H. P------, Co. H, 19th Alaine A'olunteers, aged 31 years, Avas wounded at the battle of Spottsyl- vania, Alay 12th, 1864, by a conoidal ball, Avhich entered the mouth, producing a comminuted 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 tAvo inches. He Avas on Alay 21st admitted to Finley Hospital, AA'ashington. Simple dressings were applied to the Avound. Second- ary haemorrhage from the internal carotid artery occurred Alay 28th, amounting to two pints of blood. Patient died Alay 29th, 1834. The specimen is No. 207, Sect. I, A. AI. AI. The case is reported by Surgeon G. L. Pancoast, U. S. V. Case.—Corporal Isaac AA'. Patterson, Co. E, 19th Maine Arolunteers, aged 19 years, was wounded at the battle of Spottsylvania, A'irginia, Alay 10th, 1864, by a conoidal ball, which fractured the inferior maxilla and Avounded the facial artery. He was conveyed to the hospital of the 2d division, Second Corps, and on Alay 16th he was admitted to the Lincoln Hospital, Washington. Secondary haemorrhage occurred, Avhich Avas controlled by compression and persulphate of iron. He died Alay 21st, 1834. Assistant Surgeon J. Cooper AIcKee, U. S. A., reports the case. Case.—Private William Prater, Co. B, 48th Virginia Regiment, aged 23 years, was wounded February 6th, 1865, by a conoidal ball, Avhich 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 Hospital No 1, Richmond, A'irginia. On February 13th, secondary haemorrhage occurred from the lingual artery, at the root of the tongue, Avhich Avas arrested by styptics. Case.—Sergeant Philip C. Quick, Co. H, 141st Pennsylvania A'olunteers, aged 26 years, Avas Avounded at the battle of Spottsylvania, Alay 12th, 1864. by a conoidal ball,, which caused a compound fracture of the inferior maxilla, right side. He was on Alay 16th admitted to Lincoln Hospital, Washington. Secondary haemorrhage from the sublingual and the superior thyroid artery of the left side occurred Alay 18th, and recurred on the 19th, amounting to about sixty ounces of blood. In consequence of the laceration of the muscular structure, it Avas impossible to ligate in the Avound; and after the haemorrhage occurred, the patient was too much debilitated to admit of ligating the carotid artery, which was the only alternative. As he opened his mouth AA'ith great difficulty, enemas of beef tea and brandy were administered every three or four hours. Lint, saturated with a solution of chloride of iron, was constantly applied to the Avound. He died May 19th, 1864. The case is reported by Assistant Surgeon J. C. AIcKee, U. S. A. Case.—Private Erastus Ranger, Co. E. 32d Maine Arolunteers, aged 26 years, Avas wounded at the battle of Petersburg, A'irginia, July 6th, 1864, by a conoidal ball, AA'hich entered one and a half inches below the angle of the loAver jaw, left side, passed obliquely 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 Avas conveyed to the hospital of the 2d division, Ninth Corps, Avhere several fragments of bone were removed, and on the 16th admitted to Mower Hospital, Philadelphia. Simple dressings were applied. On July 19th, haemorrhage occurred, supposed to come from the lungs. On July 21st, profuse haemorrhage took place 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 AA'illiam Reeves, Co. C, 76th New York Volunteers, aged 22 years, received, at the battle of the AVilder- ness, A'irginia, Alay 6th, 1864, a compound comminuted fracture of inferior maxilla by a conoidal ball, which entered the left cheek half an inch anterior to the angle of the jaAV, and emerged at a point nearly opposite. He Avas conveyed to a field hospital, where a large number of splinters Avere removed through the mouth and aperture of exit. He was admitted to the Stanton Hospital, AA'ashington, on Alay llth, 1864. Aperture of entrance small; that of exit about three inches in its longest diameter. On Alay 12th, secondary haemorrhage occurred. He lost about twenty-four ounces of blood, and Avas much exhausted. On the same day, at five o'clock p. jr., the left common carotid artery Avas ligated by Assistant Surgeon George A. Alursick, U. S. V. No anaesthetic was used. Patient did not rally after the operation. He died on Alay 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 York Volunteers, aged 30 years, Avas Avounded at the battle of the Wilderness, May 5th, 1864, by a conoidal ball, which fractured the inferior maxilla and divided the carotid artery, and lodged behind the tonsil. He Avas, on Alay 13th, admitted to Finley Hospital, AVashington. Successive haemorrhages from the internal wound in the fauces occurred May 14th, amounting to one pint of blood. Cold Avater dressings were applied to the Avound. On May 31st, fi-agments of bone Avere removed, and the common carotid artery Avas ligated below the right omo-hyoid muscle by Surgeon G. L. Pancoast, U. S. V. The patient died June 1st, 1864, from secondary haemor- rhage. Specimens of the common carotid artery and inferior maxilla were contributed to the museum by the operator, and are Nos. 2481 and 2482. Case.—Private Lemuel Reccord, Co. A, 7th Indiana Arolunteers, aged 24 years, Avas Avounded at the battle of the Wilderness, May 9th, 1864, by a conoidal ball, Avhich entered the nostril, right side, and passed out at the neck, fracturing the loAver jaw. He was on the same day conveyed to the hospital of the 4th division, Fifth Corps, and transferred to Alexandria on Alay 12th, Avhere he was admitted into the 2d division hospital on the 14th. Simple dressings Avere applied to the Avound. Secondary haemorrhage from the transverse facial artery occurred Alay 30th, and recurred on the 31st, amounting to tAvelve ounces of blood. Styptics Avere applied. Patient died June 2d, 1864. The case is reported by Surgeon Edwin Bentley, U. S. V. Case.—Corporal Robert V. Ricks, Co. E, 55th North Carolina Regiment, aged 25 years, Avas wounded at the battle of Spottsylvania, Alay 10th, 1864, by a conoidal ball, Avhich fractured the superior and inferior maxilla. He was on May 12th 45 FIG. 160.—R'ght ra- mus of lower j-iw frac- tured by a musket ball. Spec. 2482, Sect. I, A. M. M. 3.")1 AVOUNDS AND INJURIES OF THE FACE. admitted to the 2d division hospital, Alexandria. Secondary haemorrhage from a branch of the carotid artery occurred May Kth amounting to fourteen ounces of blood, Avhich was controlled by the application of persulphate of iron. On June 1st, he was transferred to Lincoln Hospital, AA'ashington, whence he was sent to the Old Capitol Prison, as a prisoner of Avar, June ^9th, 1834. The case is reported by Surgeon E. Bentley. U. S. A'. CASE.-Private John A. Schott, Co. C, 98th Pennsylvania A'olunteers, aged 24 years, was Avounded at the battle of Fredericksburg, Alay 3d, 1863, by a conoidal ball, Avhich entered the left side of the face, about one inch beloAV the eye, and passed inward and backAvard, entering the mouth, fracturing the hard palate and inferior maxilla, and totally destroying sight of left eye; then passed out again to the right side of the neck, and lodged superficially about one inch and one-half below the right ear. He Avas on Alay 7th admitted to Campbell Hospital, Washington, and transferred to Philadelphia, where, on June 28th, he Avas admitted into the Turners' Lane Hospital. Simple dressings and flax-seed poultices were applied to the wound. On June 30th, there Avas much pain in the right superior posterior triangle of the neck, Avhich Avas very much inflamed, and discharging freely from an opening in that region. On July 2d, the ball, with adherent piece of bone about one inch in length, supposed to be a portion of the inferior maxilla, was remoA'ed, suppuration and ulceration having taken place around it. Slight Fig. ltil.—Ball, with impacted , , , , _ -. , .,.. . . , , . . , bone, probably from the lower haemorrhage followed the removal of the ball. On December 12th, the Avound had entirely maxrtla. Spec. 4518, Sect, l, A. healed, and the patient's health Avas good, though there Avas much chronic enlargement of the right side of the face. He Avas transferred to the 2d batallion, Invalid Corps, November 4th, 1863. Shott is a pensioner. He is very much disfigured. His disability is rated total. Pension Examiner Thomas B. Reed reports that he has to use an obturator to enable him to speak distinctly. A cast of the head, shoAving deformity, and the missile, a conoidal ball much battered and increased longitudinally by compression, Avith a sr*iculse of bone lodged in it, are in the collection of the Army Medical Aluseum, and are numbered 1554 and 4518. Sect. I. The case is reported by Acting Assistant Surgeon David Burpee, who contributed the ball represented in the wood-cut (Fig. 160), and the cast of the deformed face Avas contributed by Acting Assistant Surgeons C. Carter and C. B. King. Cask.—Corporal Asa D. Smith, Co. D, 16th Alassachusetts Volunteers, was admitted into hospital at the Naval Acad- emy, Annapolis, Maryland, June 4th, 1832, with a compound fracture of the lower jaw. The treatment consisted of the removal of that portion of the jaAV lying between the molars of the opposite sides. Secondary haemorrhage, Avhich was arrested by the application of ice, occurred July 12th. He recovered, and Avas discharged from the service July 27th, 1862, Avith very little disfiguration. The case Avas reported by the operator, Acting Assistant Surgeon B. B. Miles. He is a pensioner. On September 26th, 1866, Pension Examiner George S. Jones reports that the bone is re-united, but the pensioner is unable to masticate solid food. His disability is rated total and permanent. Case.—Sergeant John Starkey, Co. F, 6th NeAV Hampshire A'olunteers, Avas Avounded at the second battle of Bull Run, A'irginia, August 3Cth, 1862, by a conoidal ball, Avhich entered the upper lip and emerged just behind the ear, right side, causing a compound comminuted fracture of the superior maxillary and malar bones of that side. A portion of the upper jaAV Avas removed on the field by Assistant Surgeon Benjamin Howard, U. S. A. He ay as admitted into the Unitarian Church Hospital, at AA'ashington, September 7th, 1832, at Avhich time there Avas erysipelas of the Avhole right side of the face, and of the right eye, Avith seATere pain. Simple dressings were applied to the Avounds, and as he could not use any solid food, beef-tea and chicken-broth, combined with a milk diet, Avas ordered, He stated that several pieces of bone had been removed in the field hospital. On September loth, the wounds Avere unhealthy, the discharges ichorous. The SAvelling of the face was disap- pearing He lost the sight of the right eye by retinitis. On the 18th, haemorrhage, which recurred several times, took place from the Avound of exit. The amount of blood lost at each time Avas small, owing to the immediate application of persulphate of iron and compress. No lacerated artery could be discoATered upon examination. He Avas very weak and reduced Avhen the haemorrhage occurred. lie died on September 22d, 1862. There was no autopsy, but the base of the brain Avas believed to be affected. The case is reported by Acting Assistant Surgeon A. A. Buck. Cask.—Corporal Amos G. Schofield, Co. F, 1st Alinnesota Volunteers, Avas Avounded at the battle of Bull Run, A'irginia, July 21st. 1861, by a conoidal ball, Avhich entered two inches behind the left mastoid process, and escaped at the mouth, fractur- ing the loAver maxilla, and carrying aAvay a portion of the primative carotid and its branches from the left side. He was admitted to the 3d division hospital, Alexandria, the next day; an aneurismal tumor had formed. The case did Avell, except that there Avas a hard circumscribed swelling beneath the left ear. On August 4th, a haemorrhage occurred from the Avound of entrance, Avhich was controlled by a graduated compress, but Avhich Avas gradually succeeded by a swelling Avhich extended from the mastoid process to the clavicle, and which Avas caused by the escape of blood into the tissues of the neck. Frequent haemorrhages occurred frOm the Avound in the mouth, which could not be controlled but by compression on the left carotid. The compression on the veins of the neck Induced great cedematous swelling of the face, the left eye Avas 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 llth, compression Avas made over the carotid, Avhen the patient appeared to have draAvn into his glottis a clot of blood, during an effort at inspiration. Apncea ensued, folloAved 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 side of the neck Avas found dis- tended by effused blood. The internal carotid Avas uninjured, but the external Avas lost in the tumor, which seemed to be a true aneurism undergoing consolidation. Behind the pharynx Avas found a quantity of dark fluid blood. In the right ventricle of the larynx Avas found a soft clot, Avhich was the immediate cause of death, since it acted as a valve permitting of expiration, but preventing inspiration. Assistant Surgeon H. LaAvrence Sheldon, U. S. A., decided against an operation, as he could not satisfy his mind as to the source of the haemorrhage. The pathological specimens, consisting of a part of the loAver jaAV and a portion of the primitive carotid and its branches exhibiting a tumor, Avere contributed to the Army Medical Museum, with a history of the case, by Assistant Surgeon AA'illiam Thompson, U. S. A., and are numbered 4923 and 4925 of the Surgical Section. GUNSHOT FRACTURES OF THE FACIAL BONES. 355 Case.— Private Samuel Stienberger, 1st United States Cavalry, was Avounded at the battle of A\Tilliamsburg, Virginia, May 5th, 1332, by a musket ball, Avhich entered to the left of the symphysis of lower jaw, fractured the bone and carried away several teeth, a part ofthe tongue, and posterior Avail of pharynx. He Avas unable to swalloAV nourishment, Avithout the greatest distress and difficulty. Swelling of injured parts ; copious haemorrhage. He was admitted to the Hygeia Hospital, Fort Alon- roe, Virginia, on Alay 9th, 1832. On May 13th, removal of ball and several teeth from abscess above clavicle. May 16th, copious haemorrhage from Avound. Sulphuric ether was administered, and the common carotid artery Avas ligated by Surgeon Eeed B. Bontecou, U. S. Ar. Seven days after ligation, haemorrhage from Avound from Avhich ball was 'extracted ; an unsuccess- ful attempt Avas made to find the bleeding point. He died on Alay 23d, 1332, from exhaustion from haemorrhage. Autopsy indicated that the ball had fractured the transverse process of the third cervical vertebra. The vertebral artery had worn against the spicula thus produced, and hence the second haemorrhage. The case is reported by the operator. Case.—PriA-ate George AA'. Scales, Co. B, 54th Indiana Volunteers, Avas Avounded at the battle of Vicksburg, Mississippi, December 29th, 1862. The missile entered the mouth, knocking in the front teeth of the upper and lower jaw, and lodging in the neck beloAV and behind the mastoid process. He was conveyed to the hospital of the 3d division, Thirteenth Corps, Avhere lie remained until January 8th, 1833, Avhen he Avas taken on board the hospital transport City of Alemphis. On January 9th, secondary haemorrhage occurred, Avhich Avas arrested by the application of persulphate of iron. On January 13th, he Avas admitted to hospital at Padiuah, Kentucky, and discharged from service July 5th, 1833, for aneurism of the left external carotid artery. The case is reported by Surgeon 11. P. Stearns, U. S. V. On .May 19th, 1833, Pension Examiner AV. A. Clapp reports that mastication is difficult, as Avell as deglutition, from injury to tongue. He rates his disability total and permanent. Case.—Captain Jacob Schwartzlander, Co. D, 104th Pennsylvania Volunteers, aged 32 years, was wounded at the battle of Fair Oaks, A'irginia, May 31st. 1832, by a conoidal ball, Avhich entered the inferior maxilla, right side, in front of its angle, passed 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 Avound of entrance, fracturing it. In its course, it shattered the 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 ball evidently 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, which bled profusely, Avere dressed with lint and adhesive strips. He became Aveak from loss of blood, and Avas conveyed to Savage Station, Avhere the Avound Avas redressed. There was some haemorrhage during the night, but not much pain, and the tongue so much swollen as to protrude from the mouth and prevent deglutition. . He Avas conveyed to the hospital transport W. AA'hillidin, for transfer to Philadelphia. On June 1st, several spiculae of bone and some teeth Avere removed, the tongue Avas replaced so far as tumefaction Avould alloAV, the fracture adjusted and pasteboard splint and bandage applied. He Avas unable to take nourishment until June 2d, Avhen beef tea Avas administered by a tube through the nostrils. He was admitted to St. Joseph's Hospital at Philadelphia, June 4th, at Avhich time he could not articulate, deglutition Avas still difficult, the Avounds Avere suppurating freely, the tongue Avas sloughing, the discharge being very fetid, and the general strength much reduced. Several spiculae of bone were extracted, and the lacerated and protruding tongue Avas removed by ligature, which came aAvay in three Aveeks. He Avas fed for eight Aveeks through a tube, the mouth aud fauces Avere syringed Avith Avater every two hours, and external applications of a solution of sulphate of copper Avere made. About August 24th, he Avas able to articulate distinctly. The tongue was gradually filling up. He was able to eat every kind of food. The deformity of jaw was disappearing, and there Avas great mobility. He Avas returned to duty. Not a pensioner. Case.—Private Anthony Surbe, Co. C, 6th IoAva Arolunteers, aged 22 years, was wounded at the battle of Dallas, Georgia, May 26th, 1834, by a conoidal ball, Avhich fractured the lower jaw, and escaped near the left angle of the mouth. He Avas admitted to the hospital ofthe 4th division, Fifteenth Corps, thence conveyed to the field hospital, Chattanooga, Tennessee, where he Avas admitted on June 4th. Tonics, stimulants and nourishing diet ordered. Secondary haemorrhage from the right external carotid artery occurred June 5th; loss of blood, one pint. Hae.norrhage recurred on the 7th, the loss of blood amounting to three quarts. Patient died June 7th, 1834. The case is reported by" Assistant Surgeon C. C. Byrne, U. S. A. Case.—Private AA'illiam Wolf, Co. K, 7th New York Heavy Artillery, aged 30 years, AA'as wounded at the battle of Peters- burg, April 7th, 1865, by a conoidal ball, which entered the loAver jaw, near the right angle, passing directly through, producing a compound comminuted fracture of the inferior maxilla, and lacerating almost from ear to ear. He was on April 15th admitted to 1st division hospital, Annapolis, Alaryland. On admission the patient was feeble and anaemic, having from time to time lost considerable blood; the Avound was looking badly and very offensive; the jaw Avas very much shattered, many of the fragments being imbedded in the cheek, others hanging loosely through the opening below the chin ; every tooth was carried away, and altogether the wound Avas frightful. The poAver of utterance Avas gone, and it Avas Avith difficulty he could swalloAV, most of the food passing through the opening beloAV. He improved up to the 23d, when secondary haemorrhage from the sub-maxillary, probably the facial artery, occurred April 23d, and recurred on the 27th, amounting to twenty-four ounces of blood, Avhich Avas controlled by pressure upon the right carotid artery and the application of tincture of muriate of iron. After the haemorrhage on the 27th, his case became hopeless. The patient died April 30th, 1835. The case is reported by Surgeon B. A. Vander- kieft, U. S. V. Case.—Quartermaster Sergeant Amos Whitney, Co. C, 5th NeAV York Heavy Artillery, aged 39 years, was wounded at Snicker's Gap, July 18th, 1864, by a conoidal ball, Avhich produced a transverse fracture ofthe lower maxilla. He Avas, on July 22d, admitted to Sandy Hook Hospital, Alaryland, and transferred on the 27th to Frederick City Hospital, Avhere he Avas admitted the same day. Simple dressings were applied to the wound. Secondary haemorrhage from the facial artery occurred July 31st, amounting to sixty-four ounces of blood. Patient died July 31st, 1864. The case is reported by Assistant Surgeon R. F. Wier, U. S. A. Case.—Lieutenant Thomas Westcott, Co. K, 8th New York Heavy Artillery, aged 23 years, Avas wounded at the battle of Cold Harbor, June 1st, 1864, by a conoidal ball, which fractured the left superior maxilla. The missile entered the left side 356 WOUNDS AND INJURIES OF THE FACE. of the nasal cavitv, passed through the levator muscle, and lodged in the stemo-cleido-mastoid muscle. He Avas conveyed to the hospital of the 2d division, Second Corps. On the 4th, he Avas admitted to Seminary Hospital, GeorgetoAvn, 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 Avere applied to the wound. The appetite Avas poor, and the patient suffered much from loss of sleep. On the 25th, he Avas transferred to Baltimore, and admitted into the Newton University Hospital. Secondary haemorrhage 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 Avas transferred to Annapolis, where he was admitted into the 1st division hospital. He was discharged the service October 16th, 1864. The case is reported by Surgeon E. McDonnell, U. S. A'. He is a pensioner; his disability is rated total and probably permanent. CASE.-Private George T. A------, Co. E, 3d North Carolina Infantry, was Avounded at the battle of Gettysburg, July 3d, 1863, by a conoidal musket ball, which fractured the right lower jaAV. He also received a wound of the neck. He was taken prisoner and treated in field hospital until July 10th, 1863, when he was admitted to the Newton University Hospital, Baltimore, Maryland, where fragments of bone were removed from the body of the right lower jaw, halfway between chin and angle, and the parts coaptated. Barton's bandage was applied, with cold water dressings. Mild saline cathartics were given, and nourish- ing liquid diet prescribed. He improved rapidly, and on July 16th 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, Richmond, Virginia, and, on September 25th, 1863, 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. AV. Jones, U. S. V., and is numbered 1691 of the Surgical Section. CASE.-Private Henry C. B------, Co., F, 30th North Carolina Infantry, received a gunshot Avound of the face at the battle of Antietam, September 17th, 1862, the entire lower jaAV 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, 1862, from exhaustion and inanition. The pathological specimen consists of the inferior maxilla. An irregular plate of neAV bone measuring two inches in length, three-fourths of an inch in Avidth, and half an inch in thickness, has formed anteriorly, and is connected to the rami on either side by ligamentous bands. It Avas 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 Pennsylvania Reserves, aged 19 years, Avas wounded at the battle of Charles City Cross Roads, A'irginia, June 30th, 1862, by a conoidal ball, AA'hich entered at the left angle of the mouth, fractured the upper jaw, cut the tongue half in tAvo, and emerged at the angle of the right loAver jaw, fracturing it and displacing the teeth. He received also a bayonet Avound in the lower part of the back, which penetrated the left thigh. He Avas admitted into the Satterlee Hospital, Philadelphia, on July 26th, 1862. On the same day, Acting Assistant Surgeon EdAvard A. Smith removed several pieces of loose bone. Cold Avater dressings were applied, and the jaAV 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 Avound healed, the jaw became gradually stiffened until February 3d, 1863, at Avhich time he Avas able to chew food of some consistence, and suffered but little. He had neuralgic pains at times, and some deterioration ofthe facial angle; his health Avas good. He Avas discharged the service on April 14th, 1863. The case is reported by the operator. On November 17th, 1869, Pension Examiner S. Logan reports that Baker's leg is paralyzed 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 Avounded at the second battle of Bull Run, August 30th, 1862, by a conoidal ball, which entered the left side of the inferior maxilla, two inches from the angle, fracturing 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 Avere secured at the two extremities by silver wire, and Barton's apparatus Avas applied. The patient Avas discharged the service on April 4th, 1863, the union of the bone being imperfect. The case is reported by Surgeon Edwin Bentley, U. S. V. On April 5th, 1868, Pension Examiner H. Frasse reports "the fracture is ununited, interfering with the patient's speech, and disables him from masticating solid food." He rates his disability total and permanent. Case.—Private Michael Donhouser, Co. H, 10th United States Infantry, aged 25 years, was wounded at Gettysburg, July 3d, 1863, by a conoidal musket ball, which fractured both rami of the inferior maxilla at the angles. Several teeth Avere carried away and the tongue injured. The haemorrhage Avas severe. He was treated in field hospital until September 26tb, 1863. when he was transferred to St. Joseph's Hospital, Central Park, New York. On admission, the jaAV was imperfectly united by fibrinous exudations on both sides. Articulation Avas destroyed. On October 1st, a small spiculum 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 hospital at Fort Columbus, New York Harbor, Avhence he Avas discharged on December 16th, 1863, on account of complete aphonia from injury to the tongue. He is not a pensioner. Case.—Lieutenant William E------, 17th United States Infantry, Avas Avounded at the battle of Gettysburg, July 2d, 1863, by a conoidal ball, Avhich entered the left side of the face, shattering the body of the inferior maxilla, and emerged beneath the ramus of right side. He Avas, on the next day, admitted to the Seminary Hospital, Gettysburg, and on July 8th, transferred to Newton University Hospital, Baltimore. On admission, he Avas much enfeebled, and the wound was in very bad condition. Surgeon C. W. Jones, U. S. Ar., at once removed the fractured portions of bone and tAvo molar teeth from left side of body of the inferior maxilla, syringed the wound, cleaned the mouth Avith tincture of myrrh, applied a dressing of lint saturated Avith a s >lution of chlorinated soda, and secured the jaw by Barton's bandage. Stimulants and nourishing diet were given. Under this treatment the patient reacted rapidly, and continued to improve steadily. In thirty-six hours he could converse intelligibly; GUNSHOT FRACTURES OF THE FACIAL BONES. 357 subsequently yeast and charcoal poultices Avere applied to the wound, which left it clean, Avith healthy granulations, and he Avas granted a leave of absence on July 14th, 1863. On January 23d, 1864, he Avas admitted to the 1st division hospital at Annapolis; the Avounds had closed AA'ith but slight deformity; the tongue Avas partially paralyzed. He Avas returned to duty on February 6th, 1864. The pathological specimen, consisting of nine small fragments of bone and two molar teeth, was contributed to the Army Medical Aluseum 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. Cask.—Private Patrick (iibney, Co. B, 31st New A'ork Volunteers, aged 19 years, received a gunshot wound ofthe face at Chancellorsville, A'irginia, on Alay 3d, 1863, the missile entering at right alae nasi and emerging near the right angle ofthe lower jaAV, Avhich it fractured. He Avas treated in field hospital until May 9th, when he was admitted to HareAvood Hospital, Wash- ington. Simple dressings were applied to the wound, and the fractured parts kept in position. He recovered, and was discharged on Alay 25th, 1863, his term of service having expired. He is not a pensioner. Cask.—Private Robert Goldsmith, Co. A, 107th Ntnv York A'olunteers, aged 23 years, Avas wounded at Antietam, September 17th, 1862, by a conoidal ball, which entered in front of the symphysis of the right inferior maxilla, passed obliquely backward beneath the tongue, then doAvmvard and backward, and lodged in the scapula just above its spine, fracturing the maxilla at the symphysis and the angle. The ball Avas cut out on the field. Considerable haemorrhage folloAved immediately after the injury, with complete paralysis of the right arm. He Avas conveyed to Philadelphia, and admitted into the Broad and Cherry Streets Hospital on September 26th, 1862. AA'hen his arm Avas still paralysed, the tissues around the jaw swollen and inflamed, and the Avounds discharging freely. The left fragment at the symphysis Avas displaced backward and slightly down- ward. The patient's general condition was good. The Avounds 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 place, the paralysis having almost entirely disappeared. The Avound, made by removing the ball, had entirely closed; the Avound of entrance was still discharging slightly. One fragment of bone was 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 llth, 1862, he Avas transferred to the Cuyler Hospital at GermantoAvn, Avliere he Avas discharged the service on January 6th, 1863. The case is reported by Acting Assistant Surgeon John Neill. The patient is a pensioner, bis disability being rated one-half and permanent. Case.—Private Robert Jeffery, Co. F, 126th NeAV York A'oluuteers, was Avounded at Gettysburg, July 3d, 1863. AA'hile lying on his breast, with his head raised, a ball struck him on the front of the nose, on a line Avith the internal canthus, fracturing the nasal bones, and, passing doAvnward through the left antrum, the hard palate, and left side of the tongue, opposite the last molar tooth, came out on the left side ofthe neck, opposite the upper border of the thyroid cartilage. The Avound bled freely for a short time. He Avas treated in field hospital until July 13th, AA'hen he was admitted to the Broad and Cherry Streets Hospital, Philadelphia. Several small spiculae of bone had been removed. The patient's general condition was good. Simple dressings were applied, the mouth was frequently Avashed Avith a solution of borax, and a fluid diet Avas ordered. Under this treatment he improved rapidly. A feAV days after admission, several small fragments of the nasal bones Avere removed, and by August 1st the Avound of entrance had entirely closed, occluding the left nostril. The Avound through the hard palate had diminished in size, leaving a fistulous opening communicating with the left antrum; that of the tongue had cicatrized and Avas adherent to the side of the jaw by false adhesions, and traumatic paralysis Avas so Avell marked that in attempting to protrude the tongue it Avas strongly draAvn to the left side; his articulation Avas slightly impaired. A slight discharge still continued from the Avound of exit, but the patient had made a rapid recovery, Avith slight deformity, considering the nature of the injury. He was discharged from service on January 19th, 1864, and pensioned. Pension Examinei H. A. Potter reports, April llth, 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 Avay. The left side of the tongue is paralysed." CASE.-Private R. R. Kates, Co. H, 12th NeAV Jersey Volunteers, aged 22 years, was Avounded at Chancellorsville, Alay 3d, 1863, by a musket ball, AA'hich entered the mesial line of the upper lip, carried away almost the entire superior maxilla of that, side, and emerged about two inches behind the left ear. He was taken to the hospital of the 3d division, Second Corps, and, on May 8th, transferred to the Douglas Hospital, AA'ashington, Avhere fragments of bone Avere extracted. There were some pieces of bone deeply imbedded in the neck, and small fragments Avere daily discharged from the mouth. On June 8th. a tooth Avas extracted from the neck behind. He Avas furloughed on June 26th, at Avhich time the posterior Avound had healed; the upper portions of the bone Avere still inflamed; he could SAvalloAV easily, but spoke indistinctly. He was returned to duty on September 29th, 1863. His name does not appear upon the Pension Roll. Cask.—Private James Kelly, Co. I, 31st NeAV York A'olunteers, aged 26 years, was Avounded at the battle of Gaines's Mill, A'irginia, June 27th, 1862, by a conoidal musket ball, which entered near the middle of the angle of the left loAver jaw; splintering the outer wall of the maxillary bone, passed doAvnward, across the neck, between the trachea and the oesophagus' fractured the right clavicle, and lodged beneath the lower edge of the pectoralis major muscle. He lay on the battle-field all night, and was taken, on the next day, to Savage Station, Avhere he remained a day and a night, Avhen, fearful of being taken prisoner, he walked to Harrison's Landing, a distance of twenty miles. On July 1st, he was sent to Fort Monroe, where a piece of dead bone Avas removed from the jaw. On July 2d, he Avas transferred to Philadelphia, entering Satterlee Hospital on the 7th. AA'hen admitted, his general health was good. An opening at the point of entrance of the ball being explored by means of a probe, loose pieces of dead bone were readily felt. The probe, a very large ball-headed one, Avas passed down along the track of the ball to the furrow marking the junction of the trachea and oesophagus. The passage betAveen these had healed up. The patient stated that, for several days after the reception of the injury, he had considerable difficulty in swalloAving. A large swelling existed at the right side of the neck, and, on July 9th, fluctuation being perceptible, an opening Avas made at 35S WOUNDS AND INJURIES OF THE FACE. its most prominent point, about opposite the middle of the neck. On July llth, the ball being distinctly felt under the loAA-er edge of the pectoralis major muscle, Acting Assistant Surgeon John H. Packard made an incision and removed it Avithout difficulty. The SAvelling at the side of the neck soon diminished, and the orifice made on July 9th came down so as to be on a level Avith the clavicle, large portions of AA'hich Avere removed from time to time, and fragments of the jaAV also came aAvay through the Avound made by the entrance of the ball. The opening by Avhich the ball Avas extracted healed up very readily. There Avas considerable SAvelling near the middle of the right clavicle, OAving to a deposit of new bone. A small opening existed at the orifice of entry, and a sinus extended doAvn tOAvard the loAver edge of the jaAV, but no dead bone could be felt. The patient recovered, and Avas discharged from service on February 5th, 1863. He is not a pensioner. CASE.-Private Francis H. Kirker, Co. E, 100th Pennsylvania A'olunteers, aged 20 years, Avas wounded at Bull Run, August 29th, 1862, by a small rifle ball, Avhich entered on the left side of the nose, at the junction of the nasal bone with its cartilage, and, passing obliquely across and slightly backward, emerged one inch above the angle of the loAVer jaw, on a vertical line Avith the external meatus, tearing away a part of the lobe of the ear. He Avas conveyed to AA'ashington, entering George- tOAvn College Hospital on September 6th; on February 4th, 1833, heAvas transferred to Broad and Cherry Streets Hospital. He stated that the Avound bled freely at intervals for several days, and that several small pieces of bone had been removed. On admission, the Avound 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 Avas slight ptosis of upper lid and partial loss of vision in the right eye. The opthalmoscope revealed a congested state of the retina. He Avas discharged from service on Alarch 19th, 1333, and pensioned. Pension Exammer A. K. McClure reports, April 6th, 1867, that there is necrosis of the superior maxilla, and that the pensioner is unable to perform any labor Avithout causing pain. CASE.-Private John McNalley, Co. H, 81st Pennsylvania, aged 23 years, Avas AVounded at Fredericksburg, A'irginia, December 13th, 1862, by a round musket ball, Avhich entered on the left side of the nose, on a line Avith the internal canthus of eye, fractured the nasal bone, and, passing obliquely across, fractured the right superior maxillary bone and penetrated the cheek opposite the second molar tooth, in its course giA-ing rise to a fistula lachrymalis on the right side. He Avas at once admitted to the hospital of the 1st division, Second Corps, and, on December 20th, sent to Catharine Street Hospital, Philadelphia, Avhence he Avas transferred, on February 2d, 1863, to Broad and Cherry Streets Hospital. AVhen admitted, both wounds had closed, Avith little depression at the Avound of entrance. The right cheek Avas considerably SAVollen. The fistula had almost healed, and closed a feAV days after admission. The patient stated that the Avounds bled very freely, at intervals, for the first twelve hours, and that several small pieces of bone Avere removed on admission to Catharine Street Hospital. He complained of partial loss of vision. The ball of the eye Avas slightly atrophied, and its pupil considerably larger than the other, and irregular and slow in action. An examination Avith the opthalmoscope shoAved the vessels of the retina to be in a congested condition. He Avas discharged from service on March 31st, 1863. He is not a pensioner. Case.—Private AA'illiam Madison, Co. IT, 118th Pennsylvania A'olunteers, aged 46 years, Avas Avounded at Blackburn's Ford, September 20th, 1862, by a conoidal ball, Avhich entered just in front of the coronoid process, on the left side, passed through the cheek and soft palate, and emerged on a line Avith, and about one-half an inch below, the lobe of the right ear, tearing away the uvula and the lateral half arches and fracturing the ramus of the jaAV on the right side just above the angle. He was conveyed to Philadelphia, and admitted into the Broad and Cherry Streets Hospital on September 27th, 1862. The patient stated that, immediately after the injury, he suffered from loss of blood, and before leaving the field the surgeon removed some tissue from his mouth. On his admission into the hospital, the right cheek was SAVollen and inflamed, and both Avounds were discharging slightly. The upper fragment of the bone Avas displaced, baclvAvard and inward; the parts Avithin looked very Avell. The right side Avas dressed with a flaxseed poultice ; the left side Avith a Avarm water dressing, and a Barton's bandage was lightly applied. Extra diet in a liquid form Avas ordered. The patient complained of a loss of sensation in the right half of the lower lip, OAving to a division of the inferior dental nerve at the seat of the fracture. He improved rapidly, and on November 1st, 1862, Avas convalescent, the wound of entrance having closed, the Avound of exit discharging slightly, and the bony union firm. He Avas transferred to the A'eteran Reserve Corps on April 21st, 1833. The case is reported by Acting Assistant Surgeon John Neill. On December 13th, 1865, Pension Examiner E. A. Smith reports that the sense of taste is destroyed, tongue paralysed on the left side, and hearing in right ear and sense of smell are much impaired. He rates the disability three-fourths and probably permanent. Case.—Sergeant Alfred Malone, Co. K, 6th West Virginia Cavalry, aged 39 years, was wounded at Springfield, Virginia, June 26th, 1864, by a pistol ball, which 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 tAvo and a half inches from the right angle ofthe mouth, on a line with the meatus auditorious externus, fracturing both sides of the superior maxilla. One molar and tAvo bicuspid teeth on the right side AA'ere removed by the patient himself at the time of the injury. He Avas admitted, on the next clay, to the hospital at Cumberland, Maryland. AA'hen admitted the incisors and canine teeth, attached to a fragment of the superior maxilla, Avere hanging loosely between his lips; the left bicuspid teeth Avere displaced, and the root of the left canine tooth was cut off and remaining loose above the fracture. A very offensive foetid odor accompanied the discharge from the wouud. Several fragments of bone had come away by suppuration, and others were exposed, but so attached to the muscular tissue as to prevent their removal A\ithout danger of haemorrhage. The anterior palate was cut through and hung pendulous in the mouth. The bleeding was free at first, but was completely arrested by cold water applications. The fractured teeth and maxilla Avere 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 cleansed with a weak solution of chlorinated soda, and resin cerate applied to the Avounds of the cheeks, with stimulants and nourishing diet internally. Under this treatment the patient 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 GUNSHOT FRACTURES OF THE FACIAL BONES, 359 through the superior maxilla had so far united as to hold up the fragment of bone and teeth Avithout the aid of the splint. He was furloughed on July 22d, 1864. While at home an abscess pointed through the right cheek, between the Avound of exit and the anide of the mouth, Avhich discharged pus freely and several spiculae of bone, among them a fragment of the hard palate, one-half inch long. By September 22d, the Avound of the left cheek had entirely healed. A small discharge still continued from the Avound in the light cheek. The upper incisors and bicuspids were held in place by union of the soft parts, but Avere not sufficiently solid to use in chewing. He was transferred to the hospital at Grafton, on September 25th, and returned to duty on October 15th. 1864. He AA'as discharged on Alay 22d, 1866, and pensioned. Pension Examiner E. I). Safford reports, October 28th, 1868, that "the bones have never united, and he has no ability to chew food, and is a great sufferer from facial neuralgia in consequence of the injury.'' Cask —Corporal Jacob M------, Co. G, 20th Michigan A'olunteers, aged 29 years, Avas wounded at the battle of Cold Harbor, A'irginia, June 3d, 1831, by a conoidal musket ball, which fractured the right loAver jaAV. He was taken to the hospital of the 3d division, Ninth Corps, and, on June 8th, admitted to the Emory Hospital, Washington. On June 10th, Surgeon N. R. Moseley. U. S. A'., removed seA-eral fragments of bone from the inferior maxilla. Simple dressings Avere applied, and, on August 6th, he was transferred to St. Mary's Hospital, Detroit, and, on October 14th, to Harper Hospital, Avhere death resulted on December 7th, 1864. from wound, complicated Avith haemorrhage of the lungs. The pathological specimen, consisting of seven pieces of bone, to which a small flattened piece of the missile is attached, was contributed to the Army Aledical Aluseum by the operator, and is numbered 2507 of the Surgical Section. Cask.—Piivate AA'illiam T. Moore, Co. G, 15th Massachusetts A'olunteers, Avas Avounded at Gettysburg, July 2d, 1853, by a conoidal ball, which entered the buccal muscle of the left side of the face, passed slightly upAvard and emerged on the right side of the face, knocking out three teeth of the left upper jaw, and fracturing the right upper jaw. He was at once admitted to the hospital of the 2d division, Second Corps; thence sent to Baltimore, and, on July 10th, 1363, admitted into the Newton University Hospital. Immediately after admission, a fragment of the alveolar process of the right superior maxilla, containing one canine and one bicuspid tooth, was removed. The parts Avere then coaptated, Barton's bandage applied with cold Avater dressings, and liquid diet given. On July 31st, he was nearly Avell, and his general condition Avas excellent. He Avas trans- ferred to the A'eteran Reserve Corps on October 26th, 1863. The pathological specimen is No. 1690, Section I, A. AI. AI., and was contributed, with the history, by Surgeon C. AA'. Jones, U. S. V. This man is a pensioner; his disability is rated one-half and permanent. Case.—Private Aladison B. AIoss, Co. I, 23d Pennsylvania Volunteers, aged 31 years, was wounded at Fair Oaks, Virginia, May 31st, 1862, by a conoidal ball, Avhich entered posteriorly, just beloAV the right condyle of the loAver jaw, and, passing obliquely forward and across, emerged at the left angle of the mouth. Most of the ramus of the right side Avas carried away; the lip was lacerated, and a part of the tongue on the right side, Avith 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 tAvo days, very much prostrated from the loss of blood. He was afterward removed to a private house; thence to Norfolk, Virginia, where he remained for three weeks, Avhen he was sent to New York, and thence to Philadelphia, and admitted into the Broad and Cherry Streets Hospital on October 3d, 1832. The patient stated that the only dressing applied Avas lint wet with cold Avater, and the mouth Avas well syringed daily. His diet consisted of beef-tea and arroAv-root. During the treatment, several pieces of bone were removed from the wound. On his admission into this hospital, the Avound of the right cheek had almost cicatrized, leaving a deep scar, Avhich extended from the ear to the angle of the mouth. The Avound on the left side had entirely healed. His health Avas good, but he is unable to take solid food. The deformity of the soft places Avas such that a benefit Avould probably result from a plastic operation. On January 14th, 1363, the patient Avas transferred to the AIoAver Hospital, Philadelphia, where he Avas discharged the service on January 19th, 1333. The case is reported by Acting Assistant Surgeon John Neill. The patient is a pensioner, his disability being rated total and permanent. Case.—Private Alrchael Murphy, Co. G, 69th New York Volunteers, aged 24 years, was Avounded at the Wilderness, Virginia, Alay 5th, 1864, by a conoidal ball, which caused a lacerated Avound of the face, injured the palate, and comminuted the upper jaAV. He was taken to the hospital of the 1st division, Second Corps, Avhere detached pieces of bone Avere removed by Surgeon O'Meagher. On Alay llth, he was transferred to Judiciary Square Hospital, AVashington, Avhence he was returned to duty en July 12th, 1864. He is not a pensioner. Cask.—Private Peter Rafferty, Co. B, 63th New York A'olunteers, Avas Avounded at the battle of Malvern Hill, Virginia, July 1st, 1862, by a conoidal ball, which entered the upper 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 obliquely across, struck the right loAver jaw at a point one inch in advance of its angle, passed doAvnward and outward and emerged through the cheek, knocking out fourteen 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 AA'as removed by the patient. He received also a gunshot fracture of the bones ofthe foot. A profuse haemorrhage folloAved, amounting to syncope, and the patient remained insensible for tAventy-four hours. Being taken prisoner, he was removed to a hospital on the field, and three days afterward was sent to Richmond, A'irginia, Avhere his Avounds were dressed Avith cold Avater, but he received poor diet. He had colliquative diarrhoea for tAvo weeks. On July 25th, 1852, he Avas paroled, and conveyed to Philadelphia, and, on July 29th, Avas admitted into the Broad and Cherry Streets Hospital in a very weak condition. The fragments of the jaw Avere exposed in the Avound for some distance; the soft parts were sloughing, and the Avound ofthe foot looked badly; that over the fractured clavicle had healed, with some union ofthe bone, the inner fragment overlapping. Lint, saturated with a solution of chlorate of potash, Avas applied to the Avound of the cheek, and a flaxseed poultice to the wound of the foot. Stimulants and anodynes and liquid diet were given. Tavo large pieces of bone were removed. A few days after admission, the patient had another attack of diarrhoea, Avhich continued two Aveeks, causing great prostration. Recovering from this, he improved rapidly. On November 1st, 1862, the wound of the cheek had nearly healed, o6l) WOUNDS AND INJURIES OF THE FACE. leaving a deep scar. No callous Avas thrown out; the jaw Avas drawn toward the right side, giving rise to considerable deformity, and tlie patient was unable to take solid food. A firm union of the clavicle had taken place. The Avound ofthe foot had nearly healed. The patient was discharged the service on January 5th, 1863, and pensioned. The case is reported by Acting Assistant Surgeon John Neill. Cask.—Private Aaron S------, Co. G, 1st Maine Heavy Artillery, received a gunshot fracture of the inferior maxilla, in an engagement before Petersburg, Virginia, June 18th, 1864. He Avas at once taken to the hospital of the 3d division, Second Corps, Avhere Dr. A. Garcelon, a volunteer surgeon, removed five fragments of the inferior maxilla, with a lateral incisor, canine and bicuspid teeth. Death resulted on June 26th, 1864. The pathological specimen, consisting of the portions of bone removed, was contributed to the Army Medical Museum by the operator, and is numbered 522 of the Surgical Section. Case.—Private Samuel AV. S------, Co. B, 1st New York Dragoons, aged 23 years, Avas wounded at Spottsylvania, May 8th, 1864, by a conoidal ball, which entered the back two inches beloAV and a little to the right of the superior angles of the rio-ht 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 Avas admitted into the general field hospital of the Cavalry Corps at Fredericksburg, A'irginia, on May 13th, 1864; thence he Avas transferred to Alexandria, Virginia; and, on May 24th, 1864, Avas admitted into the 2d division hospital. On May 27th, a copious secondary haemorrhage occurred from the mouth, which was arrested by the persulphate of iron, pressure, cold applications, and an elevated position. Extra diet was given. The patient died on June 4th, 1864. At the autopsy, it was found that the body of the inferior maxilla was fractured half Avay betAveen the angle and the symphysis. The jugular vein just above the middle of the omo-hyoid muscle Avas found discolored, shriveled, closed, and, apparently, in a sloughy condition, and filled with coagulum for tAvo inches beloAV the wound. The haemorrhage 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. M. (a wet preparation of a portion of the right internal jugular vein). The specimens and history were contributed by Acting Assistant Surgeon Jonathan Cass. Case.—Private John AAr. S------, Co. I. 82d Pennsylvania Volunteers, aged 21 years, was Avounded at the battle of Cold Harbor, Virginia, June 3d, 1861, by a conoidal 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 AVashington, and, on June 10th, admitted to Emory Hospital, where, on the next day, the ball and upper portion of the jaw Avere removed, and simple dressings applied to the Avound. On June 21st, he was transferred to Haddington Hospital, Philadelphia. Erysipelas, contiguous to the Avound, supervened on July 6th, but disappeared under the application of iodine Avith stimulants internally. He Avas returned to duty on October 19th, 1831. The pathological specimen, consisting of one inch and a half of the right condyloid extremity of the inferior maxilla, including the articular surface, Avas contributed to the Army Medical Museum by Surgeon N. R. Moseley, U. S. V., and is numbered 564 of the Surgical Section. The patient is not a pensioner. Case.—Private Johnson S------, Co. D, 6th Alabama Infantry, aged 18 years, was Avounded at Gettysburg, July 3d, 1863, by a musket ball, Avhich, entering about one inch from the chin on the left side, produced a compound fracture of the lower maxillary bone, and lodged. He Avas admitted, on July 6th, to the hospital at Frederick, Maryland, where water dressings Avere applied to the Avound. The location of the missile could not be detei mined. The patient's general condition was good. On July 10th, several small fragments of bone Avere extracted. The patient, apparently, did Avell until September 1st, the \A-ound of jaAV having healed, AA'hen he complained of pain in the neck, Avhich increased in severity. An abscess formed on the left side of the neck, discharging, Avhen opened, about four ounces of foetid pus. On September 18th, it Avas found that air passed through the opening made into this abscess. The patient complained of a feeling of numbness in the left side of the body, folloAved, on the 19th, by partial paralysis, Avhich extended into the bladder. His urine Avas drawn off twice a day. On September 21st, he Avas placed upon a water bed. The appearance of the back part of the neck indicated some displacement of the vertebra; pressure upon that part of the neck produced a gurgling sound. Complete paralysis had occurred by September 23d, and the patient's strength was rapidly failing. Milk punch Avas freely given, but a considerable quantity of all the liquids taken by the mouth passed out through the fistulous opening. He continued to sink, and died on September 28th, 1863. At the autopsy, the fractured jaw Avas found to have only partially united. The ball had lodged in the fifth cervical vertebra, producing extensive comminution. The bone Avas very much necrosed, and the soft parts greatly disorganized. The suppuration extended to the spinal canal; there Avas red softening of the spinal cord. The fistulous opening extended into the pharynx. The pathological specimen is a Avet preparation of the inferior maxilla, shoAving a fracture of the body by a musket ball, one- half inch to the left of the symphysis, partially united by ligament. The fracture runs obliquely doAvnward, forward, and inAvard, and one inch of the body of the bone, Avith the canine, bicuspid, and first molar teeth, had been comminuted and partially removed. Several small fragments remain in situ. It Avas contributed to the Army Aledical Aluseum, Avith a history ofthe case, by Assistant Surgeon R F. AA'eir, U. S A., and is numbered 3979 of the Surgical Section. CASE.-Private Samuel T------, Co. E, 88th Pennsylvania Volunteers, was Avounded at the Alexandria Prison, July 26th, 1884, by a musket ball. He died on the same day. At the autopsy, the ball was found to have entered the right corner of the mouth and emerged just beloAV the right ear, badly fracturing the right side of the loAver jaAV in several places, and rupturing the internal maxillary artery. The haemorrhage from the internal maxillary artery Avas supposed to have caused his death. The specimen is No. 3350. Sect. I, A. M. M., shoAving the right half of the inferior maxilla fractured, and a small portion of the ball attached. The specimen and history Avere contributed by Surgeon EdAvin Bentley, U. S. V. Case.—Corporal F. Augustus W------, Co. K, lilth NeAV York A'olunteers, aged 22 years, Avas wounded at Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, Avhich fractured the right side of the inferior maxilla. He Avas sent to the regimental hospital of the lilth NeAV York A'olunteers, and, on the same day, transferred to the general field hospital at Gettys- GUNSHOT FRACTURES OF THE FACIAL BONES. 361 burg; thence he Avas sent to Baltimore, and admitted into the Jarvis Hospital on July 15th, 1863. Owing to the amount of swelling and the extreme tenderness of the mouth, the wound Avas not examined. The patient was able to take food in a liquid state until noon on July 22d, 1863, Avhen he Avas found gasping for breath, and died soon after. At the autopsy, it was found that the ball had entered about one inch to the right of the symphysis, 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 epiglottis was much enlarged, and the larynx filled Avith coagulated blood. This man never had much haemorrhage, and no large artery Avas found divided. The specimens are No. 1451 (a Avet specimen of the maxilla), Sect. I, A. M. M , and No. 1440 (a Avet specimen of the larynx Avith the missile), Sect. I, A. M. AI.. and Avere contributed, with the history, by Acting Assistant Surgeon B. B. Miles. Case.—Private R. W------, Co. F, 95th Pennsylvania Volunteers, aged 39 years, Avas wounded at Chancellorsville, A'irginia, Alay 3d, 1863, by a conoidal ball, Avhich entered the left side of the face at the infra-orbital foramen of the superior maxilla, and emerged betAveen the ascending branch of the lower jaw and the transverse process of the atlas, half an inch external to the latter, in the left nuchal region, fracturing the malar bone beloAV 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 AVashington, he entered the Douglas Hospital on Alay 3th, 1853, suffering considerably from cough and impeded deglutition. On May llth, there Avas 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 from 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 Avere red and inflamed. On May 24th, the patient, while drinking a cup of tea, became suddenly suffocated and expired. At the autopsy, it was found that ulceration of the oesophagus had taken place. The ball had barely escaped the lateral process of the atlas. There Avas 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. AI. 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 orbital 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. AI. M. The specimens, with the history, Avere contributed by Assistant Surgeon W. Thomson, U. S. A. Case.—Private Daniel S. AVilkinson, Co. K, 7th AVisconsin Volunteers, aged 20 years, was wounded at the second battle of Bull Run, A'irginia, August 30th, 1862, by a conoidal ball, which entered the right side of the upper lip, just beloAV 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 NeAV York City, and admitted into the Ladies' Home Hospital on September 13th, 1862. Ordinary bandages and poultices were applied. On September 30th, 1862, a piece of bone, one-fourth of an inch in length, was removed. Several pieces of bone have been discharged from the Avound from time to time. On November 9th, 1862, the bone had com- pletely united; when the mouth was closed the coaptation between the teeth Avas not entire. On January 14th, 1863, the Avound had entirely healed, the patient's health was good, and he was returned tq duty, there being no difficulty Avith the jaAV, excepting the overlapping ofthe fragments, and conseqent shortening ofthe body of the jaAV. 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, Avas Avounded at Gettysburg, July 3d, 1863, by a conoidal ball, which entered below the angle of the loAver jaw, left side, passed under the tongue, and shattered the jaAV on the right side. He was treated in field hospital until January 6th, 1864, when he Avas 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, 1863, 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 aud permanent. Case.—Private Dennis B------, Co. I, 22d Massachusetts, was Avounded at Fredericksburg, Virginia, December 13th, 1862, by a ball, which entered above and a little forward of the posterior fold of the left axilla, passed inAvard, upward, and forward, and emerged just above the convexity of the left clavicle, which it shattered, again entered an inch nearer the neck, preserving nearly its original direction, finally emerging through the right cheek, breaking a feAV small pieces from the middle of the lower edge of the jaAV. He was conveyed to AA'ashington, and, on December 18th, admitted to Judiciary Square Hospital. There was considerable offensive discharge, particularly from the first Avound of exit. About December 30th, his mind became somewhat affected, and there was great and increasing tendency to sleep. On the night of January 12th, 1863, he Avas attacked Avith violent pain in the left hypochondrium, which Avas partly relieved by the application of sinapisms. On January 13th, two fragments of bone were removed with the forceps from the acromial portions of the clavicle from which they had become partially detached. On January 14th, he Avent to sleep after eating heartily; his breathing was shorter than usual. Upon being spoken to he opened his eyes, but closed them again; his breathing became still shorter, and Avith longer intervals, for about five minutes, when he died, perfectly quiet, and apparently without pain. At the antopsy, the head of the humerus was found destroyed, and the shaft fractured for three inches below it. The glenoid cavity and neck of the scapula were destroyed as far back as the supra-scapular notch; a partial fracture extended across the infra-spinous fossa. The front of the thyroid cartilage had been carried aAvay. A notch Avas cut out of the under surface of the inferior maxilla, right side. The left lung was compressed by an abundant pleuritic effusion, and contained a single abscess. The parenchyma of the left lung was not examined. There was not any opening into the pleura. A drop of blood taken from the axillary vein exhibited nearly as many white as red corpuscles. The specimen, consisting of the left clavicle, scapula, and upper third of the humerus, is numbered 695 of the Surgical Section of the Army Medical Museum, and was contributed, with a history of the case, by Medical 46 362 WOUNDS AND INJURIES OF THE FACE. Cadet Burt G. AYilder, IT. S. A. The ball entered the posterior aspect of the shoulder-joint, and emerged at the centre of the clavicle, causing extensive comminution of the glenoid cavity and head of the humerus. The clavicle is fractured obliquely. A fissure extends transversely through the body of the scapula beloAV the spine. The acromion and coracoid processes are detached. The shaft of the humerus exhibits several fissures. The fractured extremities of the clavicle are necrosed. The specimen shoAvs but little attempt at repair. Case.—Private Alvah Fassett, Co. B, 52d New York Volunteers, aged 26 years, Avas wounded at Fair Oaks, A'irginia, May 31st, 1362, by a round ball, Avhich entered the left side of the neck, passed through the pharynx, and emerged through the right angle of the jaAV, fracturing the inferior maxilla and paralyzing the dental nerve of the right side. He was conveyed to the field hospital. The wounds bled freely; bandages and adhesive strips Avere applied. The patient Avas transferred to the White House, thence by steamer to Philadelphia, where he was, on June 4th, admitted into the Saint Joseph's Hospital. On admission, there Avas difficulty of deglutition. Simple dressings Avere applied to the wound, and nourishing diet ordered. Several spiculae of bone were removed on July 5th, and afterAvards at various times. The motion of the jaw was much restricted, and could not be closed within one-fourth of an inch, nor opened more than one-half of an inch. Some ofthe smaller branches of the facial nerve Avere injured. He was discharged the service on August 12th, 1862. The case is reported by Acting Assistant Surgeon AA'illiam P. Moore. This man is a pensioner, his disability being rated three-fourths and permanent. Cask.—Sergeant Franz Wolbe, Co. E, 31st NeAV York Volunteers, aged 31 years, received, at the battle of AA'est Point, May 7th, 1862, a gunshot Avound. The missile entered the centre of the right cheek, carrying aAvay, in its passage, 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 Avas, on Alay llth, admitted into the general hospital, Alexandria, Virginia. The Avounds Avere healing rapidly, and the patient doing Avell. He was discharged the service on August llth, 1862. The case is reported by Surgeon John E. Summers, U. S. A. Wolbe is a pensioner. The poAver of speech is partially destroyed. His disability is rated total. Case.—Sergeant Milo A. Dix, Co. C, 49th Ohio Volunteers, aged 23 years, Avas wounded at Nashville, Tennessee, December 15th, 1864. by a conoidal ball, which entered immediately beneath the septum of the nose, fractured both superior maxillary bones at the symphysis, and emerged at the back of the neck a little to the right of the median line, fracturing the transverse processes of the cervical vertebrae. He Avas treated in regimental hospital until December 17th, Avhen he Avas admitted to hospital No. 1, Nashville, and, on December 21st, transferred to Crittenden Hospital, Louisville, Kentucky. Simple dressings Avere applied to the Avounds. Death resulted on December 23th, 1361, from pyaemia. At the autopsy, tAvo or three metastatic abscesses were found in the base of the left lung. Portions of the lower lobe of the left lung were gangrenous, and there Avas a small quantity of sero-purulent matter in the left plural cavity. Case.—Corporal James Green, Co. C. 1st United States Colored Troops, aged 26 years, received a gunshot compound fracture of the loAver jaw at Fair Oaks, A'irginia, October 27th, 1364. He was admitted, on October 29th, 1864, to Balfour Hospital, Portsmouth, A'irginia. Cold Avater Avas injected through the wound. Death resulted on November 3d, 1864, from exhaustion. Case.—Private Joseph D. Parks, Co. A, 29th Connecticut Colored Volunteers, aged 30 years, was Avounded in an engagement before Richmond, Virginia, October 27th, 1834, by a conoidal ball, Avhich entered the left side of the face, nmhvay betAveen the angle and symphysis of the inferior maxillary, passed obliquely inAvard and outAvard, abrading the tongue, and emerged at the angle of the inferior maxilla, right side, extensively fracturing the bone to within the capsule of left articulation, besides greatly comminuting the body of the jaAV. He was at once taken to the hospital of the Tenth Corps, being unable to articulate sufficiently distinct to be understood. On the same day, he Avas placed in a partially rec.ining position, and chloro- formed by Surgeon C. M. Clark, 39th Illinois Volunteers. An incision Avas 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 periosteum. After removing all the loose fragments, the stump of the left ramus was grasped Avith the bone pliers and disarticulation accomplished Avith a feAV strokes of the knife. A similar incision Avas then made on the right side to connect Avith the other, severing the geniohyo- glossus and geniohyoid muscles, and the tongue retracted so as to fill the pharynx. The tongue was then draAvn forward and retained in that position by means of a silk cord passed through it and fastened externally. The bone Avas then dissected the same as on the opposite side, and removed to within a short distance of the sigmoid notch, Avhere it was found to be sound, and was severed at the upper third of ramus by a chain saw; the wound was brought together with silk sutures. Cold water dressings and compress, Avith paste-board support, were applied, and nourishing diet administered through a tube The operation occupied one and a half hours time. Very little blood Avas lost. The only artery ligated Avas the facial; the others Avere tAvisted The patient Avas 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. Case.—Private Isaac Smith, Co. H, 39th Illinois Volunteers, aged 19 years, was wounded at Deep Bottom, Virginia, August 16th, 1864, by a conoidal ball, which caused a comminuted fractnre of the right inferior maxilla. He was admitted to the hospital at Fort Monroe, Virginia, August 18th, 1864, suffering from tramatic irritation and insomnia. On August 26th, Acting Assistant Surgeon S. J. Holley anaesthetised the patient, and excised the right ramus and tAVO-thirds of the body of the lower jaw. The haemorrhage was slight; one ligature was applied. Patient reacted promptly. On October 8th, he Avas transferred to Grant Hospital, AYillett's Point, New York, and transferred to the Veteran Reserve Corps on Alay 4th, 1835. Pension Examiner C. R. 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." GUNSHOT FRACTURES OF THE FACIAL BONES. 363 Case.—Private Samuel H-----, Co. G, 86th New York Volunteers, aged 32 years, Avas Avounded at Gettysburg, Penn- sylvania, July 3d, 1363, by a fragment of shell, which lacerated the cheek severely and fractured the left inferior maxilla, the loAver portion of the body of the bone being severely comminuted. The alveoli Avere but slightly injured. He 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, betAveen the central incisors anteriorly and the last two molars behind, folloAving the line of fracture which involved the alveolar arch at those points only. The bone, which was broken across transversely, was rendered quite smooth by the bone forceps at or near the angle of the jaw. A Hey's saw was used, the soft parts being held out of the AA-ay by a spatula. During the operation, the tongue was carefully kept in situ by a ligature passed through its tip and held by an assistant. After carefully securing all the bleeding vessels, and removing the burnt or destroved tissue, the excessively ragged wound Avas brought together in accurate apposition by the introduction of silver pins with a Avire figure-of-8 suture. On July 16th, he Avas transferred to McKim's Alansion Hospital, Baltimore, and on November 21st, 1863, to Patterson Park Hospital, where he Avas reported as convalescent. In a letter to this office, dated May 28th, ls65, the operator states that ''the cicatrix 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 complains of indigestion to some extent." The pathological specimen, consisting of the excised portion of bone, Avas fonvarded to the Army Aledical Museum by the operator, and is numbered 1532 of the Surgical Section. Not a pensioner. Case.—Private Daniel Beckhorn, Co. E, 8th New York HeaAry Artillery, aged 18 years, was Avounded at Cold Harbor, A'irginia, June 3d, 1864, by 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 conveyed to Washington, and, on June 8th, admitted to the Emory Hospital. Cold water dressings were applied, and, on June llth, be was transferred to Patterson Park Hospital, Baltimore. On June 13th, ten fragments of bone Avere removed from the jaw, and, on July 1st, three pieces more. The dressing consisted of oakum, wet with baker's yeast. On July 2Cth, the remaining loose piece of jaw, containing four teeth, commenced to unite. Fragments of bone were, at various times, removed from the wound ofthe sho'ilder, which progressed favorably, and, on September llth, the patient could move the shoulder in all directions, but the power of abduction Avas somewhat impaired. On September 12th, he was furloughed; on October 23d, admitted to the MoAver Hospital, Philadelphia, Avhence he Avas returned to duty on April loth, 1865. The pathological specimen, consisting of six fragments of bone from the inferior maxilla, was contributed to the Army Medical Museum, by Acting Assistant Surgeon J. W. Fay, and is numbered 3467 of the Surgical Section. The patient is not a pensioner. Case.—Private John Boon, Co. C, 8th Ohio Volunteers, was Avounded at Chancellorsville, Virginia, May 3d, 1863, by 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 ofthe angle of the jaw. He Avas treated in field hospital until May 9th, when he Avas admitted to the Carver Hospital, AVashington. There Avas a hard and painful swelling over the lower jaw, near its angle. There was no wound within the mouth. Fracture of the jaAV could be detected. An abscess formed below the jaw, Avhich was opened on May 18th, and again on the 20th, alloAving the escape of considerable pus. On May 22d, a bullet was discovered Avithin the Avound, which was removed with forceps by Acting Assistant Surgeon B. F. Craig. Poultices Avere applied over the jaw and wound, and on June 23d, the patient was transferred to the AicClellan Hospital, Philadelphia, thence on October 24th, to Camp Dennison, Ohio, Avhere he was treated for syphilis until November 16th, 1863, when he was returned to duty. The specimen, showing a spherical leaden ball-somewhat grooved at one portion, Avith a long fragment of bone imbedded, was contributed to the Army Medical Museum by the operator, 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, Maryland, September 17th, 1862, by a conoidal musket ball, which entered at the right angle of the mouth, cut its Avay through the upper surface of the tongue, and fractured the lower jaw at its angle. He Avas treated in field hospital until September 29th, when he was admitted to the 1st division hospital, Alexandria, Virginia. There was persistent swelling and inflammation, Avith incessant suppuration inside the mouth and at the angle of the jaw. The jaAvs became fixed, threVfifths of an inch apart. On October 30th, a large piece of loose bone, triangular in shape and an inch in altitude, consisting of the angle of the jaAV, was extracted by Surgeon John E. Summers, U. S. A., and the presence of the ball detected. On November 4th, the patient was chloroformed, and Bearch beiDg made for the ball, it was at length discovered firmly imbedded outside and beyond the angle of the jaw, Avhence it was extracted with very great difficulty. The patient recovered, and Avas returned to duty on November 18th, 1862. The missile, a conoidal ball, with a longitudinal half, obliquely and roughly torn off, and the opposite side of the cup rolled up outwardly upon itself, was contributed to the Army Medical Museum by Acting Assistant Surgeon George F. French, and is numbered 2976 of the Surgical Section. Bryant is not a pensioner. Case.—Private Peter Roth, Co. E, 4th United States Artillery, Avas wounded at Fredericksburg, Virginia, December 13th, 1862, by a musket ball, Avhich lodged in the left superior maxilla, after having shattered the malar bone. He was admitted to the Carver Hospital, AVashington, on December 21st, and on January 8th, 1863, transferred to Patterson Park Hospital, Baltimore, where, on January llth, Acting Assistant Surgeon Theodore Artaud extracted the ball and fragments of bone. After the extraction of the ball, the probe could communicate freely Avith the antrum of Highmore. The Avound healed with some depression The patient was returned to duty in June, 1863. The pathological specimen, a very greatly battered leaden bullet, was contributed to the Army Medical Museum by the operator, and is numbered 4554 of the Surgical Section. Roth is not a pensioner. Case.—Private Daniel C. Uffelman, Co. B, 198th Pennsylvania Volunteers, aged 19 years, Avas wounded at South Side Railroad, Virginia, April 1st, 1865, by a conoidal ball, Avhich entered one quarter of an inch to the left of the symphysis, and fracturing the jaw badly, emerged under the chin, reentering the neck just beside the trachea, and lodged, as Avas supposed, in the cervical vertebrae. He waB at once admitted to the field hospital of the 1st division, Fifth CorpB, where the teeth and some 364 WOUNDS AND INJURIES OF THE FACE. pieces of bone Avere removed. On April 4th, 1865, he was sent to the depot field hospital ofthe Fifth Corps, thence transferred to AVashington, and, on April 7th, admitted into the Finley Hospital. On April 14th, two pieces from the symphysis of the inferior maxilla were removed by Surgeon G. L. Pancoast, U. S. V. Splints and simple dressings Avere applied. Special diet was given. On Alay 19th, he Avas transferred to the MoAver Hospital at Philadelphia, where he was mustered out of service on June 5th, 1865, in accordance Avith general order from the AA'ar Department, dated May 3d, 1865. The specimen is No. 4288, Sect. I, A. AI. 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 operator. Uffelman is not a pensioner. CASE.-Private John Shultz, Co. H, 7th AVisconsin Volunteers, aged 28 years, was wounded at Gettysburg, Pennsyl- vania, July 1st, 1863, by a conoidal ball, Avhich entered at the right superior maxilla, passed backward and downward, and lodged under the integuments below the mastoid process of the temporal bone. He was admitted, on the next day, to the Seminary Hospital at Gettysburg, where the ball was removed, and, on July 12th, he was transferred to Turner's Lane Hospital, Philadelphia, Avhence he was transferred to the Veteran Reserve Corps on November 4th, 1863. The missile, shoAving the apex flattened upon the body, and the base laterally compressed, was contributed to the Army Medical Museum by Acting Assistant Surgeon David Burpee, and is numbered 4533 of the Surgical Section. Schultz is not a pensioner. Case.—Corporal James P. SteAvart, Independent Battery E, Pennsylvania Artillery, aged 25 years, Avas wounded at Brown's Ferry, Tennessee, October 28th, 1863, by a musket ball, which entered the right cheek just above the angle of the lower jaw, passed horizontally through and emerged from the centre of the left cheek, fracturing the inferior maxilla upon the right side, opening 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 Avas admitted, on the next day, to hospital No. 2, Chattanooga, . Tennessee. Deglutition and speech Avere entirely suspended. Simple dressings were applied to the wound, and beef soup and milk given twice a day by means of a stomach tube passed into the pharynx. 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 SAvallow a little. No further information can be obtained until April llth, 1864, Avhen he was admitted to the hospital at Pittsburg, Pennsylvania, Avhence he was discharged from service on May 3d, 1864. The poAvers of deglutition, mastication, and articula- tion 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 round 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 the extent of two inches. He was conveyed to Baltimore, and, on September 21st, admitted to the NeAvton University Hospital. On September 23d, Surgeon C. W. Jones, U. S. V., removed the fragments of bone by dilating the opening made by the exit of the ball. The wounds healed rapidly with but slight deformity, aud the patient 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 Museum by the operator, and is numbered 463 of the Surgical Section. He is not a pensioner. Case.—Corporal H. H. Pryor, Co. H, llth Pennsylvania Volunteers, aged 29 years, was wounded at Antietam, September 17th, 1862, by a conoidal ball, which entered the left side of the nose, just above the lower edge of the nasal bone, passed obliquely across through 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 haemorrhage folloAved 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 Hospital, Philadelphia, on December llth, 1862. He stated that one or two small pieces of bone were discharged from the wound of entrance; that the only treat- ment he received was the application of a simple dressing to the Avound, and that at no time did the wound give him much trouble. On his admission into this hospital the Avounds had entirely healed with very slight deformity. He Avas discharged the service January 9th, 1863. The case is reported by Acting Assistant Surgeon John Neill. Pryor is a pensioner. Case.—Sergeant Cyrus C. Holmes, Co. G, 18th Massachusetts Volunteers, was wounded at Bull Run, Virginia, August 29th, 1882, by a conoidal ball, which entered at the symphysis of the lower jaw on the median line, passed downward and backward, and emerged about tAvo inches from the place of entrance, knocking out two of the canine teeth, two bicuspids, and the first molar of the right loAver jaw. He was conveyed to Alexandria, Virginia, and admitted into the 3d division hospital on September 1st, 1862. Loose fragments of the jaAV were removed. He was discharged the service on October 27th, 1862, Avith rigidity and loss of poAver of the muscles of the jaw, caries of the bone, and fistulons ulceration of the glands. The case is reported by Surgeon EdAvin Bentley, U. S. V. Holmes 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, which entered at the posterior edge of the right sterno-cleido mastoid muscle, just below the occiput, and emerged just below the left nostril, fracturing the loAver jaw a little anterior to the ramus of the right side, destroying several teeth, passing through the hard palate, and knocking out two of the front teeth. He Avas sent to Frederick, Maryland, and, on September 24th, 1862, admitted into Hospital No. 1, and, on September 27th, was sent to the Sixteenth and Filbert Streets Hospital at Philadelphia. On his admission, the wounds were suppurating moderately. There Avas no fever, or constitutional irritation. The voice, at first lost, was partially regained. A bandage was applied to the fractured jaAA', and cerate dressings to the wounds; soft and liquid diet was ordered. He Avas discharged the service on December 30th, 1862, doing well in all respects. The case is reported 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 29th, 1862, by a conoidal ball, which entered the right cheek, at the anterior edge of the masseter muscle aud emerged GUNSHOT FRACTURES OF THE FACIAL BONES. 365 at the chin, close to the symphysis, carrying away two inches ofthe body ofthe right inferior maxilla and extensively lacerating the soft parts in the floor of the mouth. He was sent to Alexandria, Virginia, and admitted into the 3d division hospital on September 1st, 1832. Fragments of bone Avere removed from time to time. Slight inflammatory action ensued. He Avas discharged the service on December 1st, 1862, with partial anchylosis of the jaw. The case is reported by Surgeon Edwin Bentley, U. S. A'. Yoder is a pensioner, his disability being rated total and permanent. Case.—Private G. W. Gibson, Co. C, 4th A'ermont Volunteers, Avas wounded during the seven days' battles in June, 1862, by a conoidal ball, Avhich entered the middle third of the inferior maxilla, left side, passed dowmvard and backward, and made its exit at a point over the spine of the left scapula. He Avas admitted into the McKim's Mansion Hospital, Baltimore, July 25th, 1862. Eight small fragments of the inferior maxilla Avere removed from beneath the upper third of the sterno-cleido- mastoid muscle. On September 19th, 1862, the patient AA-as transferred to the AVest's Buildings Hospital, Baltimore, where he was discharged the service on October 9th, 1862, for phthisis. The specimen is No. 413, Sect. II, A. M. M., and was contributed, Avith the history, by Surgeon L. Quick, U. S. V. He is a pensioner; his disability is rated one-half. Case.—Private Ellis Ullom, Co. H, 110th Ohio A'olunteers, aged 31 years, was wounded at Monocacy, Alaryland, July 9th, 1864, by a conoidal musket ball, Avhich entered one inch before the prominence of the left malar bone, passed directly through, and escaped one inch beloAV the ear, fracturing the superior maxillary bone. He was treated in field hospital until August 16th, AA-hen he was sent to the Chester Hospital, Pennsylvania. On admission, his general health was poor, and he suffered severely from pain in the head. Both wounds were discharging healthy pus; pus Avas also discharged from the external auditory meatus. The hearing of the left ear Avas entirely gone. There Avas paralysis of the right arm immediately after the injury, Avhich still continued. Several pieces of bone were removed, and stimulants and nutritious diet administered. By August 26th, the discharge from the wound, pain in the head, and paralysis of the arm had diminished, and he had some poAver over the hand and fingers. He Avas transferred, on September 23d, to Turner's Lane Hospital; on October 1st, to Filbert Street Hospital, and, on March 6th, 1865, Avas returned to Turner's Lane Hospital, where galvanism Avas applied daily. On May 9th, 1865, he was 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 Michigan Volunteers, aged 31 years, was Avounded at Jonesboro', Georgia, September 1st, 1864, by a conoidal ball, which passed through the loAver edge ofthe ramus ofthe inferior maxilla, comminuting the bone and tearing the parts extensively. The tongue lay upon the sternum. He was taken to the hospital of the 2d division, Fourteenth Corps, where Surgeon EdAvard Batewell, 14th Michigan Volunteers, removed the fractured portions of bone, sawed off the ends of the angles, and brought the edges of the wound together by interrupted sutures. At the end of three weeks all had united, except at the lower extremity of the right angle, where the loss of substance had formed a fistulous opening. The surrounding tissues were loosened, an incision about one inch and a half long Avas made through the opening, and the edges that had been pared brought together and retained in position with pins and twisted suture. At the end of six Aveeks, the wounds were perfectly healed, and his general health was not at all impaired. A fibrous tissue appeared to take the place of the bone, and afforded considerable resistance to the upper teeth in mastication; but the tongue seemed to be the chief agent made use of by nature to compensate for the loss of the lower jaw. On October 25th, 1864, he was 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 H. Spear, Co. H, 29th Massachusetts Volunteers, aged 32 years, was wounded before Petersburg, Virginia, July 29th, 1864, by a conoidal ball, which perforated and broke the nasal process of the upper jaAV on the left side, passed obliquely downward, and emerged near the right angle of the mouth, fracturing, in its course, the superior maxilla and hard palate, and base of the lower jaw. He was taken to the hospital of the 1st division, Ninth Corps, Avhere the front of the superior maxilla and a portion of the hard palate Avere excised, and simple dressings applied to the wound. On August 1st, he was admitted to Harewood Hospital, Washington, whence, on October 22d, 1864, he Avas transferred to the Veteran Reserve Corps. In February, 1865, he was furnished with an artificial jaw, at which time the Avound had healed. He is a pensioner. The fissure through the roof of the mouth causes great inconvenience in deglutition; fluids are thrown through the nose. His disability is rated total and permanent. Case.—Corporal Alfred W. Smith, Co. D, 9th Maine Volunteers, aged 29 years, was wounded at Fair Oaks, Virginia, October 27th, 1864, by a conoidal ball, Avhich fractured the inferior maxilla. He was taken to the hospital of the Tenth Corps, where the fractured portion of the bone was removed and simple dressings applied. On October 31st, he was sent to the hospital at Fort Monroe, whence he was furloughed on December 26th, 1864. He Avas discharged from service on October 29th, 1865. He is not a pensioner. Case.—Sergeant Elias Gabriel, Co. B, 24th Iowa Volunteers, aged 24 years, was wounded at Cedar Creek, Virginia, October 19th, 1864, by a conoidal ball, Avhich entered the right side of the face, close to the ala of the nose, passed outward, and emerged on a line Avith, and one inch behind, the lobe of the left ear. He was taken to the hospital of the Nineteenth Corps, where simple dressings Avere applied to the wound. On October 25th, he was transferred to the hospital at York, Pennsylvania. There was a discharge of serous fluid from the left ear, the hearing of which was entirely destroyed. He was unable to close the left eye, but there was some motion in the lids. The Avound of exit had nearly closed. By November 2d, both nostrils Avere discharging, and there was paralysis of the muscles of the left cheek. He Avas transferred to Davenport, Iowa, on December 15th, 1864, and discharged from service on January 5th, 1865. On October 29th, 1869, Pension Examiner W. Wakefield reports that the injured bones are in a diseased condition, and exfoliating, causing pain, discharge from the nose, deafness of the right ear, and paralysis of the right side of the face. 366 WOUNDS AND INJURIES OF THE FACE. Case.__Private AA'illiam McDaniels, Co. F, 5th United States Colored Troops, aged 22 years, was wounded at Deep Bottom, A'irginia, September 29th, 1864, by a musket ball, winch entered anterior to and beloAV the right malar bone, and ranging backAvard, downward, and obliquely to the left side of the face, emerged over the left angle of the inferior maxilla. He was treated in field hospital until October 5th, 1864, when he Avas admitted to the Balfour Hospital, Portsmouth, A'irginia. On October 15th, a fragment of bone Avas removed. Simple dressings were applied to the Avound, and stimulants given internally. He improved slowly and steadily, and, on June 27th, 1865, was transferred to Fort Monroe, whence he Avas mustered out of service on October 14th, 1865. He is a pensioner. The wound healed, leaving quite a large opening into the nares betAveen the roof of the mouth and the soft palate. There is partial anchylosis of the lower jaw. His disability is rated one-half and permanent. Case—Corporal Thomas H. Matthew, Co. I, 198th Pennsylvania Volunteers, aged 26 years, was Avounded before Petersburg, Virginia, March 29th, 1865, by a conoidal ball, which entered below the left ear, and emerged below the left eye, fracturing, in its couise, the condyle and coronoid process 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 April 2d, sent to HareAvood Hospital, AYashington. When admitted, the left side of the head and face Avas very much inflamed, with slight erysipelas in right eye and face; he suffered also from the effects of the shock of the injury and transportation from Petersburg. On April 14th, the zygomatic process of the temporal and fragments of the malar bone Avere removed. By May 19th, the patient had fully recovered, with the exception of a slight anchylosis. He was discharged from service on May 29th, 1865. He is a pensioner. Pension Examiner H. S. Woodruff reports 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 A'olunteers, aged 32 years, was Avounded at Jonesboro', Georgia, September 1st, 1864, by a round ball, Avhich fractured the inferior maxilla, right side. He avhs sent to the hospital of the 1st division, Fourteenth Corps, where simple dressings were applied to the Avound. On October 27th, he Avas transferred to Hospital No. 2, Nashville, Tennessee, whence he Avas discharged from service on February 16th, 1865, on account of anchylosis of the jaw. He is a pensioner. Case.—Private AA'illiam Higginson, Co. B, 131st New York Volunteers, aged 35 years, Avas wounded at Winchester, Arirginia, by a musket ball, Avhich caused a compound comminuted fracture of the left inferior maxilla, and lodged iD the spinous process of the left scapula. He Avas taken to the field hospital of the Nineteenth Corps, where the ball was removed, and simple dressings applied to the Avound. On October 12th, he Avas transferred to the hospital at Frederick, Maryland. Fragments of bone were removed on November 4th. He Avas furloughed on March 13th, 1865, and. on April 5th, Avas admitied to Grant Hospital, AA'illett's Point, New A'ork. On June 2d, he Avas transferred to De Camp Hospital, whence he was discharged from Bervice on June 16th, 1865, on account of loss of half of lower jaw. He is a pensioner. Pension Examiner G. S. Gale reports that the remaining portion of the lower jaw does not match the upper, and mastication is quite imperfect. Case.—PriA-ate Henry Morgan, Co. D, 77th New York Volunteers, aged 24 years, was Avounded before Petersburg, A'irginia, April 2d, 1865, by a conoidal ball, Avhich entered at the left superior maxillary bone, facial surface, passed inward and downward into the mouth, destroying all the upper teeth on the left side. He Avas admitted, on the same day, to the hospital of the 2d division, Sixth Corps; simple dressings Avere applied to the wound. On April 12th, he was transferred to Harewood Hospital, AVashington. When admitted, the right side of the head and face Avere very much inflamed, erysipelas closing both eyes, Avhich disappeared under appropriate treatment, and, on May 1st, the patient was doing well. He was discharged from service on June 8th, 1865. He is a pensioner. Case.—Private Ferdinand Lauersdorf, Co. D, 6th Wisconsin Volunteers, aged 28 years, was wounded in an engagement on the South Side Railroad, near Petersburg, Virginia, March 31st, 1865, by a fragment of shell, which struck the body of the lower jaw, and tore away the entire anterior portion of the bone. He was conveyed to the hospital of the 3d division of the Fifth Corps, and, on April 6th, sent to Campbell Hospital, Washington, whence he Avas discharged from service on July 14th, 1865, on which date a photograph was taken at the Army Medical Museum. The fractured extremities of the jaw had united, and the wound had nearly healed. The movements of the jaw were very limited, but deglutition was but slightly interfered with. He is a pensioner. Cask.—Private John Keil, Co. K, 102d Pennsylvania Volunteers, aged 25 years, was wounded at the AVilderness, Virginia, May 5th, 1864, by a conoidal ball, Avhich entered at the inner canthus of the left eye, passed through under the nose, and lodged in the right antrum of Highmore, penetrating the right superior maxilla, and knocking out the second molar tooth on the right side. He Avas conveyed to Washington, and admitted into the Stanton Hospital on May llth, 1864. On Alay 23d, the AA-ound of entrance had nearly healed; there was a purulent discharge from the right nostril, and a fissure in the anterior part of the superior maxilla, the length of which could not be satisfactorily ascertained. A probe 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 up the flap of the cheek, applied a large trephine over the antrum, removed a button of bone, and extracted the ball, Avhich Avas found lying loose in the antrum. The patient's constitutional condition Avas good. On Alay 24th, he had some fever and swelling of the cheek. On Alay 25th, the SAvelling of the face had increased and was erysipelatous in character. On 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 suppurating; the discharge from the nostril had diminished, and the patient Avas doing well. On August 1st, the wound had not healed; there Avas an opening over where the bone was trephined. Some small pieces of bone were discharged, both from the wound of operation and the nostril. The patient Avas able to cheAV his food Avell. On September 3d, 1864, his term of enlistment having expired, he was discharged the service. The wound of GUNSHOT WOUNDS OF THE FACE AND NECK GUNSHOT FRACTURES OF THE FACIAL BONES. 367 operation had not entirely healed; a small sinus was leading to the antrum, the orifice of which was surrounded by pouting granulations, and a small piece of necrosed bone could be felt at the bottom. The cicatrix was rather large, but there was no other deformity. The specimen is No. 3374, Sect. II, A. M. M., showing the disk of bone removed from the superior maxilla, Avith the battered and flattened ball. The specimen and history were contributed by the operator. On March 8th, 1865, Pension Examiner G. S. McCook reports that the jaw is exfoliating, and rates the patient's disability three-fourths and permanent. CASE.-Private Hugh -F. Creighton, Co. A, 1st New Jersey Volunteers, aged 45 years, was wounded at Spottsylvania, Virginia, May 10th, 1864, by a canister, Avhich carried away all his upper teeth and fractured the lower jaw. He was conveyed to Alexandria, A'irginia, and admitted into the 3d division hospital on May 13th, 1864, and thence, on June 7th, transferred to the MoAver Hospital at Philadelphia. Simple dressings were applied to the Avound. He was discharged on June 29th, 1865. The specimen, No. 2702, Sect. II, A. AI. M., consists of seven fragments of bone from the inferior maxilla, including the coronoid process and the greater part of the ramus. It Avas contributed by Assistant Surgeou J. T. Calhoun, U. S. A. Creighton is a pensioner, his disability being rated total and permanent. Case.—Private George Messenger, Co. K, 114th Pennsylvania Volunteers, aged 34 years, was wounded at Chancellors- ville, Alay 3d, 1863, by a conoidal ball, Avhich entered the right side of the lower jaw, opposite the canine tooth, passed around, and emerged opposite the left canine, fracturing the alveolar process. He was taken to the hospital of the 1st division, Third Corps, and, on May 9th, sent to HareAvood Hospital, AVashington. On May 10th, Surgeon Thomas Antisell, U. S. V., brought the edges of the Avound together by hare-lip suture. He was afterward transferred to the 24th Regiment, Veteran Reserve Corps. On October 19th, 1864, be Avas admitted to Ricord Hospital, Washington, with a view of being operated upon to relieve the deformity Avhich still existed, but his system Avas too low to Avarrant it. The wound had entirely healed. The angle of the mouth at right side was diawn down, and there Avas also great loss of substance. He was returned to duty on May 27th, 1865.' Case.—Private Albert Silsbee, Co. D, 86th New York A'olunteers, aged 18 years, was wounded at Beverly Ford, Virginia, June 9th, 1863. AVhile lying on his left side, his head being toward the enemy, the missile, probably a buckshot, entered just anteriorly to the tragus of the ear, making a wound having an incised appearance, and lodged somewhere near the ramus of the jaAV. He was admitted, on the next day, to Lincoln Hospital, AVashington, where Avater dressings Avere applied. The ball could not be discovered. There Avas no wound of the mouth or fauces, but considerable swelling of the right cheek, with lividity about the right eye; both eyes were slightly injected and felt sore. The patient had no bad symptoms after admission, and, as he was not suffering inconvenience from the ball, operative interference was thought unjustifiable. He Avas transferred, on June 16th, to West's Buildings Hospital, Baltimore, whence he was returned to duty on June 27th, 1863. He is not a pensioner. The history of this case was reported from Lincoln Hospital by Medical Cadet J. N. Hyde, U. S. A., from West's Buildings Hospital by Surgeon T. H. Bacbe, U. S. A. The concealment of the ball under the petrous bone, perhaps, or in the pterygoid fossa, or behind the ramus of the lower jaw, was esteemed very remarkable, and the aspect of the entrance wound was unusual. Surgeon J. H. Brinton, U. S. V., therefore, had a careful draAving made, in color, of the wound, by Hospital Steward Stauch. This is accurately copied in the right-hand or upper figure of the chromo-lithograph. It is unlikely, but not impossible, that the missile fell out before the patient's admission to hospital. Of the cases above enumerated, fifty-seven were fatal. But it will be observed that the abstracts are compiled from the gravest of the reported gunshot wounds of the face, and afford no indication of the average mortality after such injuries. Fcrty-nine of the men mentioned in the abstract are pensioned. It will be noticed that secondary haemor- rhage supervened in seventy-six cases, and that the common carotid was ligated in no less than thirteen cases, five of which had a favorable issue. In thirty-six of the cases, there was removal or secondary exfoliation or extended necrosis of bone. The diversity in the nature of the injuries forbids a rigorous classification; but it would appear that of the whole number, impartially selected, seven were fractures of both the upper and lower jaws. The upper maxilla Avas principally involved in twenty-two cases; the lower in eighty cases; the buccal cavity and tongue in three cases. In twenty-seven cases the destruction of the nasal, lachrymal, turbinate, or malar bones is particularly noted. 368 PLASTIC OPERATIONS. Section III. PLASTIC OPERATIONS. Special reports, were made of the following cases of blepharoplastic, rhinoplastic, and cheiloplastic operations, of staphyloraphy and of complex operations for vicious cicatrices or losses of tissue in various portions of the soft parts of the face. Case.—Private Garrett Rozell, 16th New York Battery, aged 36 years, was wounded in an engagement at Chapin's Farm, ATrginia, September 29th, 1864, by a piece of shell, which tore away the eyebroAV, eyelid, and part of the temporal and malar bones, left side, completely extirpating the left eye, and opening a Avound into the nasal bone one-fourth by one-eighth of an inch in extent, leaving the loose appendages turned inAvard and hanging over the cheek as low as the middle of the nose. lie was sent to the hospital at Fort Monroe, A'irginia, AA'hich he entered on October 2d. He Avas furloughed on December 20th. On February 27th, 1865, he Avas admitted to the hospital at Elmira, New York. The wound had healed, but a fistula existed in the nose. On Alarch 31st, 1865, a plastic operation was performed by Acting Assistant Surgeon A. Merrill, while the patient Avas under the influence of ether. The lid and broAV Avere dissected away from the unnatural adhesions, their old positions as far as possible resumed, the cicatrized surfaces again made raw by a removal of the skin, and seven sutures taken and adhesive straps used to retain the lid in its place. Erysipelas ensued. The parts healed, and on July 21st, 1865, Rozell was discharged from the service and pensioned. Examiner Jolin G. Orton, M. D., reports, July 27th, 1867, that the face is so badly disfigured that he Avill ever be an object of pity, and unable to gain a living, except in seclusion from society. Case.—Sergeant Alexander Miller, Co. A, 2d Ohio Volunteers. Shell wound of face. Fracture of zygoma and inferior maxilla, destruction of eye and laceration of soft parts of face and of arm from shoulder to elbow. Hoover's Gap, Tennessee, June 27th, 1863. Plastic operation to repair the loss of right angle of mouth. Returned to duty December 22d, 1863. Discharged and pensioned. Case.—Private John Oaks, Co. F, 118th Pennsylvania Volunteers, aged 47 years. Fragment of shell struck the superior extremity of nasal bone, lacerated inner canthus of right eye, and destroyed the lachrimal duct. Fredericksburg, Virginia, December 13th, 1862. Transferred to Veteran Reserve Corps. In February 1864, the cornea was dull and dry, OAving to Avant of proper secretion. Paralysis of facial nerve, draAving the mouth upAvard and to the side. Ectropion of lower lid. Plastic operation performed February 25th, 1864. Extirpation of right eye on August 8th, 1864. Discharged April 13, 1865. Not a pensioner. Case.—Corporal Andros Guille, Co. K, 97th Ohio, aged 32 years, was wounded on November 25th, 1863, at the battle of Missionary Ridge, by a fragment of a shell, which carried away the entire nose to the turbinated bones and upper lip, Avith the anterior portion of alveolar process of superior maxilla from the right to the last tAvo molars on left. He also received fracture of metacarpal bone, and contusion of right shoulder from fragments of the same shell. He Avas admitted to No. 8 Hospital, Nashville, on January 28th, 1864. His constitutional condition good. Fissure of face triangular in shape, from apex to where lip should be, tAvo and a half inches in length; at base, from one side of pressure to the other, about three-fourths of an inch. Nasal bones came away, leaving their septum between exterior and posterior foramen. Suppuration nearly ceased. On February 4th, 1864, Surgeon AA'illiam C. Otterson, U. S. V., performed a plastic operation; an H flap from right cheek was turned upon itself and fastened to the opposite surface with two pins and one silver suture, and a band of adhesive plaster from cheek to cheek, as a support. No anaesthetic Avas used. Six days after operation, stitches were removed. Eight days after, erysipelas appeared, which sAvelled the face and parts involved in operation so as to burst the adhesions of the new lip. After rending suture, erysipelas subsided in a feAV days. He Avas discharged on April 23d, 1864. The case is reported by the operator Guille is a pensioner; his disability is rated total and permanent. Case.—Private Frank Hart, Co. E, 4th New York Volunteers, aged 22 years, Avas wounded at Antietam, Maryland, September 17th, 1862, by a fragment of shell, which caused a comminuted fracture of the inferior maxilla, detaching portions of the bone, and carrying aAA-ay the integuments covering the chin, Avith one-half the lower lip. He Avas treated in field hospital until October 3d, Avhen he was sent to the hospital at Chester, Pennsylvania. On admission, the patient presented a horribly disfigured appearance, the whole mass of flesh on the chin being carried aAvay, Avith part of the bones and two Qf the incisor teeth. The cavity Avas filled with lint, and the opposite sides drawn together as much as possible by adhesive strips; still, at PLASTIC OPERATIONS. 369 first, there Avas at least one inch between the edges. By December 20th, the fragments of bone had all been detached. The wound had so Avell filled with granulations that it was but one inch in perpendicular length and one-half inch in breadth. An operation for the relief of the deformity Avas performed, an incision being made perpendicularly through the old cicatrix, down to the inferior edge of the bone, and the edges of the incision and part not filled with granulations pared so as to make a V-shaped space, with the base at the superior part. The old cicatrix Avas then detached from the bone, in order to permit the free edges of the Avound to approach each other, and the parts being approximated, three hare-lip pins Avere introduced and fastened in the ordinary way. The parts Avere kept moist Avith a solution of acetate of lead and laudanum. The sutures were removed on the fourth day, Avhen union, by the first intention, was found to have taken place to the extent of three-quarters of an inch at the upper part where the edges Avere free and the parts vital; but through the old cicatrix the union Avas less perfect, there remaining about one-half an inch ununited; this, hoAvever, soon closed by granulations, and by December 31st only a small opening, about the size of a pea, remained, through Avhich the saliva dribbled. He Avas discharged from service on February 24th, 1863, entirely recovered. Case.—First Lieutenant J. AV. Meeks, jr., 38th NeAV A'ork A'olunteers, aged 31 years, was wounded at the battle of Chancellorsville, A'irginia, Alay 3d, 1863, by a conoidal ball, which entered just behind and above the left external auditory meatus, passed forward, inward, and doAvmvard through the left orbit, fracturing the orbital process of the malar bone, and emerged from the inferior extremity of the nose, fracturing, in its course, the left nasal bone. He was taken to the field hospital, Avhere simple dressings Avere applied. Several spicula? of bone Avere discharged from the Avound of exit. The sense of hearing of the left ear Avas entirely lost from the first. The patient was transferred to his home from the field hospital, and discharged from service on June 2d, 1863, and pensioned. The Avound did Avell, and healed in about eight months, the cicatrix producing ectropion of the lower lid, for Avhich an operation Avas performed in 1867, Avith a good result, though in November, 1868, there was very slight eversion, resulting from loss of bone. The sense of hearing was still entirely lost, and Mr. Meeks stated that he'occasionally detected a slight discharge from the ear. Case.—Private George C. Huntington, Co. H, 142d New York A'olunteers, aged 18 years, was wounded near Richmond, Virginia, October 27th, 1864. by a conoidal ball, which caused a wound of the right cheek. He Avas taken to the Flying Hospital of the Tenth Corps, where Surgeon David McFalls of the same regiment performed an operation. Simple dressings were applied, and he was transferred to Balfour Hospital, Portsmouth, Avhence he was discharged from service on May 27th, 1865. Case.—Alajor Ephraim DaAA'es, 53d Ohio A'olunteers, aged 25 years, Avas Avounded at Dallas, Georgia, on May 25th, 1864, by a conoidal ball, Avhich struck the loAver jaAV on the left side, one inch and a half from the chin, passed through the mouth, and emerged through the right side, comminuting the bone, destroying the lower lip, and wounding the under part of the tongue. He \A-as taken to the field hospital of the Fifteenth Corps, where loose fragments of the alveolar processes, chin, and jaw, Avere removed. On June 3d, he was admitted to the Officers' Hospital, Nashville, and on September 10th, to the Grant Hospital, Cincinnati. The patient's general health Avas good. On September 22d, Professor G. C. Blackmail chloroformed the patient, and performed an operation for restoration ofthe loAA-er lip. Hare-lip and interrupted sutures, Avith transverse adhesive straps, were used, and Avater dressings applied. The patient was discharged on October 25th, 1864, at Avhich time the lower lip was entirely restored; but the fracture remained ununited. On September 16th, 1867, Pension Examiner G. O. Hildreth reported the patient to be able to masticate readily by means of artificial teeth ; but that the injury affected his general health. He rated his disability one-half. The patient, being dissatisfied with this rating, appealed, and, upon another examination, his disability Avas rated as total. Case.—Elbert Ernest, saddler. Co. C, 9th Iowa Cavalry, aged 31 years, being admitted for small-pox into the Small-pox Hospital at St. Louis, was treated there until July 2d, 1S64, Avhen he was admitted into the Marine Hospital in very feeble health, and with a perforation of the right cheek, the orifice being about three-fourths of an inch in circumference. On July 9th, 1864, Surgeon A. Hammer, U. S. V., performed a plastic operation. Wire sutures Avere used, and simple dressings applied. The patient Avas discharged on August 12th, 1864, for " central opacity of both cornea, arising from varioloid, not much improved." The case is reported by the operator. On January 16th, 1868, Pension Examiner W, F. Peck reports that the patient's vision is totally extinct. Case.—Private John H. Felch, Co. L, 2d Massachusetts Cavalry, aged 24 years, was wounded at the battle of Fisher's Hill, Virginia, September 22d, 1864, by a conoidal ball, Avhich carried aAvay the greater portion of the lower lip, half of the lower jaw, and the front incisors. He Avas treated in the National Hospital, Baltimore, and, on October 20th, 1864, was sent to the Harvey Hospital, Aladison, Wisconsin. The remaining portion of the lower lip had firmly adhered to the jaw, anteriorly, and as far laterally on each side as the canine teeth. A fold of mucous membrane projected at each corner of the mouth. An abscess had recently opened under the right body of the jaw, which had healed. The provisional callus thrown out had been partly absorbed, and the inflammatory deposits about the jaw nearly removed. All the contraction of the soft parts that could ensue had taken place, and the saliva continually floAved from the mouth, obliging him to Avear a pad and bandage over it. On January 23d, 1865, 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 doAvnwards, leaving a portion of the remnants of the loAver lip one-fourth of an inch wide, adherent to the jaAV, which was turned doAvn so as to prevent the new lip from contracting adhesions to the jaAV in front. Quadrilateral flaps were then raised from beloAV 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 from either angle. The two flaps Avere approximated in the middle line by four pins and figured ligatures. Triangular spaces at base of jaAV were dressed Avith dry lint. As the angles of the mouth were too rounded, a small V-skaped portion was taken out of each, and the edges of each approximated by a needle and thread. There was no stress on the flaps, and no vessels divided that required taking up. Immediately after the operation, three-fourths of a grain of morphia Avas given, and 47 370 WOUNDS AND INJURIES OF THE FACE. the patient enjoined not to move his face or lip. On January 24th, the flaps having taken Avell, he was ordered to lay on his side, that the discharges might readily Hoav off from the mouth, and the attendants were instructed to remove gently and frequentlv the moisture from and about the flaps. He Avas alloAved chicken broth, and cold water and lint dressings Avere applied. This man Avas discharged on Alay 13th, 1865. and pensioned, his disability being rated total and permanent. The case is reported by the operator. Case.—Corporal Henry Gibbs, Co. K, 67th Ohio A'olunteers, Avas wounded at the battle of AA'inchester, A'irginia, March 23d, 1862, by a musket ball, Avhich entered at one angle of the jaw, passed under the tongue, and emerged at the other, fracturing the loAver jaw at both angles and in its body. He Avas conveyed to the Union Hospital at Winchester, A'irginia, and, on March 27th, Surgeon S. F. Forbes, 67th Ohio Volunteers, made an incision from the angle of the mouth on the right side to the orifice of exit, and removed the whole of the loAver jaAV. A plastic operation was then performed, pins put in, and in four Aveeks the patient had entirely recovered Avithout any apparent 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, Avas Avounded at Cold Harbor, A'irginia, by a fragment of shell, which carried aAvay the loAver incisor teeth, Avith a large portion of the anterior part of the loAver jaAV, and destroyed the Avhole under lip. He also received a severe Avound of the left hand. He Avas treated in the hospitals at Black - Avell's Island, NeAV York, and New Haven, Connecticut, and, on October 16th, he AA-as admitted into the Readville Hotpital, Massachusetts. On November 28th, 1864, Acting Assistant Surgeon Francis C. Ropes dissected up the soft parts from the jaAV, and retained them as high as possible with bandages. Dressings of chloride of soda Avere applied. There Avas a slight sloughy appearance for a feAV clays. Healthy granulations set in, and the Avound healed, Avith some improvement in appearance and comfort of patient. He Avas discharged on January 16th, 1865. The case is reported by the operator. On January 24th, 1*70, Pension Examiner J. AY. ToAvard reports that the saliva constantly dribbles from the patient's mouth. The mouth presents a shocking deformity, AA'hich, in a great measure, excludes him from society. He has had three operations performed on his lip. Case.—Private Donald Gray, Co. E, 38th New York A'olunteers, aged 38 years, Avas wounded at Fredericksburg, A'irginia, December 13th, 1862, by a round musket ball, AA-hich entered just under the right eye, fractured the upper maxilla, not materially separating the fragments, and lodged. On admission to the Satterlee Hospital, Philadelphia, December 23d, 1862, the cheek was greatly SAVollen. On January 3d, 1863, the SAvelling having considerably subsided, the ball AA-as 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 lodgement, discharged freely, and Avas kept open by the introduction of a tent. On the 22d, the Avound had entirely healed. Gray had been wounded once, in the Crimea, in the head, and four times during the late Avar. One of these Avounds had disfigured his nose. The right side Avas slit, at the junction of the ala and septum, for about half an inch, and on the left, a /VsnaPe WOUNDS AND INJURIES OF THE FACE. FiG. 167.—Appe.iraiice cf patient with loss of upper maxilla and soft tissues, irom sloughing, prior to operation. See casts and photographs, A. M. M., No. 4655, Sect. I. chalk, and sixty-five grains of blue pill. Stimulants and nutritious diet were administered. On August 6th, a jagged ulcer was discovered on the right edge of the tongue. On the 10th. a slough appeared on the gum at the root of the right upper bicuspid tooth. The ulcer rapidly extended to the cheek and the roof ofthe mouth; by the 21st, it had neatly 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 Avas 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 maxilla, the vertical plate of the palate bone, and a narroAV strip of"the left maxilla, being quite separated from the healthy bone, Avere removed (FiG. 171). The great loss of substance on the right side of the face caused frightful deformity. The right eye was destroyed and sunken; the right half of the upper lip, the right ala ofthe nose, and the adjacent portion of the cheek, besides the right superior maxillary bone, Avere gone, leaving an exten- sive opening directly into the cavity of the mouth and right nasal fossa. The margin of the opening, Avhich was everywhere cicatrized, Avas constituted below and outAvardly by the border of the loAver lip, which was stretched obliquely upAvard and outAvard, and termi- nated at the malar bone, Avhere the superior maxilla had separated from it and where it was closely adherent. From this point, which corresponded nearly to the middle of the cheek, the margin extended upAvard and Fig. 169.—Artificial roof of mouth, with teeth. (From a photograph furnished by Mr. Gunning.) FiG. 168.—Cap for holding up roof-piece (FiG. 16!). From a photograph from Mr. (iun- inward, in a curved direction, to the side of the nose, approaching within a finger's breadth of the ning). 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 theloAverlip, at its right extremity, appeared to have belonged to the upper lip, and to have assumed its present position, in a continuous line AA'ith the loAver lip, in consequence of the adhesions Avhich had taken place in the cicatriz- ing process. The integu- ment and subjacent tissues Avere supple throughout the margin, up to the line of their adhesion. The Avails of the cavity exposed to vieAv by this opening, presented the folloAA'ing: inward, tOAvard the median line, was the septum nasi, deflected someAvhat toward the left side, incomplete anteriorly and inferiorly, Avhere its cartilaginous portion had been de- stroyed, and Avhere the anterior portion of the inferior turbinated bone, AA'ith 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 Avas lost beloAV in the general cavity of the mouth; the floor of the caA-ity Avas occupied by the tongue. The posterior portion of the bony palate, con- stituted by the palatine process of the palate bone, presented its free anterior j • . • j i ♦ * v i, • Fig 17° — Armearacee of Burgan after the fifth and final edge cicatrized and stretching horizon- ^^ (A\{& photograph, and plaster casts presented by tally across the middle of the cavity Dr. liuok.) Fig. 170.—Nose-pioco devised by Mr. T. T5. Gunning. (From a photograph.) Flo. 171.—Inferior maxilla ex foliated after disease. Spec. .;)57 Sect. I. A. M. M. PLASTIC OPERATIONS. 377 posteriorly. The line of separation betAveen the tAvo superior maxillary bones having taken place a little to the left of the median suture, the left middle incisor tooth had been carried away. The lining membrane of the cavity presented everywhere a remarkably healthy appearance. The palatine process of the palate bone, Avith the velum, having escaped, deglutition was performed without disturbance; his speech, howe\-er, Avas A-ery indistinct, and resembled that of an individual with a bad cleft palate. A puffy condition was observed beloAV the inner half of the loAver 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 2'2d, Burgan Avas discharged from service to go to NeAV York City, entering the Citv Hospital on December 31st, Avhere a plan Avas devised for the restoration of the parts destroyed. Before commencing the operation, dental fixtures, partly temporary, Avere ingeniously constructed by Mr. Thomas B. Gunning, of New York, and fitted to the cavity of the mouth to afford solid support to the soft parts that Avere 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 supplementary. The upper piece filled out the right half of the nose; the loAver piece formed an artificial palate; the third part connected with the palate piece by bent spiral Avire; the patient Avore them two weeks prior to the first operation. On March 26th, ether having been administered, the first operation Avas performed, which consisted, first, in liberating and shaping the left half of the upper lip; second, in supplying 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 neAvly transposed neighboring half of the mouth. Nothing further AA-as attempted at this operation. It occupied at least tAvo hours and a half; much of the time, however, was employed in the readministration of the ether to keep the patient quiet. No adhesive plasters were applied, the sutures being exclusively relied on. AVarm AA-ater dressings Avere directed to the parts. On April 23d, the parts involved in the first operation being free from SAvelling and having regained their suppleness, a second operation Avas performed, the object of which Avas to improve the mouth by extending it tOAvard the right side and converting the circular turn into an angle, which was accomplished while the patient A\-as under the influence of ether. On June 18th, a third operation was performed to close the remaining opening in the cheek and cover the sile of the nose Avith a flap from the forehead, AA'hich 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 nose, resulting from the previous operation, and, on October 27th, another, to remove a furrow and notch in the nose. In June, 1864, Burgan enjoyed good health, and had, for several months, been able to discharge efficiently the duties of an assistant nurse in a large Avard of the New York Hospital. The hypertrophied condition of the nasal patch still persisted, and might be regarded as a permanent condition; quite the reverse of Avhat was anticipated, it had the advantage of main- taining the side of the nose in a plump form. AYhen the patch Avas pricked the sensation was no longer referred to the forehead as at first, but to the parts irritated. The cicatricial bands on the inside of the mouth had been kept from contracting by the persevering efforts of the patient, who had faithfully executed the directions given him on the subject, which Avere to introduce one or two fingers into the mouth and stretch the bands to their utmost endurance, and repeat the process several times daily. The only dental fixture worn by the patient at that time Avas the principal piece, which covered the roof of the mouth and supplied the lost teeth of the right upper maxilla (Fig. 169). It Avas worn constantly with entire comfort, and Avas removed and replaced at pleasure. AA'hen the mouth was open to its fullest extent, the forefinger could be introduced edgeAvise between the front teeth. Mastication of all descriptions of food was performed Avith facility. The speech, which, without the dental fixture, was hardly intelligible, scarcely betrayed any defect Avhen it Avas Avorn. An artificial eye was adapted to the right orbital socket, and was worn by the patient a part of the time. A colored plaster cast of his face Avas prepared previous to the patient's discharge, and, with the pathological specimen, consisting of the greater portion of the right superior maxilla, shoAving necrosis, was contributed to the Army Medical Museum by Assistant Surgeon R. F. AA'eir, U. S. A., and is numbered 557 of the Surgical 378 WOUNDS AND INJURIES OF THE FACE. On February 24th, 1865, he Avas admitted to Carver Hospital, Washington. The Avound was entirely healed when admitted but the cicatrix produced great deformity of the upper lip, interfering with proper articulation. On March 8th, Surgeon 0. A. Judson, U. S. A., decided to operate, and having etherized the patient, made an incision from wound of entrance down- ward through the upper lip and a large portion of the cicatrix. The adhesions that were found beneath were dissected up, and the parts brought in apposition by pinsutures. Simple dressings Avere applied to the Avound. The case progressed favorably, and, by Alarch 22d, the Avound had nearly healed by 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, Philadelphia, whence he Avas discharged from service on June 24th, 1865. On January 3d, 1866, Pension Examiner II. T. Montgomery reports " a large opening from mouth to nose; great permanent deformity of face; voice and mastication impaired." He rates his disability three-fourths, partly by reason of the wound of the foot. Case.—Private Edgar AI. Chaney, Co. A, 32d AA'isconsin A'olunteers, aged 29 years, Avas wounded in an engagement on the Combahee River, South Carolina, February 3d, 1865, by a conoidal ball, Avhich entered over the right malar bone, and, passing 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 upon the bridge of the nose, half an inch from its point. He Avas conveyed to Beaufort, and, on February 6th, admitted to division No. 1 hospital. On February 24th, he Avas transferred to Grant Hospital, NeAV York Harbor, and, on April 17th, to Harvey Hospital, Madison, AATsconsin. When admitted his consitutional condition was good. The right alar cartilage was drawn up belo\A-, so as to stand at the bridge half an inch higher than the septum nasi, while attachment at its base was natural; the left alar cartilage Avas somewhat draAvn up at the apex of the nose; the right loAA'er eyelid, drawn doAvn and outward, was attached to the right malar bone and everted, Avith a large fold of its mucous membrane presenting; and the tarsal cartilage had united by cellular tissue at its middle third. Rest and occasional laxatives having improved the patient's condition, Surgeon H. Culbertson, U. S. Y., decided on performing a plastic operation. On May 2d, 1835, chloroform Avas administered and the nostrils plugged. An incision Avas commenced at the bridge of the nose, and carried to a level Avith the cheek through the right alar cartilage and mucous membrane ofthe nose, and which extended to the point. The cartilage being then depressed to its natural level, another incisionwas 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 by 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 Avere approximated by sutures. An incision, parallel Avith the lower border of the orbit, Avas then made, and the cicatrix removed, and the remaining portion of the lower eyelid brought up to its natural position. A flap was afterAvards raised as deeply as superficial fascia—but broader than shown in the figure—reverted, placed in situ, as seen at 6, and secured by sutures. The edges of the wound at c Avere approximated and secured by sutures, and additional support was furnished by adhesive strips. After the operation, the patient's hands Avere secured to the sides of his bed, a grain of morphine Avas given, lint moistened with sweet-oil Avas applied over the pedicles and margins of the flaps, and 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 flaps healed by granulation, and Avere kept in situ by fine pins. The pedicles were divided on the 21st day, and thrown back into their original beds—i. e., the part of flaps not required. This man Avas mustered out of service on June 8th, 1865. The lower eyelid was nearly natural in appearance; the nose AA-as slightly depressed on the bridge, and the beds from The patient appeared as indicated by the Avood-cut, on Avhich the lines of the Fig. 17.">.—Incisions in a plastic operation on the lower eye-lid and nose. (From a drawing by the operator). AA'hich the flaps Avere taken had nearly healed incision are also traced. Case.—Private A. Gilbert, Co. B, 126th Ohio Arolunteers, aged 24 years, Avas AA-ounded at the Wilderness, May 12th, 1364, by a conoidal ball, which entered the left side of the face at a point corresponding to the body of the malar bone, passed inward and forward, and emerged at symphysis of superior maxilla. He Avas treated in field hospital until May 16th, when he Avas sent to Lincoln Hospital, AA'ashington, where simple dressings were applied. The wound healed rapidly, leaving an opening through the upper lip. On Alay 28th, he was transferred to MoAver Hospital, Philadelphia. On October 5th, Dr. Morton closed the opening in the upper lip by taking a flap of tissue from the left side of the face and making union as for hare- lip. Water dressings were applied. Gilbert Avas discharged from service May 27th, 1865. CASE.-Private William M. Cook, Co. K, 3d Georgia Regiment, received, at Chancellorsville, Alay 3d, 1863, a wound in in the face by a fragment of shell, which extensively mutilated the upper lip and nostrils. He was admitted to Hospital No. 1, Richmond, Virginia, Avhere a plastic operation was performed about six months after the injury. He was furloughed on August 18th, 1663, for sixty days, and afterward returned to duty in his regiment. Case.—Private Robert Spornitz, Co. B, 5th Minnesota Volunteers, waB discharged from service at Fort Ridgely, Minne- sota, on October 24th, 1662, on account of a gunshot Avound through the upper jaw, Avith loss of all the upper teeth, received in a fight with Indians. The operation of staphylorraphy was successfully performed. PLASTIC OPERATIONS. 379 Plastic Operations.—In the foregoing thirty 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 Avas afforded. Dr. Buck's operation (p. 374) must be reckoned among the chief triumphs of modern plastic surgery. The history of Corporal Henry Gibbs (p. 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 Avhich 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 maxillae, 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 seAreral 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 Avas found that the anterior nares had so contracted, from disease, that a closure of the traumatic orifice Avas 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 Rolls, and personal examinations of many patients and pensioners mutilated by gunshot wounds of the face, convinces me that the occasions on which autoplastic operations are likely to be employed advantageously are few in number. Xow 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 deformiti* s 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. Chisholm [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. Prepared by Bvt. I,t. Col. G. A. OTIS; by direction of the Surgeon Genera), AVashington, 1865-1870. Vol. I, p. 32; Vol. II, pp. 29, 30; Vol. III. p. 35; Vol. IV, p. 36. \See Photographs of Surgical Cases, etc., op. cit. Vol. VII, p. 12. 380 WOUNDS AND INJUEIES OF THE FACE. regarding the surgery in the Confederate army only two cases are to be 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 be 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 modular 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 stitched on by interrupted metallic sutures, and covered lightly by carded raAV 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 feAV 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 procedures 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. * It is unnecessary to enlarge on the literature of the subject, unless to indicate to medical officers the principal works accessible in the Library of the Surgeon General's Office, among others the princeps edition in vellum (1597) of Taliacotius, the Venice edition of Tagliacozzi, and several more modern reprints, or translations, of this famous Bolognese surgeon's Avritings and plates, and Dieffenbach's earlier essays: Taliacotius, De curtorum chirurgiaper insitionem, Venet., 1597; FlERUS (of Antwerp), Libri chirurgici, Tract XII, 1612; Paulus AEGINETA, Lib. VI, Cap. 26; FABRIClL'S Hildanus, Observat. chirurg., Cent. Ill, Obs. 31; Sciienkius, De Naribus, Observ. 8; AMBROSE PAREY, translated by TH. JOHNSON, p, 526; FALLOPIUS, De decoratione, Cap. 2; SCHOTTI, Italia illustrata, 1610; BENEDICTUS, De prax. med. Lib. IV, Cap. 39; GOURMELENUS, Chirurgia, Lib. I; LEONARDO Fioravanti, 11 segretti de Chirurgia; Blegny, Zodiacus medico-gallicus, Genevae, 1680; Cei.sls, De re medica., Lib. VII, Cap. IX; Fabricils (ab Aquapendente), Op. Chir., Cap. 61; BLANDIN, Del'autoplastic, Paris, 1836; BUSHNAN, Surgical Observations on the Restoration ofthe Nose, London, 1833; Ammon UND BAUMGARTEN, Die Plastische Chirurgie, Berlin, 1842; FRITZE, Die Plastische Chirurgie, Berlin, 1845 (with 48 engravings); JOBERT, Traite de chirurgie plastique, Paris, 1849; Zeis, Handbuch der plastischen Chirurgie, Berlin, 1838 ; MICHON, Memoire et observations sur quelques cas d'autoplastie de la face, Paris, 1847; SEDILLOT, De Vapplication de la mithode anaplastique, etc., Strasbourg, 1845; Serre, Traite sur Vart de restaurer les diffor mites de la face, Montpellier, 1842; NASEMANN, Questiones de rhinoplastice, Halis, 1849; DROOP, De usu labii superioris in rhinoplastice, Halis, 1844; Labat, De la rhinoplastie, Paris, 1840; DlEFFENBACH, Die Operative Chirurgie, Leipzig, 1845; CARPUE, Account of two successful Operations, etc., London, 1815; GARENGEOT, Traiti des operations de chirurgie, Paris, 1748; 'VA'eiseman, De coalitu partium a reliquo corpore prorsus disjunctiarum, Lipsise, 1824; Blnger, Gelungener Fall einer Nastnbildung, in v. GRAEFE und V. Walther'S Journal, Bd. IV, p. 569; LARREY, Clinique Chirurgicale, Paris, 1829, T. II, p. 12; SlMS, Silver sutures in Surgery, New York, 1858; Skey, Operative Surgery, 2d ed. p. 521; HOLMES, A system of Surgery, Vol. \T, p. 558; C F. V. GRAEFE, Rhinoplastik ; FRICKE, in v. GRAEFE und V. Walther'S Journal, Bd. 22, p. 456; Friedberg, Chirurgische Klinik, Jena, 1855; MALGAIGNE, Med. operat., 1843, p. 421; Erichsen, Science and Art of Surgery, p. 670; Albucasis, Chirurgia, Lib. II, Cap. 13 et 14; THEVENIN, Oeuvres, Chap. 99, 100, Paris, 1659; PLATNER, Institutiones chirurg., Lips. 1745, Par. 580; TEXTOR, Ueber Cheiloplaslilc, Bd. XXI, Heft 5 u. 6, p. 496; CRAMPTON, Essay on entropium, London, 1815; Delpech, Chirurgie clinique, Tom. II, p. 587; Carron du A'illard, Restaurations des paupieres, in Gazette des h&pitaux, 1836; Sanson, Journal universale et hebdomadaire, No. 162 u. 164, Nov. 18~3; Rust, Handbuch der Chirurgie, Bd. IV, p. 575; Chopart, Anaplastie des Uvres, de* joues et de* paupieres, Paris, 1841, p. 60; A'ELPEAU, Lane, franc, gaz. d'Hopit, 13, Aout, 1840; MAISONABE, Clinique sur le* difformiti* dan* Vesp'ece humaine, Paris, 1834, Tom. II, p. 100; BECK, Handbuch der Augenheilkunde, Heidelberg, 1823; DESMARRES, AnnaUs d'Oculist, Oct. 1843; and also the works of Syme, Larcher, Follin, Partridge, Nelaton, Earle, Coote, See, MI'ller, Teele, Pancoast, Prlnce, B. Brown, J. M.Warren, Ollier, Langenbeck, Buchanan, CoorER, Gensoul, Chelius, Dzondy, Jaeger (Vienna), Baum, Lisfranc, Duplytrkn, Roux, Lallemand, Mouleau, Thomain, Hutchinson, Davies, Syme, Tyrrel, Liston, Hoefft, Pirogoff, Dybeck, and Clot-Bey. WOUNDS AND INJURIES OF THE FACE. 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 gunshot,—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. Inferior maxilla........ Superior maxilla....... Both maxillae.......... Maxilla; not stated.:... Malar................. Nasal................. Palate................. Several bones implicated Aggregates... Cases. 1,607 555 157 260 218 93 17 405 3,312 Died. Discharged. Duty. Unknown. 121 779 550 157 42 247 228 38 13 86 46 12 33 96 80 51 14 95 89 20 26 53 14 7 7 3 117 152 101 35 340 1,488 1,154 330 It appears from 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, * Not one hundred and thirty-five, as erroneously printed on page 345, 382 WOUNDS AND INJUBIES OF THE FACE. beside the considerable rate cf mortality in these three thousand cases, a large proportion of those who recovered Avere disabled, and invalided. The lodgement 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 haemorrhages from \Tessels 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 JSinc Hundred and Fourteen Cases of Gunshot Wounds of the Face, without known Fracture. INJURIES. Cases. Died. Duty. V. R. C. Exchanged. Discharged. Deserted. Furloughed. Unknown. Flesh Wounds of the Face... 4,914 58 2,147 156 93 780 187 343 1,150 Of the above 4,914 cases, seventeen were complicated Avith 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 typhoid 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 Thousind Eight Hundred and Fifteen Injuries of the Face from all Causes. Cases. Duty. Discharged. Died. Unknown 64 40 15 2 7 64 37 17 3 7 271 167 83 3 18 4,914 2,396 1,310 58 1,150 1,190 379 679 64 68 3,312 1,154 1,488 340 470 330 9,815 4,173 3,592 1,580 In the eight thousand two hundred and thirty-five cases in which the results were determined, the mortality rate was 5.7. But it was probable that this ratio would be much diminished if the termination of the remaining one thousand five hundred and INJURIES. Sabre and Bayonet wounds........................ Fractures of the bones of the face from various causes Injuries of the face from miscellaneous causes......., Gunshot flesh wounds of the face...............*__ Gunshot wound's of the orbital region............... Gunshot fractures of the bones of the face........... RESULTS of operations. 3S3 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 XLV, 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 mortality of one hundred and eighty-four, or 13 per cent. In his statistics of the Italian Avar of 1859, the same authorj 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 Hundred and Seventy-one Operations after Wounds of the Face. OPERATIONS. Excision of portions of the inferior maxilla. Excision of portions of the superior maxilla. Excision, maxilla not specified............. Excision, malar.......................... Excision, several bones................... Removal of bone......................... Extraction of ball........................ Ligation of common carotid............... Ligation of external carotid............... Ligation of common and external carotid--- Ligation of facial......................... Ligation of lingual....................... Ligation of internal jugular vein .......... Ligation of branch of superior thyroid...... Plastic operations......................... Cases. Died. Discharged. Duty. Unknown. 81 8 58 9 6 13 3 2 1 8 3 4 4 2 3 7 ....... 1 1 7 1 268 16 136 98 18 192 9 92 65 26 52 37 11 3 1 6 2 2 1 1 2 1 1 1 1 5 2 1 1 1 1 80 1 27 1 32 4 1 671 349 186 56 Aggregates................................................' 671 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 History of the British army, which served in the Crimea, during the war against Russia, in the years 1854, 1855, 1850. London, 1858. Vol. II, p. 304. t Rapport au Conseil de Santi des Armeis sur Us Risultats du Service Medico- Chirurgical aux Ambulances de Crimie et aux HSpitaux Militaires Francaisen Turquie pendant la Campagne d'Orient en 1854, 1855, 1856. Par J. C. Chenu, D. M., Medecin Principal, Bibliothecaire de l'ficole Imperiale de Medecine Militaire, Officier de la Legion d'Honneur, etc. Paris: Victor Masson et Fils, 1865. Quarto, p. 145. } Statistique Medico-Chirurgicale de la Campagne d'ltalie en 1859 et 1860. Par le Dr. J. C CHENU, Medecin Principal d'Armee en retraite, etc., etc. Paris: 1869, T. II, 447. 384 WOUNDS AND INJURIES OF THE FACE. 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 balls 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 Avarm fomentations, and a roller bandage. The results were generally unfavorable, the injured tissues, in a few days, sloughing away. Xearly 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 AVilderness, 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 destroyed. 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 riglit 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 opthalmoscope reveals degeneration of the left optic disc. These symptoms are due to a circumscribed 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 (820 per month). Permanent, 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 Avas 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 verified. Baron Larrey1 and Dr. Hennen,2 have sanctioned the belief that the auricle may be nearly torn off, and yet be made to re-unite. Dr. Nathan R. Smith holds the same opinion,3 and describes the proper mode of promoting adhesion by using sutures of the integument on either side, sparing the cartilage, a precept disregarded by Leschevin4 and Verduc,5 but inculcated by the ancients. Pare 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 Avounds. 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,6 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 i D. J. Larrev, Clin. Chir., ed. cit. T. V., p. 61, and Mem. de Chir. Mil. 1817, T. IV, p. 239. 2 John Henxe.v Op. cit. 3d ed. p. 353. '■'' See his SuppUment to a Translation of Saissy's Work on Diseases qf the External Ear. Baltimore, 1829, p. 20C. 1 Leschevtx, Mem. pour les Prix de I'Acad. de Chir. Paris, 1819. T. IV. p. 85. s Verduc. Abrege de la Chir. de Guy de Chauliac. Paris, 1740. * Holmes. Syst.ofSurg. 2d ed. A'ol. IT, p. 420. 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 the 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 Avas 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 lodgement 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 further on the effect on hearing of loss of the auricle, WErFER, Ueber das schwere Gehor, Leipzig, 1794, p. 19; J. F. Meckel, Handbuch der Pathologischen Anatomic, B. I, p. 400, Leipzig, 1812; FRITELLI, Orteschi Giorn. di Med. T. Ill, p. 80; OrsERTELTFER in Stark's Neues Archiv. B. II, p. 638, and Mr. Darwin, Descent of Man, Vol. I, p. 12. Itard, Traite des Maladies de V Oreille, et de VAudition, Paris, 1842. says that " everything combines to show that the auricle is absolutely useless in man ; that the hearing is not altered when it is removed, I have hud occasion to assure myself most positively." Valsalva (De aure humana tractatus, Bologne, 1703) and Haller (Disputationes anatomicse) and Leschevin (Prix de VAcad., T. IV, p. 87) express an opposite opiuion ; but adduce no evidence in support of their assertions. Wilde, On Aural Surgery (Am. ed. 1853, p. 164); Kramer, Handbuch der Ohrenheilkunde, Berlin, 1867; PILCHER, Treatise on the Ear (Am. ed., Phila., 1843, p. 41), say nothing to con- trovert Itard'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 observed case of a sailor, whose external ear was bitten off without any impairment of hearing. Consult further on this subject: Wright, Varieties of Deafness, London, 1829, p. 8 ; Erhard, On Examination of the • Ear with Reference to Soldiers and Medico-Legal Questions, translated from Wien. Wochenschrift, 1864, pp. 730, 761, and Brauchbare Horohre, Berl. Klin. Wochenschrift; THOMSON, A., Edinburgh Jour, of Med. Sci., 1847; Moos, Ueber das Subjective Hb'ren wirklicher musikalischer Tone, Virchow's Archiv., XXXIX, 2, p. 280; Agnew, C. R., Sinus through Mastoid from Old Otitis Media, Transactions of the American Otological Society, Boston, 1870; LUCE, Ueber eine Neue Methode zur Untersuehung des Gchb'rorgans zu Physiologischen and Diagnostichen Zwecken, in Arch, fur Ohrenheil- kunde, III, 2, No. 3, p. 186; Roosa, D. B., in Trans. Am. Otol. Society, Boston, 1870, and Am. Jour. Med. Sci., April, 1871; Pagexstecher, On Trephining the Mastoid Process and Petrous 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 ; Eistaciiius, 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; Triixm-LL, Clinical Manual of Diseases of the Ear, Phila., 1872; A. Berard, Did. de Med. ou Rep. Gin. des Sci. Med. 2™- ed. Paris, 1840, T. XXII, p. 350; Cassebohm, Dissertationes de aure interna, Francfort, 1730 ; Casserius, De vocis auditusque organis historia anatomica, Ferraria, 1600-01; Cotunnius, De aquxductibus auris humanse internse, Neapol., 1760; Troltscii, Diseases of the Ear, their Diagnosis and Treatment, New York, 1864, Gruber, Lehrbuch der Ohrenheilkunde, Wien, 1870; Faxo, Traite ilementaire 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. 49 386 WOUNDS AND INJURIES OF THE FACE. of Surgeon Joseph H. Hildreth, 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, who lost an eye at Gettysburg,^ has observed, with natural interest, the remote effects 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 Avore 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. C, 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, Avith 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 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 at 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 Massa- chusetts, while on furlough, 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 Ravaton1 and Larrey2 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 se\7eral cases of sabre cuts of the nose are enumerated, and illustrations of gunshot wounds of the nose 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 can be learned. But in the recent Prussian- French War, we learn from Dr. L. A7ASLIN's Etudes sur Us Plaies par Armefd'Feu, Paris, 1872, p. 203, et seq., that Dr. Galezow6ki was able to determine the existence of subchoroidean effusions and of lacerations of the choroid by contrecoup. These refinements, like that of detecting a cherry- stone in the oesophagus by percussion, are not of practical utility. \ Being shot through the descending colon and left popliteal space as well, and having, after eight years, a fistula in the lumbar region and false anchylosis of the knee. i Op. cit. p. 175. 2 Clin. Chir. T. 1, 396. Remarkable examples of foreign bodies lodged for many years in the orbit, are recorded by Dr. Galezowski, Traite de Maladies des Yeux, Paris, 1872, p. 815, and by M. De.MAKQUaY, Mem. sur Us Corps elrang. arretis dans V OrbiU, L'Lnion Med. 1859. pp. 82, 123. REVIEW, AVOUNDS OF THE CHEEK. 387 the cartilaginous portion of the nose the parts Avere 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 afford. As has been seen in Section III {ante p. 368). something 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 spong) 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 years. 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 gunshot projectiles, and ugly cicatrices were left; but in the majority of cases the missiles penetrated or perforated the buccal cavity, often implicating the teeth or jaws. Of wounds involving 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 incurable; but I had one case under my immediate care, of an incised wound of the anterior part of the right duct of Steno, in Avhich 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 preserved, 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 Academy of Surgery.J Many instances are reported where wounds of the portio dura ot the seventh pair, or branches of the fifth pair, caused various paralyses or nervous twitch- ings, or tics in the muscles of the face. Several examples will be found in the preceding pages, 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 care- ful observations, made at the military hospital at Christian Street, Philadelphia, illustrate the utility of electric currents in the treatment of such cases, besides affording interesting physiological and clinical studies. * There have been not a few instances of discharged soldiers who have relinquished humble positions under Government, and of officers who have gone into retirement on account of their sensitiveness regarding disfigurements after wounds of the nose, that were ascribed by the ignorant and uncharit- able to combats under the inspiration, not of Mars, but of Venus. tOn wounds of the nose consult Baudexs, Clin, des Plaies d'Armes d Feu, Paris, 1836, p. 173 ; D. J. LARREY, Mem. de Chir. Mil., Paris, 1817 T. TV, pp. 21 and 211; Gahengeot, Traite d'Op., T. Ill, p. 55. Fioraventi, Dioms, Mollinelli, Bridenbach, Louvet, Bartiielkmy, Carlizzi, Blegny, Leyser, and Hoffacker, have reported instances of adhesion after entire detachment of the cartilaginous part of the nose; Gauvin, These de Paris, No. 232, 1865, p. 35; JaMAI.v, Path. Chir., T. I, p. 677; DEXONVILLERS et GOSSELIN, Comp. de Chir. Prat., T. Ill, p. 23. IMimoires de VAcadimie Royale de Chirurgie, Paris, 4l0, 1757, T. Ill, p. 431, et seq.; DurHENix, Moraxd, and Louis, in their several disserta- tions relate many personal observations respecting wounds of the salivary canals, and cite from Pare (Book 10, ch. 26), FabRICIUS OF AQUAl'ENDEXTE (De Vuln. particul.), Mixnicks (Prax. Chirurg., Lib. 2, c. 16), Rooxhuis, Beaupre, Vanherwiel (06s. rar., T. 2), Moroagxi (Advers. Anatom. VI), Regxier de Graaf and Verrheyen, and many others important facts respecting this form of injury. See also LEGOUEST, I. c. p. 382. 38S WOUNDS AND INJURIES OF THE FACE. It is well known that Larrey1 recommended, in accordance with the precepts of Desault,2 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. Chisholm,3 P. A. C. S., sought to generalize this method, and a circular letter was issued by the Confederate Surgeon General, calling for reports on the subject. Surgeon Middleton Michel, P. A. C. S., published4 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,5 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 proportionate fatality than the observations of European surgeons would have lead us to anticipate. Our reports indicated that the patients who escaped the immediate dangers of haemorrhage, either primary or consecutive, had often to undergo such complications as erysipelas and pysemia; while copious and protracted suppurations and the accidents pertaining to the ingestion of decomposed secretions into the digestive organs were other perils to be encountered. Dr. Chisholm (op. cit. 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 Matthews (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 cavities 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 reception of their injuries,—and to indicate how long such wounds may remain unhealed, I will here cite the case of a pensioner of the war of 1812, for which I am indebted to Dr. A. L. Lowell, of the Pension Bureau: Case —Private Noah Austin, of Captain Brown's Co., New York State Militia (Pension Claim No. 1700), was enlisted, August 30th, 1812, and was wounded at Queenstown on October 13th, 1812, and died on September 12th, 1870; the following are copies ofthe various surgical certificates in tlie 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 wound*, 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." 3d, filed October 9th, 1831: "External wound a little above alse 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 affects the health, so as to disqualify from manual labor." 4th, filed September 3d, 1839: " Gunshot wound ofthe head; ball still remains lodged in the head, causing constant i C7ui. Chir., T. II, p. 3. 2Desault, Oeuvres Chirurg., 3d ed. Paris, 1813, T II. s Chisholm, op. cit. * Richmond Med. Jour., 1866, \Tol I, p. 448. 6 Op. cit. p. 385. REVIEW, WOUNDS OF THE UPPER JAAV. 389 discharge from the nostrils. The shot has changed position since 1833. Disability increased." 5th, filed March 26lh, 1850: " Canister shot in left cheek; constant pain and intense headache when stooping, and totally unfitting him for manual labor." 6th, filed September Vith, 1870: "The pensioner died from the effects of a gunshot wound of the head and face. For many vears 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 the 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 lournal, 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, Avho 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 profuse 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 Ridge, 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 186^ and 1870. Dr. Chis- holm (I. 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 adherent, 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 Avound in the face, after a careful adjustment of the movable fragments, should be closed Avith 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 haemorrhage; then to bring the soft parts as nearly in apposition as practicable, connecting them with adhesive straps, and dressing lightly with 390 WOUNDS AND INJURIES OF THE FACE. compresses dipped in cold lotions, and supported by a bandage—such Avas the simple routine commonly observed by the Union surgeons, and with fair results usually, though much deformity was left in many cases, and the proportion of fatal results Avas not incon- siderable. Mr. Blenkins (I. 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. Williamson {op. 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 tediousness of their cure,—ofthe caries and necrosis and " profuse and very foetid suppurative discharge "x that followed such injuries. Matthews, 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 footnote2 is appended his view regarding the treatment of detached bone fragments and teeth. Mr. Matthews cites a case of grave secondary bleeding, in which the application of perchloride of iron proved successful; and Dr. Chisholm 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 painfully conspicuous. In wounds of the upper jaws especially, they increased the inflammatory phenomena, and, moreover, converted the tissues into a blackened mass, in Avhich the relations of parts could not be distinguished, and bleeding vessels could be properly secured by ligature only with the greatest difficulty. Such is my intense aversion to the employ- ment of these styptics that I am not, on this point, an impartial judge, and will prefer to cite a very competent authority, Dr. Garretson :3 "Monsel's solutions, so warmly lauded for their styptic qualities, have exhibited to me more ill results than I have eATer met with from any dozen other articles. If used at all, I think the bleeding points should be alone touched; but of one thing any one using them may be assured: if the application does not control the haemorrhage instantly and permanently, he will have increased his trouble manifold." Wounds of the Lower Jaw.—Guthrie remarks (I. c. p. 525) that these injuries "are perhaps 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 (I. 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 than two thousand cases (see Table XII, p. 381) the ratio of mortality Was nearly equal in the two classes of injuries: 8.1 per cent, for the upper, and 8.3 for the lower maxilla.4 ' See Preparation 2955 of the Netley Museum. 2 " There is, indeed, no great object beyond, perhaps, the present comfort of the patient to be attained in removing either fragments of bone or loosened teeth in the great majority of instances. If they die, they become loose, and are readily lifted away without trouble to the surgeon, and but little pain to the patient. This observation is specially applicable to fractures of the lower jaw. Surgeons in this [the Crimean] war have seen so many cases of badly-fractured instances of this kind unite, and that with a very small amount of deformity, that men of experience are now excessively chary of removing any portion of this bone, unless it has become dead, or the fragment is so situated as to interfere considerably with the adjustment of the remainder, or the bone so much comminuted as to give no probable hope of its becoming consolidated, or so sharply angular as to threaten further injury to the soft parts, or to interfere materially with their adjustment." Op. cit., Vol. II. p. :J05. 3 G ahuetson, James E. A Treatise on the Diseases and Surgery of the Mouth, Jaws, and Associate Parts. Philadelphia, 1869, p. 474. * Dupuytren fell into another error by reasoning deductively, and teaching that on account of the great density and hardness of the inferior maxilla, the resistance opposed by it, a shock to the cerebrum was often produced by the impact of balls, a species of contrecoup, causing cerebral commotion. His disciples, H. Larrey and Legouest, "Jind this an hard doctrine." There is nothing in the records we are examining to sanction it. REVIEAV, WOUNDS OF THE LOWER JAW. 391 In the Confederate armies, some form of inter-dental splint was often employed in ounshot fractures of the lower jaw. An apparatus devised and successfully used in many unpromising cases by Dr. J. B. Bean, a dentist of Atlanta, Georgia, is praised highly by many of the Southern surgeons,1 and forty or more examples of its useful application have been published. According to Dr. Chisholm (I. c. p. 305) the usual method of treat- ing gunshot fractures of the lower jaw was that described in the footnote.2 As Malgaigne has remarked, in treating of fractures of the lower jaw, the '[fixation des dents" 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. Wales, U. S. N., some years ago contrived an apparatus, which, he tells us,3 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 perhaps, 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 performed of portions of body or of the rami. In the base hospitals, complex apparatus of leather, gutta percha, papier mach6, Avere employed, according to the prevailing fashion of the section of country in which the hospital was situated.4 The experiment of wiring the fractured extremities of the maxilla, as proposed and practiced by Baudens, was occasionally employed; but Dr. Bentley and others 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.5 A single additional illustration 1 Covet, Richmond Med. and Surg. Jour. Vol. I, p. 81; BOLTON, p. 318. 2 " The surgeon accompanying the transports usually sends injuries of the face to the field infirmary untouched, or should the lower jaw he broken, applies a folded handkerchief or band under it to support it. This fracture is permanently put up at the field infirmary in a pasteboard splint, well padded with carded cotton, and secured by 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 by pins. Before the dressings are applied the wounds should have been examined carefully with the finger, and all perfectly detached spicula of bone should have been removed. From the excessive vascularity of all the tissues of this region the bones 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 surgeon must be prepared to meet much swelling and profuse salivation. All gunshot injuries to the bones of the face being compound, suppuration is soon established, and the secretion of pus is copious. When the ball has perforated the buccal cavity, causing inflamma- tion and salivation, it will add much to the comfort of the patient if his mouth be swabbed out daily with a piece of soft rag or sponge attached to a thin piece of wood. From the difficulty in swallowing, fluid nourishment must be prescribed. The constant thirst of those wounded will be relieved by small doses of morphine, or by acidulated drinks, made either with diluted nitric acid or vinegar. Injuries about the face are very liable to erysipelatous attack s, which, however, are readily controlled by the free use of the muriated tincture of iron,—thirty drops every three hours often checking the progress of the disease by the end of the first day of treatment." 5 Walbs, Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations. Philadelphia, 1867, p. 384. 4 It would be superfluous to enumerate the different splints, bandages, and complicated dental, inter-dental and submental contrivances that were occasionally employed at the general hospitals in the treatment of fractures of the lower jaw. Barton's aud Gibson's methods of bandaging were frequently employed (E. Wariien, op. cit. p. 364). A few examples are noted of the application of the apparatus of Dr. Garretson (loc. cit. p. 518), of Mr. Nasmyth, and of Dr. Gunning; still fewer of the cork splint of Boycr, and Mutter's silver clasp. Startin's wire splint, Lonsdale's clamp, and Hamilton's apparatus were employed, each in a single case, with satisfactory results. There are indications in the reports thai the medical officers were not ignorant of the methods of dressing devised by Kutenick, Salicet, Jousset, Bush, Hartig and Houselot, Kluge and Malgaigne, but they found the simplest dressings the best for field service. 6 See Photograph 326, Surgical Series, for Dr. Hewit's remarkable specimen of reparation of the body of the inferior maxilla after a gunshot injury nearly destroying the lower jaw, reported on page 356. It was impracticable to get a wood-cut of this interesting preparation in season for the press. Excellent illustrations of united simple fractures of the body and the rami of the lower jaw are afforded by specimens 5146, 5149, 5147 ;—and specimens 5151 and 5148 exhibit the effects of caries and necrosis following injury. 392 WOUNDS AND INJURIES OF THE FACE. may be cited, as it relates to the next subject to be considered. Eecurring secondary haemorrhage, probably from the lingual artery, was unsuccessfully treated by ligating the common carotid. CASE.-Private G. T- -, Co. C, 82d Pennsylvania Volunteers, Fig. 176.—Gunshot fracture of the body of the lower jaw- Spec. 3542, A. M. M. aged 22 years, was wounded at Spottsylvania, Alay 10th, 1864, by a bullet, which entered the left side of the face, one inch anterior to the angle of the inferior maxilla, and comminuting its body, passed through the tongue inferiorly, and escaped two inches posterior to tlie symphysis ofthe right side. He was sent to AVashington, and admitted to Douglas Hospital on the 25th. The tongue was so swollen as to project from the mouth, and render articulation and deglutition almost impossible. The patient was nourished with milk and beef-essence, which were injected into the oesophagus. Secondary haemorrhage, to the extent of twelve ounces, occurred on June 2d, requiring the liga- tion of the left primitive carotid. The internal jugular vein was also tied, having been nicked during the operation. On the 3d, a slight return of haemorrhage to the extent of two ounces took 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 AV. 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 (I. c. p. 116) cites from Bartholin, Mangetus, and Pare 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 and Cox (p. 347), Heiser (p. 349), Kilburn (p. 350), Merchant, Mcllroy, Murray, and Mclnnis (p. 351), Maley (p. 352), Reeves and John R---- (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 preparations in the Army Medical Museum. review, haemorrhages and ligations. 393 f'As;p.__Serjeant Lyman A. P------, Co. V», Sth New A'ork Heavy Artillery, aged 21 years, was wounded ■it Ream's Station, August 2">tli, 1801, by ;i 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 Ream's Station, he was conveyed to the liase Hospital at City Point, and thence was sent to AA'ashington 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 inflamed 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 haemorrhage, supposed 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 alarming 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 was ligated by Acting Assistant Surgeon AV. W. A'alk, the patient being etherized. The ligature was placed a short distance below the bifurcation, and coagula were removed, and the ball, already mentioned, was extracted from near the angle of the jaw. On the 10th, the patient was quiet, with a frequent pulse; on the llth, bleeding recurred, and again on the 12th, but ceased spontaneously. There was diarrhoea and vomiting. On the llth and 15th, the symptoms were regarded by Dr. Sherman as favorable. On the 18th. there were several recurrences of haemorrhage; on the 19th, there was much swelling of the face and neck, when the ligature was removed. The patient died from haemorrhage on the following day. The following 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 was in a suppurating condition; * * the jugular vein was perfectly normal; there was an abscess extending above and below the point of the artery ligated about three-fourths of an inch ; the ligature had come away, and the two extremities of the artery, at the point of ligation, were covered with pus." The wound already adverted to, behind the right ear, was connected with an abscess, which extended down to the angle of the inferior maxilla, and contained a dark- colored foetid pus. The artery from which the haemorrhage came was not detected. The case is reported by Drs. Sherman and Dean, and Suigeon AlrKee, in his quarterly report, gives no further remarks on the case by Dr. A7alk. The pathological specimen, figured in the wood-cut, shows one-third ofthe calibre of the vessel undivided. In the wood-cut (Fig. 177). the ligature on the internal carotid was apparently, as Dr. AVoodhull has remarked, an experiment upon the cadaver. FIG. 177.-Innom- inata, portion of subclavian and three carotids, showing division by ulceration on the tenth day af- ter ligation of the common carotid. Spec. 3252, Sect.I, A. M. M. C.\SE.—Private P. O'C- -, Co. H, 18th U. S. Infantry, was wounded at Chickamauga, September r 20th, 1863, by a conoidal ball, which entered below the left zygomatic arch, passed through to the right side, and made its exit below the angle ofthe inferior maxilla. Secondary haemorrhage occurred from the wound of exit and from the mouth on October 2d, but it was temporarily checked by compresses. October 4th, Surgeon Peter H. Cleary. U. S. X., ligated the external carotid. The patient improved rapidly and appeared perfectly safe, when, on October 12th, haemorrhage recurred; but was again checked by compression. The wounds were nearly healed, but the patient was greatly enfeebled from repeated loss of blood. On October 23d, a profuse haemorrhage set in .from the wound 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, forwarded to the Aluseum by Dr. Moses, U. S. V., is represented in the wood-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. Cask.—Corporal O. P------, Co. H, 91st Pennsylvania Arolunteers, aged 28 years, was admitted to Emory Hospital AVashington, October 31st, 1864, for a gunshot wound of the face, received near South Side Railroad, Virginia, October 27th. A ball had entered the chin at the left side, passed inward and lodged beneath the angle of the inferior maxilla, whence it was extracted through the mouth. The wound was dressed with cold water, and a compress was applied to the jaw. On November 4th, secondary haemorrhage occurred, which was arrested by plugging the wound with sponges. The common carotid artery was tied in the continuity, just above the omo-hyoid, bv Surgeon N. R. Mosely. V. S. X., for recur- ring haemorrhage 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 wet Fio. 17:).-Ob- preparation, showing the extent of this formation, was contributed to the Army Aledical lum^fr^tne"™" Museum by Acting Assistant Surgeon W. H. Coombs, and is represented in the adjoining mary carotid. j x ,t- ,.n, Spec.340:t, Sec. wood-cut (11<;. 179). T A. M_ M. In Table XV, fifty-four cases of ligation of the common carotid after gunshot wounds of the face are accounted for, including two instances in which the external carotid was also tied. Nineteen cases have been recited, with such particulars as were communicated. The remaining thirty-five must be consolidated in a tabular statement. 50 The limited space afforded by the arrangement of the table enables me to add a few particulars respecting some of the cases already briefly referred to. Dr. T. K. Crosby's patient (Ames, p. 332,—misspelled Amos on some of the reports), in 1870, five years after the operation, was, as reported by Drs. W. Craig and C. R. Porter, of Albany, totally disabled by the impairment of vision in the remaining eye. Dr. J. H. Coover's case (Martin, p. 339) was a secondary one, the operation being performed on the fifty-second day; the patient lived thirty-eight days afterward, or ninety days after receiving the wound. Lieut. Maley's was also a secondary case. He was in tolerably good health in August, 1868. The operations in the four remaining cases of recovery were intermediary, having been performed on the 4th, 5th, 6th, and llth days, respectively. Tabular Statement of Thirty-five Ligations of the Common Carotid Artery for Gunshot Injuries of the Face. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 NAME AND MIL. DES. INJURY. LIGATION. Date or Wound. Date of HjEMQRR'AGE. Date of Operation. RESULT. REMARKS. Recovery. Death. Beard, J. J., Lieut., 19th Va. Cavalry. Fuglcson, C, Serg't, 4th Ohio. Higgins, Pat'k, Private, 56th New York. Klingenberg, C, Private, 7th New York Artillerj'. Reed, James, 12th Mass...... R-----, J. R. P., 30th Mass.. Sandy, N.B., Private,3d West Virginia. Siggins, T., Lieut., 49th Mass. Salmon, G. A., Private, 27th Pennsylvania. Watts, W. W., Private, 6th South Carolina Cavalry. • Bacfius, J. W., Private, 12th Georgia. Clark, J., Private, 57th Penn-sylvania. Aug. 13, 1864 Ano-. Q1 iflfid Sept. 4, 1864 June 25,1864, July 1, 1864. May 31, 1862 Operator, Surgeon W. S. Love, P. A. C S. Operator, Surgeon D. W. Bliss, U. S. V. The facial artery was tied on May 12, 1864. Operator, Surgeon Z. E. Bliss, IT. S. V. Dis-ability three-fourths and permanent, January, 1870. Disability seven-eighths and permanent, April, 1867. Operator, Ass't Surgeon R. F. Weir, U. S. A. Operator, Assistant Surgeon Philip Adolphus, U. S. A. Operator, Assistant Surgeon Franris O. Greene, 30th Massachusetts Volunteers. Disability one-half and permanent, March, 1864. G. S. P. of lower jaw, with wound of sublingual artery. G. S. F. of lower jaw___ Conoidal musket ball frac-turing right upper max-illa. G. S. AV. of mouth....... bifurcation. Right common carotid___ Right common carotid___ Common carotid, just above omo-hyoid Right common carotid___ May 12, 1864 May 3, 1862 June 3,1864 Sept. 17,1862 Sept. 17,1862 Aug. 30,1862 May 27,1863 April 2,1865 Oct. 30, 1864 Sept. 4, 1862 Feb. 20, 1865 Nov. 14,1863 May 31,1862 Sept. 25,1862, recurred Nov. 14, 1862. Sept. 28,1862 Right common carotid.... Sept. 6, 1862 June 16,1863 April 10,1865 Sept. 6, 1862 June 16,1863 April 11,1865 Oct. 10, 1862 Sept. 1, 1863 May 18,1865 O. R. F. of upper and lower jaw; sight of one eye destroyed. G. S. F. of inferior maxilla. G. S. W. of face.......... Right common carotid.... Operator, Acting Ass't Surgeon N. A. Robbins. Operator, Ass't Surgeon R. F. Weir, U. S. A. Operator, Acting Ass't Surgeon J. 11. Packard. G. S. W.of left ear....... G. S.W. of inferior maxilla, right side. G. R. F. of upper jaw, right side. G. R. AV. of right side of 1 face. Left common carotid, at lower triangle. Right common carotid, un-der omo-hyoid. Oct. 16,1864 July 9, 1864 Sept. 30,1864 June 19.1864 Oct. 29, 1864 July 19, 1864, recurred Aug. 27,28,29, and 30, 1864. Oct. 29, 1864 July 20, 1864, re-ligated Aug. 30,1864. Oct. 21, 1864 July 4, 1864, re-ligated July 6, 1864. Nov. 2, 1864 Sept. 1, 1864 Oct. 22, 1864 July 6, 1864 July 1, 1864 York. 1 bifurcation. C------, W. R., Private, 61st Alabama. F------, A., Sergeant, Co. D, llth Indiana. Guthrie, W. F., Private, 38th Virginia. Houston, T. C„ Private, 2d Alabama. Hutts, M., Private, C. S. A... Jones, E , Private, 29th Iowa. Jones, J. P., Private, 2d Miss. Jungk, J. G., Serg't, 46th N. Y, Lilly, E.F., Private, 8th Texas Cavalry. McGuire, J. H., Private, 24th Mississippi. Plaskett, J., Private, 120th N. York. Quick, J., Corp'l, 33th N.York. Renwick,A.F., 16th Kentucky Schlicher, J., Corporal, 20th Massachusetts. Sheppard, P., Private, 42d Indiana. S-----, M., Private, 52d Penn- sylvania. Schenok, W., Private, 119th New York. Trabey, H., Private, 5th Penn- sylvania Cavalry. Theilman, H., Private, 15th New York Heavy Artillery. Winter, F., Private, 3d Illinois Cavalry. Ward, P. H., Private, 24th Wisconsin. G. S.W. of left side of face. G. S. W. of lower Jaw. - - G.S.W.of face.......... G. S.F. of right malar bone G. S. W. of lower jaw___ G. S. F. of inferior maxilla, left side. G.S.F. of superior maxilla. G. S. F. of upper jaw..... G.S.W.of face.......... G. S. W. of left mastoid process. G. S.W. of mouth....... G. S. F. of lower jaw, left side. G.S.W.of face.......... G.S. F. of superior maxilla, left side. G. S. F. of right malar and inferior maxilla. G. S. W. of leftside of face. G.S.F. of superior maxilla. G. S. flesh wound of face.. G. S. W. of leftside of face. G. S. F. of upper and lower maxilla. G. S. F. of inferior maxilla. Common carotid. Right common oarotid___ Common carotid. Right common carotid, above omohyoid. Right common carotid. Left common carotid, in superior triangle. Common carotid. Common carotid. Right common carotid, in the inferior triangle. Common carotid, upper third. Common carotid, just be- low bifurcation. Left common carotid, just above omo-hyoid. Left common carotid...... Left common carotid, in lower part of anterior superior triangle. Right common carotid, in the inferior triangle. Left common carotid, just above omo-hyoid. Common carotid. Common carotid. Left common carotid, at crossing of omo-hyoid muscle. Left common carotid, just below bifurcation. Common carotid. Sept. 19,1861 June 34,1864 May 16,1864 April 9, 1865 July 4, 1863 May 3, 1863 Sept. 30,1864 May 9, 1864 Sept. 20,1863 Dec. 13,1862 June 2, 1864 July 1, 1863 Aug. 1, 1864 May 31, 1862 June 15,1864 May 8, 1864 June 19,1864 Aug. 21,1864 Dec. 30,1862 July 8, 1864, recurred July 9, 1864. June 19 and 22, 1864. July 18, 1863, recurred July 20 and 21. June 3, 5, and 7, 1863. Oct. 7, 1864 May 16, 1864, recurred same day. Oct. 10, 1863 Dec. 25,26, and 27, 1862. June 17,18, and 19, 1864. July 8, 1863, recurred July 19, 1863. Aug,29and30, 1864. June 13 and 14, 1862, recurred June 22,1862. July 6, 1864, recurred July 16, 1864. Sept. 4, 1864 Oct. 7, 1864, recurred same day. July R, 1864, re-ligutcd. June 23, 1864 May 7, 1865 June 7, 1863 July 18, 1863 June 7, 1863 Oct. 7, 1864 May 16, 1864 Oct. 10, 1863 Sept. 19,1864 Dec. 27, 1862 June 19, 1864 July 16, 1863 Aug. 30,1864 June 14,1862 July 10, 1864 June 27,1864 July 6, 1864 Sept. 6, 1864 Oct. 8, 1864 July 10, 1864 June 25,1864 May 26, 1865 June 8, 1863 July 26, 1863 June 7, 1863 Oct. 12, 1864 May 16, 1864 Oct. 24, 1863 Oct. 6, 1864 Jan. 6, 1863 June 22,1864 Aug. 26,1863 Aug. 30,1864 June 24,1862 July 20,1864 July 5, 1864 July 12, 1864 Sept. 8, 1864 Jan. 15, 1863 Operator, Surgeon W. S. Love, P. A. C. S. (See Catalogue of the Surg. Sect, of the Army Med. Mus., SPEC Nos. 1635 and 16IS6. Wash- ington, 1866.) Operator, Surgeon A. McMahon, U. S. V. Operator, Acting Ass't Surgeon G. A. Chesley. Operator, Surg. W. B. Reynolds, 2d U. S. S. S. Operator, Acting Ass't Surgeon, H. N. Fisher. Operator, Acting Ass't Surgeon W. AV. Keen. Operator, Surgeon B. B. Breed, U. S. V. Operator, Acting Assistant Surgeon David W. Cheever. (See Cat. of the Surg. Sect, ofthe Army Med. Mus., SPE. 508, AA'ashington, i866.) Operator, Acting Ass't Surgeon D. J. Griffith. Operator, Ass't Surg. Warren AVebster, U. S. A. Operator, Acting Ass't Surgeon O. \AT. Peck. Operator Acting Assistant Surgeon J. Z. Hall. < tn s O so w K > Q CO > 00 396 WOUNDS AND INJURIES OF THE FACE. The results of ligation of the common carotid for gunshot injuries of the face were ascertained in fifty-three of the fifty-four cases reported. There were fifteen recoveries and thirty-eight deaths (or 71.7 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 sixteen cases. In Case 30, reported by Dr. Cheever, the ligature being applied on the fourteenth day after the injury, the patient had recurrent haemorrhages; but survived until the twenty-fourth day (Fig. 180). In the case of R. J. F-----(p. 349), death occurred on the eighth day after the reception of the wound. The specimen is represented in Fig. 180.—Clot in left primary carotid. Spec. 508, Sect. I, A. M. M. the wood-cut, Fig. 181. FIG. 181.—Partial division of the external carotid, near the origin of the internal maxillary. Spec. 2222, Sect. I, A. M. M. Of the fifty-four 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-eight of the fifty-four cases cited, giving an average of eighteen days. The period between the date of operation and the date of death is recorded in thirty-seven of the thirty-eight 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 the common trunk. Four of the six may be regarded as successful, in the sense of recovery from the operation: Bryant, W., Private, 17th Indiana Volunteers. Gunshot wound of inferior maxilla, June 25th, 1863. Haemorrhage occurred July 5th, 1863. Ligation of external carotid, July 5th, 1863. Haemorrhage recurred, and artery re-ligated, July 8th, 1863. Eecovered 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. Hsemorrhage from right external carotid occurred September 22d, 1862. Artery ligated September 22d, 1862. Eecov- ered November 19th, 1862. September 4th, 1865, Pension Examiner Th. A. Eeamy 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. Hsemorrhage 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. Haemorrhage occurred from right external carotid, September ICth, 1862. Artery ligated September 15th. Eecovered October 15th, 1862. In June, 1863, his disability was rated two-thirds and temporary. Nelson, G. W., Private, 12th Georgia Eegiment. Gunshot fracture of zygoma, June 6th, 1864. Hemorrhage occurred from left external carotid, June 6th and 7th. Artery ligated June 7th. Hemorrhage recurred June 19th. Died June 19th, 1^64 Thompson, L. C, Private, 1st Texas Eegiment. Gunshot fracture of right inferior maxilla, December 14th, 1864. Haemorrhage occurred from right external carotid, December 14th, 1864. Artery ligated December 14th, 1864, by Surgeon J. C. Jones, 4th Texas. Eecovered January llth, 1865. REVIEW, HEMORRHAGES AND LIGATIONS. 397 A single instance is noted of ligation of the internal jugular for a wound made in extracting a ball lodged behind the great vessels: Cask.—Private William McDonald. Co. F, 51st New York Volunteers, was wounded at New Berne, March 14th, 1862, bv a musket ball, which entered the lower jaw, one and ahalf 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 llth, 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 loth. At that date, he suffered 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, 1883, the bullet was removed by Surgeon Alexander B. Mott, TJ. 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 surrounding 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, owino- to the above facts it was accidentally wounded. The hsemorrhage, 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 was 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, 1863. Pension Examining Surgeon S. Gale reports, September 30th, 1868, that exfoliation is still progressing; difficulty oi deglutition; left arm paralytic from probable injury of the cervical nerves. I\To 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. Hsemorrhage recurred July 14th, and both lingual arteries were tiel in the wound en masse the same day. The patient recovered. In September, 1835, 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. Haemorrhage occurred from a branch of the superior thyroid, November 7th, 1884. Thyroid ligated November 7th, 1864. Eecovered April 19th, l->65. In June, 1866, his disability was rated one-half aud 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 hsemorrhage. On June 23d, Acting Assistant Surgeon C. C. Ella ligated the right facial artery just below the com- mencement of the ascending palatine, but the case terminated fatally on the same day at ten in the evening. Cask —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 hsemorrhage 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. Bkssel, A. J., Sergeant, 14th Michigan Volunteers. Gunshot fracture of inferior maxilla, light side, July 5th, 1864 Hsemorrhage occuned and facial artery ligated. Discharged January 4th, 1865. McCray, J., Private, 145th Pennsylvania Volunteers. Gunshot wound of lower jaw, May 12th, 1864. Hsemorrhage occurred June 4th, 1864. Facial artery ligated in wound, June 4th, 1864. 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. Eecovered February 19th, 1884. 'Consult, on ligations, Dr. Gordon Buck (N. T. Med. Times, Nov. 18.35). See the important papers of Dr. George NORMS (Am. Jour. Med. Sci., 1847, VoL XIV, p. 13) and the first in the Medico-Chirurgical Transactions (by Mr. ASTLEY COOPER, and read Jan. 29th, 1806) ; M. P. Bkoca, Des anevrysmes, Paris, 1856, p. 505; Dr. James R. WOOD (Ar. Y. Jour, of Med., July, 18.37); N. CHEVERS, Land. Med. Gaz., N. S., Vol. I, p. 1140 ; HORNER, W. L., Amer. Jour. Med. Sci., 1832, Vol. X, p. 403 ; Browx, J. B., Surgeon U. S. A. Am. Jour. Med. Sci., N. S., Vol. XXVIII, p. 415 ; ISAACS, C E., A ■ T. Jour, of Med., Vol. XV., N. S., p. 151 ; see also Blackmax, Western Lancet, Vol. XVI; TWITCHELL, New Eng. Jour. Med. and Surg., October, 1842; Mussey and Cogswell, same Journal, Vols. XI, p. 389, and Vol. XIII, p. 357, 1824; WARREX, J. C, Boston Med. and Surg. Jour., Vol. I, p. 42, lt<28. and Lewis, same Journal, Vol. II, p. 371, li~29. 398 WOUNDS AND INJURIES OF THE FACE. Leaving the ligations, which will be reverted to in connection with operations for injuries of the neck, it may be noted that but few of the cases reported as excisions appear to have been extensive operations; but rather the removal of portions of bone that were partially detached or had perished from necrosis and required slight operative interference for their extraction. Yet there were important exceptions 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 ; but 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 operation of such nicety. Of trephining the antrum to extract balls, a very few cases were reported, and one only (Keil, p. 366) in any detail. An example of a ball splitting on the symphysis of the lower maxilla, after wounding the right common carotid, is illustrated by Fig. no. 182—conoidai ban, 182. An instance of the extraction from the orbit of two pieces of wire split on impact with lower T,AxnM. iipec'4537'Sect' is described and figured in the following case: Case.—Private Simon Flory, Co. F, 1st Pennyslvania Artillery, aged 22 years, was admitted to Turner's Lane Hospital, Philadelphia, on July llth, for a wound of the eye, received at Gettysburg, July 2d, 1863. A piece of iron wire, possibly from a case-shot, had entered the upper and inner part of the right orbit, and lodged. It was at once removed by the regimental surgeon, being broken in two pieces. By December 12th, the wound had healed, but the sight of the eye was destroyed. The above particulars, with the specimen, which is represented in the adjoining cut (Fig. 183) were contributed by Assistant Surgeon C. H. Alden, U. S. A. The man is a pensioner, and his disability was rated one-half in December, 1865, the eye being amaurotic. Examing Surgeon J. J. Crawford, of Williamsport, Lycoming County, Pennsylvania, under date of September llth, 1866, states: " The projectile, a piece of canister wire the shape of a half circle, entered one point above the right eyeball, the other at the inner canthus of the same eye. The supra-orbital nerve was wounded by the upper point, and the violent concussion of the brain Fig. 183.—Iron wire removed injured the optic nerve. The eye is amaurotic." The foreign body was removed by Surgeon M. a.'al'm. P ' F. Price, 1st Pennsylvania Artillery. In the shocking cases in which the greater portion of the lower maxilla was carried away by large projectiles, or where considerable parts of both jaws were destroyed, the mortality was far^ less than might have been anticipated. In many of these instances, ingenious prothetic apparatus was adapted, 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 balls remaining lodged for a long time in the tongue, such as Larrey records. The most important complication of wounds of the face, viz: haemorrhage, will be reverted to in connection with wounds of the neck.* * Consult Holmes, op. cit. Vol. U, p. 183; D5BBELIN, De Uniendis Virlnerum Oris, Halae; WISEMAN, Several Chirurgical Treatitet, London, 1676, p. 361; Ribes, Diet, de* Sci. Mid., Paris, 1818, T. 29, p. 375; Garretson, A Treatise on the Diseases and Surgery of the Mouth, Jaut, and Associated Parts, Phila., 1869; Joudaix, A Treatise on the Diseases and Surgical Operations of the Mouth and Parts Adjacent, Phila., 1851; Mal- gaigne, Traitede*Fractures et des Luxations, Paris, 1874, T. I, p. 378 ; Journ. Gin. de Midecine, T. LXIII, p. 4, and T. LXVI, p. 80 ; Revue Midieale, 1824, T. IV, p. 465 ; Diet, de Midecine, Paris, 1832-1845, T. XIX; Houzelot, These Inaug., Paris, 1827 ; NEUCOKT, 06s. de Fract. de la Machoire Inf.; Journ. de Chir., 1844, p. 359; Desault, Journ. de Chir., T. I, p. 8; Lecat, Remarques sur une Espice Part, de Fract. de la Machoire Inf., SuppU- ment aux Inst. Chir. d' Heister, p. 154; Rossi, Mid. Opirat., T. I, p. 78 ; Vidal, Traite de Path. Ext., Paris, 1861, T. Ill, p. 502 ; FLAJANI, ColUzione osservazioni, etc., Roma, 1802, T. Ill, p. 166; AnnaUs de la Chirurgie, T. VIII, p. 472; MlCHAELIS, Beschreibung, etc., Journal der Chirurgie, vox GRAEFE und Walther, 1823 ; Berard, Gaz. des Hopitaux, 19 Aout, 1841: Bush, London Med. and Phys. Journal, Nov. 1822, p. 401; WALES, A Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations, Phila., 1867; PERCY, 1. c. p. 116; BOYER, 1. c; DELALA1N, Bulletin de VAcad, de Med., Paris, April 15th, 1872. CHAPTER III. WOUNDS AND INJURIES OF 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 complicated, either by lesions of the face, or of the chest, or of the cervical vertebra?, 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 PUNCTURED WOUNDS, AND MISCELLANEOUS INJURIES. 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: Little, J. H., Private, Co. B, 18th Pennsylvania Cavalry, aged 24 years. Flesh wound of left side of neck; sabre. Satterlee Hospital, Philadelphia. Duty, January 23d, 1864. Payton, William, Private, Co. K, 8th Virginia Cavalry, aged 22 years. Sabre wound of left side of neck. Bunker Hill, Virginia, September 3d, 1864. Division No. 1 Hospital, Annapolis, October 9th. Deserted, November 29th, 1864. McIntosh, Davlt>, Sergeant, Co. E, 6th Ohio Cavalry. Sabre wound of back of neck. Cavalry raid in Virginia, May 9th to 15th, 1864. Mooney, Daniel T., Private, Co. H, 2d New Jersey Cavalry. Sabre wound of right side of neck. Newark Hospital, Newark, New Jersey, February 22d, 1864. Discharged April 8th, 1865, for unreducible dislocation of right shoulder. Jacobs, Thomas, Private, Co. I, 1st Potomac Home Brigade. Sabre wound of neck; slight. Monocacy Junction, Maryland, July 9th, 1864. Hospital at Frederick, July 13th, 1864. Transferred to Baltimore, and returned to duty on August 2d, 1864. 400 WOUNDS AND IN.TUKIES OF THE NECK. Bayonet Wounds.—Three slight cases and one that was fatal were reported. In the latter, the great vessels of the neck were perforated: Hassf.tt, B. J., Bugler, Co. F, 121st New York Volunteers, aged 19 years. Bayonet wound of right side of neck; slight. Wilderness, May 5th, 1^64 Washington, Baltimore, and Annapolis hospitals. Returned to duty on August 16th, 18(>4. Moore. James, Corporal, Co. D, 38th Ohio Volunteers, aged 24 years. Bayonet wound of neck, Jonesboro', Ceor"i;i, September 1st, 1864. Nashville, Cincinnati. Mustered out on June 21st, 1865. Dr.STix, Elbridge, Private, Co. B, 9th New Hampshire. Bayonet wound of neck. Jackson, Mississippi, July, 13th 1863. Surprised on picket and brought into hospital dead.* Little, 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. Results of Forty-six Cases of Injuries of the Neck from Miscellaneous Causes. CHARACTER OF INJURY. Cases. Duty. Discharged. Died. Unknown. 5 4 9 2 27 2 1 6 1 16 2 2 1 1 3 1 2 4 5 47 26 8 6 7 Tlie 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 ofthe 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. '1 he 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 pharynx and escape through the wound. He required eight pailfuls, or twenty gallons of water daily. Unavailing attempts were made to anaesthetize him in order to administer nourishment. He died exhausted on April 15th, 1865. Case.—H. W------, jailor, was hanged at Washington, November 10th, 13G5. 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, Tlie 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 fracture 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 pleuritic adhesions; aortic insutficiency, with calcareous deposits; in the abdomen, nothing abnormal. On the right forearm were cicatrices and two small indolent ulcers, 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 apnoca 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 (Fio. 184). Fk;. LH.—Fracture of hyoid hone, from isiiension. Spec. 29H, Sect. I, A. M. M. * See Reports of Surgeon W. A. Webstsr 9th .N'ew Hampshire Vols., and of Xatt Head, Adjutant General of X. H. GUNSHOT WOUNDS OF THE NECK. 401 Suction II. GUNSHOT WOUNDS. Gunshot wounds of the neck may be subdivided into those of the anterior, lateral, or posterior cervical region. The injuries of the anterior region may be 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 Jefferson Barracks, and finally mustered out at the expiration 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 neck. On May 27th, he was admitted to the 1st division hospital, Annapolis, Maryland. The wounds healed, and he was returned to duty on March 1st, 1861 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 protuberance, and emerging 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 Harewood Hospital; on June 18th, to Summit House Hospital, Philadelphia, and, on August 18th, to the Satterlee Hospital. By October 25th, the wound of exit had entirely healed, but reopened on December 25th, discharging freely. On July 18th, 1865, he 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, 1864, 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 applied 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 suffering but little from his wound. He is not a pensioner. Case.—Private J. J Gibson, 17th South Carolina Eegiment, 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. Jl. Brinton, U. S. V., as an excellent illustration of the incised appearance occasionally presented by the entrance wounds of conoidal balls, and a water-colored drawing (No. 11, Surgical Series) was made, by Dr. Brinton'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 INJURIES OF THE NECK. Case.—Private Anthony Speigle, Co. K, 5th United States Cavalry, was wounded at Beverly Ford, Virginia, June 9th, 1803, by a ball, which entered the back of the neck and passed out on the right side some two inches above the clavicle. He was sent to Washington; admitted to Lincoln Hospital on the 10th; transferred to Philadelphia on the 22d, and admitted to the McClellan Hospital on the 23d. By this time, a cicatrix had formed. He was returned to duty cured on August 23d, 1863. Spcigle 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, A'irginia, August 9th, 180'2. 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, on the 13th, to the 3d division hospital, 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 Rest 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 llth, admitted to the hospital of the Tenth Corps, near Hum- phrey's Station. 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 that 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 from 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 cedematous condition. The wounds looked healthy, with the exception of the neck. There was considerable haemorrhage 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 cedematous. 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 ofthe lower teeth, and escaped. Being sent to Washington, the patient was admitted to the Judiciary Scjuare 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 6th, 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 llth, 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 with- out any changes or symptoms worthy of notice. On April 15th, 1861, the patient is reported to be unable to turn his head lively from side to side, in consequence ofthe sterno-cleido-mastoid muscle having lost its function. He was transferred to dutv in the Veteran Reserve Corps, May 3d, 1864. Examining Surgeon J. L. Suesserott, of I hambersburg, Pennsylvania, reported March 9th, l~f>7. that * * * "his right arm is weak and somewhat atrophied." His disability is rated at the Pension Office as one-half and not permanent. >'r. it W\- 1 ifif '■ *«rv t" ^.v ml i ••).>■ i I-.- Kd Siiiuoh |jiii.x' .1 ]li.-i, Clii-..iu«>lnh. WOUNDS OF THE NECK BY CONOIDAL MUSKET BALLS. BALLS LODGED, EXTRACTED, OR DISCHARGED. 403 There were others pensioned on account of wounds of the neck, regarding whom it it was difficult to decide, either 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, by a conoidal ball, 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 freely, 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 great 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 sterno-cleido mastoid muscle, anterior border. He was admitted to Cliffburne Hospital, Washington, June 15th, 1S62. 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, 1803. 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 McRvaine, Co. E, 110th 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 by hsema- 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 Rutan, Co. I, 1st New Jersey Cavalry, aged 20 years, received a gunshot wound of the neck by a conoidal ball, at Salem Creek, Virginia, May 28th, 1864. He was taken to the hospital ofthe 2d division, Cavalry Corps; on June 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 appetite 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. Ralls 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 lodgement 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 hospital; the ball could 404 WOUNDS AND INJURIES OF THE NECK. be felt in seat of lodgement. The patient was so refractory that it could not be cut to in the mouth, where the incision would have been slight. Partial anaesthesia was induced with difficulty. The ball was pressed by the finger, below the right sub- maxillary gland, the forceps had been passed to the ball by way of entrance, but extraction was impracticable. On June llth, he was sent to Mount Pleasant Hospital, Washington, and, on June 16th, to West'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 Beslin, Louisiana, April 9th, 18(53, by a fragment of shell, which struck the posterior surface of the neck. The missile was cut out. In August, 1867. Davis reenlisted in the Veteran 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, 1869. His claim for pension is pending. Case.—Corporal Albion L. Jackson, Co. I, 13th Massachusetts Volunteer;1, 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 suffering 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 26th, 1863, 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, Avhich 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, 1864, 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 was extracted on November 7th. On December llth, he was admitted to Mower Hospital, Philadelphia, whence he was discharged the service on June 7th, 1865. 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 Frederick 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 horn 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, 1862, 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 ball removed by forceps after it had been raised by external manipulation. During the operation a considerable 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, 1863, from apncea. 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 were so much congested and swollen as to preclude the possibility of performing 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 was 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 James A. Hayes, Co. A, 6th Alabama Regiment, aged 18 years, was wounded at South Mountain, September 14th 1862, by a conoidal ball, which entered above the clavicle, and lodged between the scapula and the spinal column, right side. He was, on September 24tb, 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 quantity of pus flowed through the incision made to remove the ball. The patient had one attack of erysipelas On November 29th, he was sent to the Niuth to be exchanged, cured. ' See Report of the Wounded at the BattU of New Berne, American Jlertical Times, July 5, 18l>2. FOREIGN BODIES EXTRACTED. 405 Case.—Private Jeruel Leonard, Co. I, 38th, Indiana Volunteers, aged 21 years, received, at Perryville, October 8th, 18G2. 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 appeared, 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 minutes; profuse sweating and costi veness. On November 5th, the convulsions were less frequent 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 Pith, 1863. The case is reported by Acting Assistant Surgeon A. W. Kayes. Leonard is not a pensioner. Foreign Rodies 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.—Private Garret Lukens, Co. E, 88th Pennsylvania Volunteers, aged 40 years, was wounded at Gettysburg, July 1st, 1863, by a conoidal ball, which entered just below the middle of the sterno-cleido-mastoid muscle, and emerged over the sixth cervical vertebra. He was, on July 7th, admitted to Satterlee Hospital, Philadelphia. Flaxseed poultices were applied to the wound ; tonics, stimulants, and cod-liver oil were administered, and full diet ordered. On August 25th, a piece of blouse was taken from the posterior part ofthe wound. The patient had severe night sweats, and a tendency to anaemia. On October 20th, he had slight tonsilitis. and stiffness of the neck. He was returned to duty March 24th, 181 il. The case is reported by Acting Assistant Surgeon W. J. Grier. Lukens is not a pensioner. Cask.—Sergeant J. R. Geinmel, 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 vertebra, passed upward and inward, and lodged in the superior carotid triangle, immediately external to the trachea. On the reception of the injury the patient fell from his horse, receiving a contusion ofthe left arm. He was, on June 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 llth, 1852. The case is reported by Assistant Surgeon William Thomson, U. S. A. Gemmel is a pensioner. The Examining Surgeon reports 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 subject. 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, Virginia, 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 suffering from a severe hernia. Partial torticollis supervened. He was discharged from service on April 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 missile passed under the trapezius muscle and emerged at the opposite side. He was, on the following day, admitted to the Mansion House Hospital, Baltimore, Maryland. He was returned to duty on November 18th, 1862. 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, 1803, having been wounded the same day by a conoidal ball, which entered the left cheek, passed downward and backward, struck the front of the atlas, and passing forward into the pharynx, was thrown out of the mouth. Simple dressings were applied to the wound. The patient was discharged the service on October 2d, 1863. There was permanent wry neck, and almost perfect deafness. His disability is rated at one-half. Pension Examiner H. A. Buck reports, 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 Volunteers, aged 19 years, was wounded at Roanoke Island, February 8th, 1862, by a musket ball, which entered one inch below the lower jaw, and passed through the neck, just behind the windpipe, emerging at the same point on the opposite side, wounding the larynx and oesophagus in its transit. He was conveyed to the Craven Hospital, New Berne. The patient had severe haemorrhage, which was controlled by pressure. He was transferred to Boston in April, 1862. He recovered, his head drawn to one side, and was discharged the service on August 18th, 1862. He is not a pensioner. * Maximen der Kriegsheilkunst, S. 423. 406 WOUNDS AND INJURIES OF THE NECK. 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 hsemorrhage 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. W. Terry, Co. B, 14th Virginia, was wounded at Spottsylvania, May 10th, 1864, 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 May llth, 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 16th, the Wound of entrance had closed; but, 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 bed 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. Case.—Private Patrick Riley, Co. D, 1st New York Volunteers, aged 21 years, was wounded at Chancellorsville, May 1st, 1863, by a musket ball, which entered on the left side of the neck, passed behind the trachea, near the cricoid cartilage, and in front of the oesophagus, laying open both tubes. He was, on May 12th, admitted to Stanton Hospital, Washington. Enemata, stimulants, and opiates were administered, and beef tea injected by an oesophageal tube. Air and nourishment passed through the wound. The patient had a severe cough, and was restless and constipated. May 24th, vomiting occurred; 28th, emaciated from inanition ; capillary circulation diminished; skin cool and moist; pulse slow and feeble, and the mind wandering. 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, Washington, June 4th, 1802, 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 saliva 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 apncea. Case.—Captain Ferdinand Mueller, Co. B, 9th Ohio Volunteers, was wounded at Chickamauga, Georgia, September 20th, 1833, by a conoidal ball, which entered the base of the neck on the right side, passed transversely and obliquely upward, and emerged beneath and midway between angle and chin of inferior maxilla, involving the trachea, thyroid and cricoid cartilages, WOUNDS OF THE LARYNX AND TRACHEA. 407 and external jugular vein. He also received a wound of the shoulder-joint. He was admitted, on the next day, to the hospital at Chattanooga, Tennessee. There was considerable swelling at first. He did well up to the 25th, when secondary haemorrhage occurred. There was not much loss of blood. On the 26th 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. Chisholm* tells us of similar cases observed in the Southern armies, some requiring the use of a tracheal tube to prevent apncea: Case.—Sergeant Adolphus Mepsen, Co. F, 103d New York Volunteers, was wounded at Suffolk, May 3d, 1863, 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 injury, and lost the power of speech partially. Air made its escape by the wounds. Slight external haemorrhage, 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 Corps. The case is reported by Surgeon T. H. Squires, 89th New York Volunteers. This soldier is not a pensioner. Case.—Private Joseph Pearson, Co. F, 64th niinois 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 Camp Douglas, Blinois. His case is diagnosed as " aphonia from gunshot wound." Simple dressings. Pension Examiner John F. Daggett, reports. October 30, 1807, 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. He was discharged 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, 1863, by a musket ball, which passed laterally through the thyroid cartilage, destroying the upper half and two-thirds of the anterior part, thereby injuring the chordae vocales. He was, on July 9th, admitted to Satterlee Hospital, Philadelphia. Respi- 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 flexed 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. Tlie case is reported by Acting Assistant Surgeon W. W. 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, 1864, 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 oesophagus. 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. Thishyperaesthetic condition ofthe inferior laryngeal nerve seems to depend upon deep cicatricial contraction rather than upon a neuritis, as in the latter case, the length of tune 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, September 19th, 1863, by a conoidal ball, which entered the right shoulder, just behind the acromion, passed inward, injured the cavity of the shoulder-joint, fractured the clavicle badly in its external and middle thirds, produced a comminuted fracture of the nrst rib, passed obliquely upward under the skin, penetrating the neck between the trachea and the oesophagus, and emerged just in front of the left carotid artery, on a level with the pomum 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 Corps, where water dressings were applied, and liquid diet given. Severe inflammation ensued, followed by ulceration over the middle of the first Several instances have occurred in the Confederate campaigns, where the trachea has been perforated by a shot, or the larynx carried away. Such contraction of the air passage and difficulty of breathing follows upon this accident, as to force the patient to wear, permanently, a tracheal tube, to protect him from attacks threatening suffocation. In such cases the voice is reduced to a whisper." Chisholm, op. cit. p. 309. 408 WOUNDS AND INJURIES OF THE NECK. rib and beneath the clavicle. On September 25th, the patient was sent to hospital No. 16, Nashville, and, on October 3d, to hospital No. 1. Pus was discharged for several months, during which time several spiculae of bone came away. On May 12th, 1804, he was transferred to the Corps d'Afrique 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 reports that he examined Shaw while home on furlough in February, 18(54. The external wounds were healed. The ulceration beneath the clavicle discharged large quantities of pus, with an occasional spicula of bone. The whole shoulder was very sore, tender, and immovable, and tlie 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 re-exam- ined this patient in April, 1866. He suffered 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 appeared to be good. Wounds of the Pharynx and (Esophagus.—The gunshot wounds of these regions, that came under treatment in the hospitals, were less numerous than those of the more exposed portion of the anterior region of the neck. Complicated by 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 sympathy zing 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 R. Wiseman, Co. C, 6th 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, Winchester. Simple dressings were applied to the wound. The patient suffocated from internal haemorrhage, and died on September 21st, 1864. Case.—Private Lewis O. 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 cartilage, 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 loth, discharged freely; patient exhausted, laboring 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. The case is reported by Surgeon D. W. Bliss, U. S. V. Pension Examiner H. 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. The missile having entered the right side near the submaxillary triangle, emerged on the opposite side, near the median line, perfo- rating the cricord cartilage and wounding the oesophagus. Cold-water dressings were applied to the wound, and a full diet allowed. For some days after the reception ofthe 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 Pleasant 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, are more the objects of speculative calculation in the closet than the results of actual experience, and can seldom be of any practical utility in the field or hospital." Op. cit. 3d ed., p. 361. PARALYSIS IN GUNSHOT WOUNDS OF THE CERVICAL REGION. 409 Case.—Private Joseph Hollinger, Co. G, 6th Maryland Volunteers, aged 32 years, was wounded at Winchester, Virginia, September 19th. 1804. 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 ot the left shoulder, three inches above the spine 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 ISth, he was transferred to the Mower Hospital, Philadelphia, and, on January 26th, 1805. to Turner's Lane 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 partial paralysis of the arm, with slight atrophy; galvanism was applied daily to the arm. On May 24th, he was transferred to McClellan Hospital. Friction was applied, and the arm rubbed with liniment. He was discharged from service on June 10th, 1805, at which time he had recovered from paralysis. He is not a pensioner. Cask.—Private William Hunter, Co. F, 5th Maryland Volunteers, received, at the battle of Antietam, Maryland, September 17th, 1802. 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 vertebra. He was taken to the hospital of the 3d division, Second Corps. On January 14th, 1863, he was admitted to Carver Hospital and discharged from service on March 30th, 1863. Pension Examiner H. W. Owings reports. January 24th. 1807. 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, 1803. the ball entering below the right jaw and lodging near the vertebra of the neck. He was treated infield hospital until June 24th, 1803. when he was conveyed to Memphis, Tennessee. On July 9th, he was admitted to the Citv Hospital, St. Louis, and transferred to Jefferson Barracks, Missouri, July 24th, 1803, at which time there was partial paralysis of the whole system. He was discharged from service on August 14th, 1803. Pension Examiner William 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 Dearstyne, Co. F, 44th New York Volunteers, received a gunshot wound of the neck at Bull Run, Virginia, August 30th, 1802. 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, aud reporting, at the expiration of his leave, to Ira Harris Hospital, Albany, New York, was discharged from service on November 10th, 1882, 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, May. 1st, 1833, 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 over 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. Cask.—Private John Hartman, Co. E, 15th New York Heavy Artillery, aged 24 years, was wounded on the South Side Railroad, Virginia. April 1st, 1805, by a conoidal ball, which entered just beneath the angle of the left inferior maxilla, passed downward and backward, and emerged over the spinous process 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 House Hospital, Philadelphia, whence he was discharged from service on June 15th, 1885. Pension Examiner W. M. Chamberlain reports, May 2d, 1809, that the brachial plexus was probably injured, as the arm is semi-paralyzed and feeble. Case.—Private G. Bourn, Co. D, 51st North Carolina, aged 31 years, was wounded near Richmond, Virginia, May 10th, 1864, by a conoidal ball, which entered at the top ofthe sternum and emerged at the internal superior portion ofthe left scapula, 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 applied. 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, 1861. 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, by a pistol ball, which entered near the right primitive carotid artery, and emerged near the inferior border of the scapula 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 applied and anodynes giveD. During the night the patient was extremely restless, continually calling for water, 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 feces 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 in 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, 1883, 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 was admitted on the same day. On July 2d, he was transferred to Hammond Hospital, Point Lookout, whence he was returned to duty on June 14th, 1864. On September 3d, 1864. Examining 8urgeon George Stevens Jones stated that a fistulous opening existed, and that his left arm was nearly powerless and useless. 52 410 WOUNDS AND INJURIES OF THE NECK. Case.—Private F. B. Smith, Co. B, 17th Michigan Volunteers, aged 27 years, received, on May 6th, 1^64. a gunshot wound of the upper third of the neck, posteriorly. He was, on May 25th, admitted to Campbell Hospital, Washington. The patient had total paralysis of the right hand, and partial of the left. He died on June 2d, 1804. Case.—Private James Carson, Co. G, 95th Pennsylvania Volunteers, aged 19 years, received, at Spottsylvania, on May Pith. 1804, a gunshot wound ofthe 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 September 5th, a small piece of necrosed bone was removed. He was discharged the service on December 9th, 1*04, 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. 1804, by a conoidal ball, which entered the left side of the neck, one inch anterior to the stemo-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 -26111, admitted to Brown Hospital, Louisville, Kentucky, and thence transferred to Mound 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 llth, 1865. The case is reported by Surgeon 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, Pennsylvania, July 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 ofthe thorax, where it lodged. He was admitted, on October 25th, to Satterlee Hospital, Phila- delphia. 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 mueh enlarged. Case.—Private Frederick Gening, Co. H, 100th New York Volunteers, was admitted to Ira Harris Hospital, Albany, New York, 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. He 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, lilth Blinois Volunteers, aged 35 years, was wounded at Fort McAllister, December 13th. 1804. 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 stemo-cleido-mastoid muscle ofthe right side, wounding, 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, Beaufort, South Carolina, whence he was discharged from service on December 30th, 1864. Pension Examiner W. 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 weeks. The limb was carried at right angles, and sulphate of morphia exhibited hypodermic-ally 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 carry a light cane. lie was discharged from the service on May 6th, 1863. H. W. Sawtelle, M. D., reports, under date of November 20th, 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 pronating and supiuating the limb, a sharp pain is experienced in the thumb and index finger." Mr. Ewer is a clerk in the Treasury Department. He is a pensioner. HEMORRHAGE. 411 Case.—Private J. II. MCullough, Co. F, 59th Alabama Regiment, aged 27 years, was wounded near Richmond, Virginia, Mav 16th, 1864, by a conoidal ball, which passed transversely through the neck from the right side, one and a half inches below the thvroid 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 Robert T. Arnold, Co. A, 4th Georgia Regiment, was wounded on May 8th, 1804, by a conoidal ball, 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 July isth, 1864, for sixty days. On February 25th, 1805, he was admitted into the Jackson Hospital at Richmond, Virginia, whence he was returned to duty on February 28tb, 1805. Case.—Private William L. Switzer, Co. F, 5th Iowa Volunteers, aged 25 years, was wounded at Iuka, September 19th, 1802, by a musket ball, which struck the larynx near its centre, just below the left portion of the lower jaw, passed through it aud emerged at the edge of the sterno-cleido-mastoid muscle, about three inches below the angle of the jaw; another ball struck near the acromion process of the right shoulder in front, passed 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. I. 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 trachea, 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 28th, 1802. 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 AVest A'irginia Volunteers, aged 30 years, received a gunshot wound of the neck at Antietam, 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 ofthe left arm. The Pension Examining Board at Wheeling, A'irginia, 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, 1802. He was admitted to hospital at Benton Barracks, St. Louis, June 29th, 1803, and was discharged the service on October 22d, 1863, for total deafness. His disability is rated one-half. Case.—Private George Peake, 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 hsemorrhage was the prin- cipal feature, the following may be cited: Case.—Major Richard Lanning, 80th Ohio A'olunteers, 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 haemorrhage, on October 3d, 1862. The case is reported by Surgeon E. P. Buell, 80th Ohio Arolunteers. Case.—Private Edward B. Taylor, Co. I, 6th Connecticut Arolunteers, 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. It was decided that to operate upon him would hasten his death on account of hsemorrhage. He died on July 27th, 1863. Case.—Colonel John J. Mudd, 2d Illinois Cavalry, received a gunshot wound of the neck, in June, 1803, by being fired at from 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 parotid 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 haemorrhage 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 AVhitehall, North Carolina, December 16th, 1802, by a conoidal ball, which entered just above the right clavical, and, traversing the neck, passed out immediately below the spinous process 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 tonics, stimulants, and nutritious fluids administered. On December 24th, there was external hsemorrhage to a considerable extent, which recurred on the 28th. It was decided that operative interference could afford no relief. Death resulted in a few hours after the recurrence of the hsemorrhage, on December 28th, 1802. The autopsy revealed a wound of one of. the important branches of the thyroid axis and of the external jugular vein, with sloughing of the neighboring integument. Case.—Sergeant J. W. J. Junks, Co. D, 28th Mississippi Cavalry, was wounded at Franklin, Tennessee, April 10th, 1803. by a conoidal ball, which entered opposite 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. at Franklin on the same day. He lost, in the course of three hours, perhaps two quarts of blood, after which the hremorrhnge ceased. On the second day, he was taken with severe chills, which recurred at the rate of two or three a day, followed by high febrile reaction. Death resulted on April 16th, 1863. 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 pus. Case.—Captain Jarvis N. Lake, Co. B, 93d Ohio A'olunteers, aged 31 years, was wounded at Missionary Ridge, November 23d, 1863, by a musket ball, which entered the right side of the neck, on a level with the pomum Adami, passed between the jugular vein and carotid artery in a direction downward and backward, and emerged one inch and a half below and one inch to the right ofthe 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 applied to the wound, and restoratives administered. He was transferred to Nashville on December 22d. Pension Exam- iner E. Mendenhall states, on January 4th, 1864, that "the patient's wounds are healed, but the side of the neck, the entire 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 patient could use his forearm and hand; some of the muscles of the shoulder were atrophied. His general health was good. Cask.—Private Joseph Step, Co. I, 40th Georgia Volunteers, 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 humerus. He was admitted to Institute Hospital, Atlanta, where amputation at the upper third of the left arm was performed. The patient was weak from loss of blood; there was considerable constitutional disturbance. Secondary haemorrhage occurred from the wTounds 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, by 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 haemorrhage from the common carotid artefy ocourred on July llth, 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 scapula over the spinal column. He was, on May llth, admitted to Armory Square Hospital, Washington. Stimulants were administered, and generous diet ordered. The patient had frequent chills, and all the symptoms of pyaemia, and was very much exhausted. Secondary haemorrhage, which was slight, occurred on June 3d, from an ulceration of the external jugular vein. He died on June 3d, 1864. The case is reported by Surgeon D. W. Bliss, U. S. Ar. Case.—Private Alonzo Hoyt, Co. 1,14th Michigan Volunteers, was admitted from the field into hospital No. 1, Nashville, on January 4th, 1883, for a gunshot wound of the neck, received at the battle of Murfreesboro', on the 3d. The missile had passed 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 llth, secondary haemorrhage 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 freely 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 explanation 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 Charles Guttery, Co. D, 140th Pennsylvania Volunteers, aged 18 years, received, at Spottsylvania, May 12th, 1864, a gunshot wound of the upper and posterior part of the neck. He was, on May 15th, admitted to Lincoln Hospital, Washington, and, on the 18th, transferred to Pennsylvania, where he was admitted into the York Hospital, May 21st. Simple dressings were applied to the Avounds. Erysipelas set in, which covered the entire face and seal]). On June 13th, he was trans- ferred to the Pittsburg Hospital, whence he was returned to duty on September 22d, 1804. '■' "It i- remarkable that the large arteries and veins in the neck should escape injury so frequently in gunshot wounds. This may, in isome me.;.»uie. be accounted for by the structures in this region being so loose and movable that they yield or recede before any pro.j'.M tile." Williamson, Op. cit. p. 72. SLOUGHING AND GANGRENE, AND PYEMIA. 413 Case.—Private John II. Betts, Co. IT, 120th New A'ork Volunteers, was wounded at Gettysburg, July 2d, 1863, by a musket ball, which entered at a point over the scalenus medius 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 5tl\ admitted to Satterlee Hospital, Philadelphia. On admission, the parts were erysipelatous, and the patient had some difficulty of swallowing. He stated that after the reception 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 freely, 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 from a rigidity of the anterior muscles of the neck. He was returned to duty on September 23d, 1863. 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 405. 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: Case.—Private John McCafferty, Co. I, 114th Pennsylvania Arolunteers, aged 23 years, received a gunshot flesh wound of the right side of the neck by a conoidal ball, at Gettysburg, July 2d, 1803. He was taken to the hospital of the 1st division, Third Corps, and on July 7th, sent to Mower Hospital, Philadelphia. AVhen admitted the wound was unhealthy and painful, with a tendency to slough. Cold-water dressings were applied to the wound, with stimulants internally. By Jr.ly 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 22d, 1863, at which time the wound had entirely healed. He is not a pensioner. Case.—Private Frank Eastman, Co. D, Cth New Hampshire Volunteers, aged 18 years, was wounded before Petersburg, Virginia, April 2d, 1865, by a frag- 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 hospital, and, on the 4th, transferred, per steamer Cosmopolitan, to AA'ashington, 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 healthy pus and granulating finely. On May 15th, he was transferred to AVebster 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. There 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. 185), a reduced copy of an excellent photograph. FIG. 185.—Sloughing shell-wound of neck. Phot, of Surg. Cases, A. M. M., Vol. I, p. 21. Ryavnia.—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 Arolunteers, aged 31 years, was wounded at Chancellorsville, May 3d, 1863, by a musket ball, which grazed the ramus 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, AVashington. Cold water dressings were applied to the wound; stimulants were administered, and generous diet ordered. On May llth, the patient had 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 frequent; slight venous hsemorrhage. The patient died on May 23d, 1863. The post mortem examination revealed an abscess like an egg, in the spleen, 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. Case.—Sergeant John Parker, Co. G, 39th, New York Volunteers, aged 30 years, received, at Ream's Station, August 25th, 1864, a gunshot wound of the neck. The missile, a conoidal ball, entered over the sterno-cleido-mastoid muscle, on a line with the inferior edge of the thyroid cartilage and lodged, fracturing the first rib. He was conveyed to the hospital of the 1st 414 AVOUNDS AND INJURIES OF THE NECK. division, Second Corps, and transferred to Washington, 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 sanguineus liquor fro/n the wound, which was arrested by compression and bandages. The patient was pale and anaemic; on September 2d, had chills; sallow look; the surface ofthe body covered with a profuse perspiration. Pyaemia supervened, and the patient died on September 13th, 1864. 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, Phil- adelphia. 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. Many cases are included of grave injuries that never came under treatment: Table XVII. Table of Four Thousand Fight Hundred and Ninety-five Cases of Gunshot Wounds of the Neck without Known Injury to the Cervical Vertebra3. CHARACTER OF WOUND. Gunshot Wounds of the Gunshot AATounds of the Gunshot Wounds of the Gunshot Wounds of the Gunshot Wounds of the Gunshot AATounds of the Gunshot Wounds of the Guoshot AA'ounds of the Gunshot AVounds of the Gunshot \ATounds of the Gunshot AVounds of the Neck................................. Neck, injuring Trachea................. Neck, injuring Larynx................. Neck, injuring Pharynx................ Neck, injuring Oesophagus.............. Neck, injuring Trachea and Larynx..... Neck, injuring Trachea and Pharynx___ Neck, injuring Trachea and Oesophagus.. Neck, injuring Larynx and Oesophagus-. Neck, injuring Pharynx and Oesophagus Neck, injuring Pharynx and Larynx____ Cases. 4739 41 30 13 10 4 2 2 1 1 2 Died. 570 21 10 7 6 Discharged. 1056 11 8 2 2 1 2 Duty. 2394 769 1 10 1 Aggregates................................................ 4895 618 1083 2413 781 OPERATIONS 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 Avas 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 Neck. CHARACTER. Ligations........... Tracheotomy........ Laryngotomy....... Excision of Tonsils.. Removal of Balls...- Aggregates Cases. Died. 29 22 14 8 6 5 2 87 12 138 47 Discharged. 2 4 1 2 36 Duty. 29 10 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 beep 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 haemorrhage 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 days air had escaped from the wound at each expiration, but now it had entirely ceased. The wound (supposed to have been made by a buckshot) is located over the centre of the left plate 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 soon 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 oedema 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 perform tracheotomy. The instruments selected for the operation not being at hand, they were kindly furnished by a distinguished Burgeon of Baltimore. A straight incision, commencing over the cricoid cartilage, 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 infiltrated with air, fibrin, and bloody serum, as indeed were all the tissues. Carefully dissecting 416 WOUNDS AND INJURIES OF THE NECK. the parts on a grooved director, the lower edge of the cricoid cartilage and the upper ring of the trachea were finally reached. A grooved tenaculum was hooked through the trachea just below the cricoid cartilage, and held firm by tlie hands of an assistant, with the handle resting on the patient's chin. A narrow, sharp-pointed knife, guided by the groove of the tenaculum, was then inserted to jierforate the trachea, which, owing to its unusual and great thickness caused considerable impediment to the first attempt. The length of the blade passed out of sight without accomplishing the object, and the patient uttered a complaint of too much pressure. The tenaculum was still steadily held while further dissections and slight enlargement of the bottom of the incision were made. The second attempt proved less difficult, and was immediately followed by the escape of bubbles of air. The fresh wound was thoroughly cleansed, and through the opening a blunt-pointed narrow knife was passed and carried down- ward and fonvard until at least three rings of the trachea had been divided. Aery little blood escaped into the trachea, and one or two explosive efforts cleared it of these small clots and a quantity of tough mucus, and the patient breathed easily through the new opening. The operation was completed by introducing a large-sized Dessault's tube, which was properly retained in position in the usual manner. No ligatures were required, and the amount of blood lost was insignificant. The relief experienced by the patient was instantaneous, and a change for the better in all his alarming symptoms was immediately noticed. His pulse fell to 96, and he was soon enjoying a pleasant sleep. July 6th. The patient's condition is much improved, the swelling is subsiding, and the wounds look healthy. The treatment consists in keeping the patient quiet, giving him flaxseed tea to drink, and fluid nourishment. July 9th. The patient continues to improve, and as the swelling of the neck has entirely disappeared, the tube was removed and left out. He was watched closely, and on the following day he commenced breathing freely through the natural passages. July 18th. The wounds have almost healed, the patient walks about, and his voice is as strong as ever. Being anxious to return to his home, he was discharged cured. The operation performed in this case is the one recommended by M. Chassaignac. The steps of the operation were not familiar to me, and I am indebted to Dr. Christopher Johnson, of Baltimore, for its adoption. I consider it preferable to an}-1 have witnessed, and should judge it was particularly applicable in children, where it is all important to retain the larynx and trachea under perfect control during their struggles. The operation was conjointly performed by Dr. Johnson and myself, and I have been truly pleased with the result. [The case is reported by the operator, Assistant Surgeon De AVitt C, Peters, U. S. A. On April 7th, 1864, Pension Examiner H. P. Moody stated that the wound had seriously affected the air passages and might lead to confirmed tuberculosis. There appears to be no later records of this patient at the Pension Office.] Case.—Private John H. Murphy, Co. D, 30th Illinois Arolunteers, was wounded at Black River Bridge, May 3d, 1863, by a musket ball, which entered the superior portion of the larynx, passed downward, backward, and outward through the superior angle of the left scapula, injuring the sheath of the carotid artery. On May 4th, he was admitted to Mary Anne Hospital, Mississippi, almost moribund; had dyspnoea, and great difficulty of deglutition. Cold water dressings were applied to the wound. On May 6th, Acting Assistant Surgeon C. B. Miller performed the operation of laryngo-tracheotomy. The patient died on May 6th, 1863. The post-mortem examination revealed great extravasation of blood upon the pneumogastric nerve, which was purple, and within the sheath of the carotid artery. The case is reported by the operator. Case.—Private Lysander Martin, independent company, Andrew's Massachusetts Sharpshooters, aged 28 years, was wounded at Fredericksburg, June 10th, 1863, by a conoidal ball, which entered the neck three-fourths of an inch under the left ear, passed through the root of the tongue, and emerged through the middle of the right cheek. On June 14th, he was admitted to Hammond Hospital, Maryland, suffering much from pharyngitis, difficulty of deglutition, and very distressing dyspnoea. Cold water dressings were applied to the wound, and liquid diet administered by means of the stomach pump. On June 19th, Acting Assistant Surgeon T. Liebold performed tracheotomy, and a large quantity of sanguino-purulent matter escaped from the trachea. The immediate relief in breathing was great, but it became soon evident that he could not survive. ' The patient died on June 19th, 1863. The post-mortem examination revealed the pharynx considerably lacerated, epiglottis swollen, and the' trachea and bronchia lined with a thick false membrane. The bases of the lungs, gorged with blood, presented an appearance as in red hepatization, and had a few small abscesses in them. The case is reported by the operator. Case.—Private John Durham, Co. K, 21st New York Cavalry, was admitted to the field hospital at Sandy Hook, Maryland, on July 27th, 1804, having received, two days previously, at the battle of AVinchester, Arirginia, a gunshot wound, fracturing the neck and perforating the trachea. The soft parts were lacerated, and there was extreme difficulty in breathing; constitutional condition fair. On the day of his admission to hospital, tracheotomy was performed by Assistant Surgeon J. S. Taylor, 23d Illinois Infantry. Subsequent treatment was restorative. The patient died on July 30th. CASE.-Private P. C. Young, Co. I, 3d Alassachusetts Cavalry, aged 34 years, was admitted to hospital at Readville, Massachusetts, January 2d, 1865, having received, at Cedar Creek, Virginia, October 19th, 18(54, a gunshot wound of the neck, causing aphonia and dyspncea. A laryngoscopy examination showed great swelling of the superior opening of the glottis, the apparent cause of marked dyspncea. Difficulty of breathing gradually increased to such an extent, notwithstanding frequent applications of nitrate of silver to the glottis, as to render an operation imperative. On January 5th, the patient was etherized and tracheotomy performed by Acting Assistant Surgeon S. AV. 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 aphnoea from difficult respiration. The operation was followed by instant relief of the dyspncea, and rapid recovery of health and strength The wound healed kindly under the application of tepid water dressings. On March 26th, the original tube was removed and a double fenestrated canula substituted. A laryngoscopy examination showed great swelling and depression of the epiglottis, effectually preventing observation of the parts below. Direct application of glycerine and tannin solution by aid of the laryngoscope resulted in restoring the epiglottis to its normal size and position by March 30th, and the patient was able to articulate distinctly a few words. He still wore the tube. On July 6th, 18(35, this man was transferred to Dale Hospital. His name is not on the Pension List, OPERATIONS ON THE AIR-PASSAGES. 417 fASK.—Private W. J. Hindles, Co. II. 6th North Carolina Regiment, aged 30 years, received a gunshot wound at AVin- chester, A'irginia, September 19th, 1804, 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. he had become anaemic from repeated hsemorrhage. The entire neck in front was distended from diffused clot. Surgeon A. Atkinson, U. S. Ar., performed tracheotomv on occurrence of asphyxia 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 haemorrhage. 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 vertebra? were found fractured, and the vertebral artery severed. Rronchotomy for Disease.—Six cases of laryngotomy or laryngo-tracheotomy, and eight of tracheotomy for non-traumatic causes wore reported. Of the fourteen cases, one of laryngotomy and four of tracheotomy were successful. In six of these cases, the operation Avas performed on account otcedema of the glottis: Case.—Private Samuel Frosh, Co. F, 1st Regiment Potomac Home Brigade, aged 21 years, was admitted to Hospital No. 1, Frederick, Alaryland, March 21th, 1804, 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 verv 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 cusbionv. 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. Oedema of the glottis was diagnosed. The treatment consisted of incisions, which were thoroughly made, and the application, externally, of tinctire of iodine, with inhalation of vapor from warm water. The incisions gave him great relief. At three o'clock a. ji , on the 13th, he had an alarming attack of dyspnoea. The incisions were continued, aud the epiglottis and arytaeno-epiglottidean folds scarified. At two o'clock P. m., it was decided to operate. Assistant Surgeon R, F. AVeir, U. 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 Alay 3d, he was returned to duty; the tube was no longer worn ; the granulating surface at the site ofthe incision was very nearly healed; otherwise, he was perfectly well. He visited the hospital on June 9th, 1831, 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 26 years, was admitted to Douglas Hospital, Washington, April 7th, 1835. suffering 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 pharynx was found to be a little reddened, and covered with an abundance of tenacious mucus At about 2.30 v. M\, on the 25th, he was suddenly seized with great dyspncea; respiration stertorous, countenance livid, and lips blue. There was complete orthopnoea, 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 AA'illiam 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 haemorrhage. 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 mucous 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. Alay 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, larynx, and heart removed together. The larynx was pale. The epiglottis, with the edges and upper portion of the glottis, was swollen and cedematous, 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, outsile of the larynx, and 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. AI. AI.. and was contributed, with a history of the case, by Assistant Surgeon William F. Norris, U. S. A. Case.—Private William H. Schlosser, Co. F, 140th Indiana Arolunteers, aged 43 year-:, was admitted to Douglas Hospital, Washington, February 3d, 1865, with slight bronchitis, which improved up to February 12th, when he was attacked witrrsore throat and inflammation of the glands of the neck. The symptoms were not severe until the 17th, when great dyspnoea suddenly Bet in. The cedematous epiglottis, which was seen and felt, was immediately scarified, with some relief, which, however, was only temporary, and in the nfterno:>n the operation of laryngotomv was decided upon, which was performed bv Assistant 53 418 WOUNDS AND INJURIES OF THE NECK. Surgeon William F. Norris, U. S. A. The patient died at the close of the operation from apncea. At the necropsv the chink ofthe glottis was found almost closed by oedema of the tissues surrounding it. The epiglottis was also cedematous. 1 he 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 AAllliam Carpenter, Co. B, 1st Wisconsin Heavy Artillery, aged 20 years, was admitted to Harvey Hospital, Madison, Wisconsin, October 10th, 1864, with an abscess near the larynx. On December 25th, Surgeon H. Culbertson, U. S. A\, performed tracheotomy for suffocation 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 flowed 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 haemorrhage, and a tube introduced. He died on December 25th, 1864, 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 the 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 nearly 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 having 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 greatly 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 I'ebruary 10th, 1865. There Avere three operations for diphtheria, a successful instance of laryngotomy, and tAvo of tracheotomy that terminated unfavorably: Case.—Private S. G. Inlay, Co. K, 180th Ohio Infantry, aged 30 years, was admitted to the 3d division hospital, Alexandria, 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 June llth, 1865. Case.—Sergeant James AV. Sutherland, Co. D, 1st Maine Volunteers, aged 24 years, received a gunshot wound ofthe right thigh, at Cedar Creek, Alrginia, 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 spliut, a large amount of provisional callus being deposited. From this time he did well, and improved rapidly under the use of tonics, stimulants, and good diet; but there were several sinuses which communi- cated externally, and were still discharging a considerable amount of pus. On the morning of May 24th, 1865, he complained of some soreness of the throat, but symptoms of diphtheria were not specially marked, there being no" traces of membrane whatever. About 10 o'clock P. M., the same day, the nurse was awakened by the groans and efforts of the patient to breathe. AA'hen medical attendance, which was close at hand, reached him, he was breathing stertorously; his tonsils were so much swollen as to nearly close the glottis and fauces, and the posterior nares were covered with diphtheritic membrane. Measures were at once resorted to for his relief, but without effect. About 12 o'clock p m., an operation was deemed necessary, and tracheotomy was performed by Acting Assistant Surgeon F. P. Foster, which seemed to give relief for a time; but he soon relapsed and gradually grew worse, until death, which occurred about 4 o'clock a. m., May 25th, 1885. At the necropsy the tonsils were found greatly enlarged, and the larynx and posterior nares covered with diphtheritic membrane, which extended a considerable distance down the trachea. C.\SE.—Private Clement Dennison, Co. E, 32d Alaine A'olunteers. aged 17 years, was admitted to the hospital at Fort AA'ood, New York Harbor, October 29th, 1864, suffering from inflammation of the tonsils, with diphtheria. The constitutional condition of the patient was bad. On November 1st, Acting Assistant Surgeon Frederick D. Sturges performed tracheotomy, with but little loss of blood The neck being short aud much swollen, the operation was quite difficult. Death resulted, November 2d, 1864, from exhaustion. OPERATIONS ON THE AIR-PASSAGES. 419 There were two successful operations for simple laryngitis: CASE.-Private Martin Bowen, Co. K, 149th Pennsylvania A'olunteers, aged 31 years, was admitted to Lincoln Hospital, Washington, October 24th, 1863, with pneumonia of the lower lobe of both lungs. On November 24th, asphyxia set in. Ether was administered, and Acting Assistant Surgeon AV. F. Peck performed tracheotomy. One small vessel was ligated. About half an ounce of blood Avas lost, Tonics, stimulants, aud 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 hospital at Whitehall, Pennsylvania, and discharged from service June 26th, 1865. Case.—Private Alfred Newcomer, Co. H, 7th Michigan A'olunteers, 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 hours 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 giveu. He soon commenced to improve, and in two weeks was able to sit up, and in four was walking about. He could breathe quite free through the tube, but it was found that it could not be removed. Discharged from service about the middle of October, 1802. Examiner 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 Taylor Misinger, Co. H, 130th Indiana A'olunteers. 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 Surgeon Robert McNeilly, 19th Ohio Volunteers, performed the operation of tracheotomy, 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, 1884. the wound had healed entirely, and the patient was returned to duty. Case.—Private Elias E. Terry, Co. AI, 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 laryngotomy. He died seven hours after the operation from asyhyxia. The necropsy showed extensive inflammation ofthe larynx, bronchi, and trachea. The lungs were much engorged. 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 Redfern 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 haemorrhage 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 arytseno-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 Alay 25th, 1865. Case.—Private Milton Scott, 24th Ohio Battery, aged 21 years, was admitted to Desmarres Hospital, Chicago, Illinois, October 28th, 1864, suffering from double otirrhcea. The tonsils became largely hypertrophied, closing at least three-fourths of the isthmus of the fauces. On January 28th, 1865, Surgeon J 8. Hildreth, U. S. V., excised both tonsils. Little inflam- 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 J. W. Robinson, 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, wouuded the internal [-20 AVOUNDS AND INJURIES OF THE NECK. carotid artery, and probably some branch of the occipital. He was ccmveyedto the AA'ashington Street Hospital. Petersburg, A'irginia, where the left common carotid artery was ligated in the superior triangle. On July 2d, the haemorrhage recurred. July 3d, the ligature came away ; the artery was re-ligated below the omohyoid, but the haemorrhage still continued, though in diminished quantity, until July 5th, when death occurred. Case.—Lieutenant AA'illiam Fisher, Co. A, 99th Pennsylvania A'olunteers, was wounded at Petersburg, A'irginia, October 7th. 1804. 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 AA'illiam B. Reynolds, 2d U. S. Sharpshooters, ligated the left common carotid artery below the omo-hyoid muscle. Death resulted in twenty-six hours after the operation. Case.—Lieutenant Charles Debolt, Co. D, 82d Ohio Volunteers, received a gunshot wound of the neck at Bull Pasture Mountain, A'irginia, May 8th. 1862. 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. A'. Cantwell, 82d Ohio A'olunteers, 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 remarkably well up to the 15th day. 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 v> ell 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 llth, per steamer Cosmopolitan, to Beaufort, South Carolina, entering the 1st division hospital on the 15th. On the 18th, a violent haemorrhage 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 gaiu strength imtil December 27th, when hsemorrhage 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 haemorrhage 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 hsemorrhage from wounds of the extremities, there will be ample opportunity of demonstrating the soundness of the views of Guthrie on haemorrhage, 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, haemorrhage occurred to the amount of a quart, recurring on the 30th. Three other haemorrhages, of October 0th, 9th, and 10th, respectively, so reduced the strength of the patient that the common carotid wTas 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 llth, 1864, and mustered out June 24th, 1805, as corporal. CASE.-Private G. AA'. B------, Co. G, 42d A'irginia, aged 25 years, was admitted to hospital at Frederick, Maryland, for a gunshot wound of the neck and face received at (iettysburg, July 3d, 1863, There was secondary hsemorrhage 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. Haemorrhage did not recur. The patient died July 13th, 1803. A wet preparation of the ligated artery was contributed to the Arniv Medical Museum, with the history, by Assistant Surgeon R. F. Weir, U. >• A., -Gunshot wound of external * • ■ * .... j » Spec. 3969, Sect. I, A. M. M. and is No. 3969 of the Surgical Section. It is represented in the adjoining wood-cut. Tabular Statement of Fifteen ligations of the Common Carotid Artery for Gunshot Injuries of the Neck. NAME AND MIL. DES. Hemic. J. l'rivsito, llth Penn- sylvania Volunteers. Burns, R.. Private, 10th Mas- sachusetts Volunteers. Clink, M., Private, 95th Penn- svlvauia Volunteers. Cree.cy, B. Private, 42d Vir- ginia Regiment. Dainnby, E., Private,1st Maim Cavalry. Felix, W., Private, 9th Vir- ginia Regiment. Gardner. J. B.. Private, 5th Louisiana Regiment. Husrhcs, D. (!., Private llth Virginia Volunteers. Harrington, M., Private, 21st New York Volunteers. Messenger, P. B., Sergeant, 11 Ith Pennsylvania Vols. McKenney, E., Private, (ith Pennsylvania Cavalry. Moore, J. G.. Corporal, 110th Pennsylvania Volunteers. Rollin. J. N., Private, 1st N. Carolina Volunteers. Smith, W. W., Confederate . Kclley, R.. Private, Gth Loui- siana Volunteers. Gunshot wound of neck and left shoulder; common caro- tid and jugular vein injured. Gunshot wound of mouth and neck. Gunshot wound of head; hall entered neck on riyht side, behind, passing through un- trim, and out beside nose. Ball passed through larynx, at upper margin of thyroid cartilage, impinging slightly upon thyro-hyoid membrane. Missile entered below jaw, passed down and out of back of neck, wounding carotid artery. Gunshot fracture of right in- ferior maxilla; ball severed lingual artery and oesopha- gus, and lodged against seventh cervical vertebra, wounding vertebral artery. Missile entered one inch ante- rior to left ear, passed in- ward, downward, and back- ward and lodged. (iunshot wound of neck...... LIGATION. Lower portion of left com- mon carotid. Common carotid and lin- gual arteries. Common carotid......... Left common carotid, at point of election; right common carotid, at point of election. Musket ball entered at outer margin ofthe left malar bone, and emerged beneath left mastoid process. Gunshot wound of lower jaw and throat. Buckshot entered left side of neck, just over anterior edge of sterno-mastoid muscle, a little below body of thyroid notch, and passed out below and to the left ofthe occipital protuberance. Gunshot wound left side of head. Carotid Left common carotid, be- low omo-hyoid. Left common carotid, a few lines from its origin. Left common carotid; right common carotid. Left common carotid, at point opposite cricoid cartilage; right common carotid. Right common carotid___ Left common carotid...... Left common carotid. Conoidal ball entered back of Common carotid. neck and passed out of left cheek. Gunshot wound of head and neck. Gunshot wound of neck; di- vision of external carotid artery. Common carotid. Common carotid. Date of Woi;no. May 10, 1864 May 30, 1862 May 3, 1863 May 3, 1863 April 12, 1865 Date 01' ILumohii'aof.. May 15, 18(14, recur ed May 21, 1864. Date ok Ol'ICIlATION. I May 15, 1864 June 18, 18(12 May 1C, 1863 May 12,1863, May 12, 1863 recurred Mav May 15, 1863 15 & 20, 1863. RESULT. Kkcovkiiy. i Death. REMARKS. May 21, 1864 Operator, Surgeon Edwin Bentley, II. S. V June 19, 1862 May 20, 18(i3 May 5, 1865 Aug. 25, 1864 ; Sept, 3, 1864, Sept. 3, 1864 recurred I Sept. 4, 1864. July 24, 1864 Nov. 14, 1863 Jan. 1, 1863 Feb. 6, 1865 Oot. 19, 1864 Mav 20, 1863 Operator, Surgeon Russell Murdock, P. A 1 C. S. Mav 15, 1865 Feb. 17, 20, Feb. 22, 1865 21, 22, 1865. May 17, 1862 Aug. 9, 1864, recurred Aug. 14, 1864. Dec. 3, 1863 Jan. 1, 1863, recurred April 6, 18(i3. Feb. 15,1865, recurred Feb. 23, 24, 1865. Aug. 10, 1864 Aug. 14, 1864 Dec. 3, 1863 Feb. 26, 1863 Sept. 4, 1864 ■ Operator, Assistant Surgeon R. F. Weir, U. S. A. Feb. 22, 1865 Operator, Assistant Surgeon W. F. Richard son, P. A. C. S. May 17, 1862 Aug. 19, 1864 Surgeon J. B. Lewis, U. S. V. Feb. 15, 1865, re-ligated Feb. 21, 1865. Nov. 9, 1864 May 5, 1864 : May 12, daily May 21, 1864 until May 21, 1864. July 3, 1863 July 13, 1863 Dec. 8, 1863 j Operator. Assistant Surgeon Henry Pearec, 150th N. Y. V. A. M. M. Spec.Xo. 2018. April 6, 1863 \ Operator, Assistant Surgeon R. F. Weir, U. S. A. Feb. 25, 1865 Operator, Assistant Surgeon John Vansant, U. S. A. Nov. 9, 1864 Operator, Acting Assistant Surgeon G. G. Brewer. May 22, 1864 422 WOUNDS AND INJURIES OF THE NECK. Ligation 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: Graves, 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 6th, 1861. Hsemorrhage occurred December 14th, 1864. Left subclavian artery ligated in third portion by Assistant Surgeon W. E. Day, 117th 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: Dtjtton, A. H., Colonel, 21st Connecticut Volunteers. Gunshot wound of right side of neck. Ball fractured the lower maxilla and passed through the larynx, May 29th, 1864. Haemorrages occurred May 31st and June 2d. Facial artery ligated at entrance of wound, June 2d. Died June 4th, 1864. Barrick, T., Corporal, 44th New York Volunteers. Gunshot wound left side of neck, July 2d, 1863; ball lodged. Ball extracted. Haemorrhage occurred July 21st. Suprascapular artery and two or three branches ligated on the same day. Recovered August 15th, 1863. Adzer, L. C, Private, Co. K, 9th Louisiana Eegiment, aged 20 years, was wounded at Monocacy Junction, July 9th, 1861, by a conoidal 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 haemorrhage 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 transferred to West's Buildings Hospital, Baltimore, August 5th. Transferred to Fort McHenry for exchange, November 19th, 1864. Holliday, D., Sergeant, 26th Pennsylvania Volunteers. Flesh wound of left side of neck, July 2d, 1863. Haemorrhage 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. Haemorrhage, 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 5th, 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 right side, external to the sterno-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 ofthe 3d division, First Corps. Cold water dressings were applied to the wounds, and beef tea administered, which partly escaped through the wound of exit, giving evidence of injury of the pharynx. He was transferred to hospital via Fredericksburg and Belle Plain; the mode of conveyance being an army wagon, the jolting of which caused a slight haemorrhage, which he expectorated per orem; he also stated having expectorated a piece of meat one inch in length. He was, on May llth, admitted to Douglas Hospital, Washington. Cold water dressings were applied to the wounds, and the patient was fed through gum- elastic bougies, and injections per 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 Nth, 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 occurred, 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 occurred, 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, Philadelphia, on September llth. On his admission, the wounds had closed; sensation and motion feeble throughout the right arm; neck had only one-fourth 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 parts; 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; * Gross, Amer. Jour, of Med. Sci., 1867, Vol. LIII, pp. 17, 305. HEMORRHAGE AND LIGATIONS. 423 tact and pain still absent. On the 20th, there was some feeling in the tongue, but no motion on the left side. He was returned to duty on December 9th, 1864. On May 2d, 1866, Exaniiuing Surgeon E. Winslow reports that Seymour's wounds had healed externally; but the trachea was constantly discharging pus, brought up by coughing, and was hoarse, and his right arm weak. The fatal 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 Venous and Arterial Haemorrhages. 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-five ligations of the common carotid, with a mortality of .78. 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, and will furnish M. Le"on Lefort {Gaz Hebdom. 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 anatomical and physiological relations of the region. Nothing that is not corrobora- tive 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 throroughly and ably discussed by Acting * On page 397 (ante) have been cited a few works on ligations. Consult further: JONES, J. F. D., A Treatise on the Process employed by Nature in suppressing the Hmmorrhage from Divided and Punctured Arteries and on the Use of the Ligature, London, 1810 ; Pli.z, C, Zur Ligatur der Arteria Carotis Communis nebst einer Statistik dieser Operation, in Archiv filr Klinische Chirurgie, von Dr. B. VON LANGENBECK, Berlin, 1868, IX Band, S. I.; Manec, On the Ligature of Arteries, Halifax, 1832, and Traiti thiorique el pratique de la Ligature des Artires, Paris, 1834; Tear Book of Medicine and Surgery, London, 1862, pp. 80, 240; KEITH, Successful Ligation of the Internal Carotid, Monthly Jour, of Med. Sci., Edinburgh, May, 1851, p. 435, probably an unique case; BOUCHARD, De la Pathoginie des himorrhagies, Paris, 1869; CHASSAGNT, Nouveaux moyens hemostatiques, Paris, 1868; MOTT, A. B., Haemorrhage from Wounds, and the best means of arresting, New York, 1863; Sanson, Des himorrhagies traumatiques, Paris, 1836; VtLrEAU, Recherches sur la cessation spontanee des himorrhagies traumatiques primitives, Paris, 1830; LISTER, Observations on Liga- tures of Arteries on the antiseptic System, Edinburgh, 1869. I believe that Hennen's statement, that he was "not acquainted with any monograph upon wounds of the neck," might be reiterated at the present day, unless the article of Mr. Arthur E. Durham, in Holmes's System, Vol. II, p. 436, be regarded as an exception. Consult Pare, par Malgaigne, Paris, 1840, T. II, p. 81; Rust, J. N., Einige Beobachtungen ii. d. Wunden der Luft- und Speiserbhre, etc., Wien, 1814 ; Allan Burns, Surg. Anat. of the Head and Neck, 1811, 1st ed., 1824, 2d ed.; SlMONNEAU, Essai sur les solutions de continuiti du pharynx et de Vcesophage, 1808, These de Paris, No. 150; G. BOULIN, Dissertation sur les plaies de Vossophage, 1828, These de Paris, No. 146 ; Sabatier, Des plaies du cou, in Med. Oper. 1832, T. II, p. 70; JOBERT, Plaies d'armes a feu. 1833, p. 155 ; LAUGIER, Dictionnaire en trente (Blessures du com), 1835, T. IX, p. 162 ; Larrey, Sur les Plaies de Vcesophage, in Clin. Chirurg., 1829, T. II, p. 154 ; DurUYTREN, Blessures du cou in Lecons oral, de cl. chirurg., 2"* ed., T. VI, p. 271, 1839; Legouest, op. cit. p. 406, 1863; FORESTLS, P., Observationum et Curationum Mediciualium ac Chirurgicarum Opera Omnia, Francofurti, 1634, I, p. 423 ; TltKEN, Observationum Medico-Chirurgicarum Fasciculus, Lugduni, 1743 ; GUATT NI, Essai sur I'CEsopha- gotomie, Mim. de I'Acad. de Chir., Paris, 1819, T. Ill, p. 343; Verdier, Sur une Plaie de la Gorge, avec des Remarques intiressantes sur ce sujet, Ibid., p. If3; Larrey, Mim. de Chir. Mil., Paris, 1817, T. IV, p. 249; GROSS, op. cit., Phil, 1866, p. 382; Gibb, Diseases of the Throat and Windpipe, as reflected by the Laryngoscope, London, 1864; WISEMAN, Several Chirurgical Treatises, London, 1676, p. 363; DIEFFENBACH, J. F., Die Operative Chirurgie, B. II, S. 321, Leipzig, 3848; BELL, J., A Manual of the Operations of Surgery, London, 1866, p. 178; Hunt, Wm., in Amer. Jour, of Med. Sci., April, 1866, p. 378. 424 WOUNDS AND INJURIES OF THE NECK. Assistant Surgeons S. Weir Mitchell, George R. Moorehouse, and William W. Keen, who were assigned to the wards in the United States Army Hospital, Christian Street, Phila- delphia, with a view to this special enquiry. How well they acquitted themselves of their task is shown by their publications.* It is better to refer the reader to those careful studies than to attempt an elaboration of the disconnected clinical notes recorded in this Office. Two cases, however, specially communicated, of relief of paralysis by the removal of balls, must not be omitted: Case.—Sergeant F. C------, Co. F, 60th Alabama Regiment, aged 24 years, was wounded at Petersburg, March 31st, 180."), by a conoidal ball, which entered the face one inch and a half above the left angle of the mouth, knocked out two bicuspides and half of the first molar of the upper jaw; chipped the second molar of the lower jaw, transfixed the tongue, which it split about two inches to the apex, and lodged in the supra-hyoid space. Profuse haemorrhage occurred at the time of the injury, and continued more or less for several days. 'Ihe wound was probed in search of the ball, but it could not be reached; the vessels were, however, secured, and the haemorrhage arrested. The tongue became very much swollen, in which condition it remained for about a week, during which period no solid food was taken. On April 7th, the patient was admitted into the Confederate hospital at Danville, where another unsuccessful search was made for the ball. He was furloughed on April llth, and sent to Montgomery, Alabama. The wound healed rapidly, and he was not disturbed until the middle of July, when, after much uneasiness during deglutition, his tongue became paralyzed and continued so until about August 10th, when power and motion returned to the organ. On September '20th, violent pain set in, and continued until October 1st, during which time an abscess formed on the anterior surface of .the right side of the neck, on a level with the cornua of the hyoid bone; this was opened, discharging pus very freely. His condition was relieved until the middle of December, when the pain in the neck returned. Upon examination, it was discovered that the depressor muscles of the neck were in a partially paralyzed condition. The pain continued until February 1st, when it ceased, but soon returned with increased violence. On February 14th, the patient reported to Dr. R. Fraser Michel, at Montgomery, who detected a foreign body in the lower part of the neck, near the trachea, which proved to be the ball. Tins was removed through an incision along the anterior margin of the sterno-mastoid at a point where the omo-hyoid crosses the cervical region. The base of the ball rested beneath the deep-seated cervical fascia, where its layers unite upon the anterior border of the sterno-mastoid to be prolonged onwards to the middle line of the neck. After the removal of the ball, a considerable quantity of pus was discharged. The wound healed in a few days, and the patient was entirely relieved. The ball was very ragged, twelve points of extreme asperity being detected upon its external surface. Three fossa;, evidently depressions made by the three teeth from the upper jaw, were discernible, and, near the base, quite an excavation, in which was lodged the chipped portion of the middle molar of the lower jaw, so imbedded that it could not be removed without injuring the specimen. The point of interest in the case is the passage of a ball through the entire length of the neck, amid important blood-vessels and nerves, without material injury to the part. First, pressing upon the hypo-glossal nerve and producing paralysis ofthe tongue; and, secondly, touching the descendens noni and producing partial paralysis of the depressor muscles of the larynx. Case.—Private George T. Cottrell, Co. G, 1st United States Sharp-shooters, aged 21 years, was wounded, while in the act of firing, at the battle of Chancellorsville, Virginia, May 2d, 1803, by a conoidal ball entering about one-half an inch above left clavicle, and about an inch from its sternal extremity, and passing behind the trachea, lodged just under the right clavicle where the subclavian emerges. He was conveyed to Washington, D. C, and admitted into St. Aloysius Hospital, May 7th, 18l>3. There was but little blood lost. A numb pain ensued, which lasted six months, referred particularly to the elbow-joint and fingers, the fingers remaining semi-flexed three months. He was unable to speak aloud for two weeks, and nourishment could only be taken in liquid form. The limb was carried at right angles, and, by the middle of July, the wound had perfectly healed and never re-opened. At this date, the joint, which had become firmly fixed at right angles, from inaction, was straightened while the patient was under the influence of chloroform, and frequent flexion and extension subsequently fully restored the use of the joint He was returned to duty in 2d battalion, Veteran Reserve Curps, October 31st, 1863, and discharged from the service on September llth, 1864. The hand and fingers continued to be very sensitive to cold and heat, and, at times, were very painful. One morning, in the fall of 18:i5, he found that the power of supporting the head was lost to such an extent, that he was unable to rise from his bed; and clonic muscular contraction, drawing the head to the right shoulder, lasted four days, but did not recur. Late in December, 1869, the pain at the point of lodgement began to increase; and on January 31st, 1870, Prof. X. S. Lincoln, M. D., having placed the patient under the influence of chloroform, cut down and removed the ball, which was found thrust in between the subclavian and a branch of the brachial plexus, the missile resting on the artery just where it emerges from beneath the clavicle, and the nerve drawn tightly across the ball in front. On pushing aside this nerve from the missile, vigorous contraction of the limb was produced. The wound closed readily by granulation. The limb is now equal to its fellow in size and strength, and, with the exception of a very slight sensitiveness of the fingers to cold and heat, which is improving, the patient is entirely relieved. He is unwilling to present the ball to the Museum. Mr. Cottrell is a clerk in the Treasury Department. In May, 1-72. there was a dull pain from the shoulder, along the course ofthe nerve ofthe arm, during cold and damp weather. Case reported by Dr. H. XV. Sawtelle of the Treasury Department. Other cases germane to this'subject will be found in the next chapter. * Circular JVo. 6. Surgeon General's Office, March 10th, 1864, On Reflex Paralysis. See also Gunshot Wounds and Other Injuries of Nereis, 12 mo., pp. 164, Philadelphia, 1864; Mitchell, Injuries of Nerves and their Consequences, small 8 vo. pp. 377, Phila., Lippincott & Co., 187:2. CHAPTER IV. WOUNDS AND INJURIES OF THE SPINE. Cases belonging to this category are commonly discussed by systematic writers immediately after lesions involving the head and encephalon. But inasmuch as, in the majority of cases, the fractures and other injuries of the vertebral column are complicated by injuries of the neck, chest, or abdomen, it seems best to devote to them a separate chapter. The total number of cases reported is about six hundred. They will be referred to under three sections: Section I. INCISED WOUNDS, CONTUSIONS, AND MISCELLANEOUS INJURIES. Seventy-seven cases of this class are on record. Incised Wounds.—Only two incised wounds of the spine are recorded; one with a fatal termination, the other resulting in recovery. Case.—Private William P. Cook, Co. D, 6th Tennessee Cavalry, aged 25 years, was admitted to Overton Hospital, Memphis, Tennessee, November 25th, 1864, with an incised wound of the spine inflicted on November 10th, 1864, with a knife. Simple dressings were applied to the wound. He was returned to duty on December 15th, 1864. Case.—Private George S----, Co. B, 15th New York Engineers, was admitted to Armory Square Hospital, Washington, on April 22d, 1863, having been stabbed with a knife in the back, at Falmouth, Virginia, on the 20th. He was completely paraplegic; the urine had to be drawn off by the catheter, and nothing but croton oil, in three-drop doses, succeeded in producing a passage three days after admission, two days after which, involuntary defecation and micturition set in. Sphacelus on all the projecting parts of the lower part of the body soon followed, proceeding rapidly until it nearly reached the spine of the sacrum. On May 10th, chills came on and recurred daily: death ensued on May 26th from exhaustion. The fourth, fifth, and a portion of the sixth dorsal vertebrae, sawn longitudinally to exhibit the blade of the knife, which appears to have been broken off at the time of injury and remains fixed in the specimen, are numbered 1160 of the Surgical Section, and were contributed to the Army Medical Museum by Assistant Surgeon C. C. Byrne, U. S. A. See adjoining wood-cut (Fig. 188). 54 Fig. 188.—Fourth, fifth, and a portion of the sixth dorsal vertebras, sawn asunder to exhibit a dirk which traversed the spinal canal. Spec. 1160, Sect. I, A. M. M. 42G WOUNDS AND INJURIES OF THE SPINE. Contusions and Miscellaneous Injuries.—Seventy-nine cases are reported; caused principally by falling from horses, by blows from muskets or other blunt weapons, and by falling of trees. A few proved fatal from fracture or luxation or from peritonitis, and, in one instance, from the complication of small-pox: Cask.—Corporal John B------, Co. C, 10th New York Volunteers, of good constitution and physical condition, while felling trees at Hatcher's Run, Virginia, March llth, 1863, was struck across the dor3al and lumbar vertebrae by a falling limb, which had been severed by a shell. Being knocked senseless, he remained in this condition for an hour or more, until awakened by the motion of the ambulance that conveyed him to regimental headquarters. On returning to consciousness, he was unable to move the lower portion of his body. Arriving at Patrick's Station, he was cupped, and mustard applied to the calves of the legs and to the spinal region. He complained of pain in the lower portion of the body. He was blistered, and the blisters dressed with lint. He was sent to City Point, and finally, to Washington, where he entered Finley Hospital on the 19th. When admitted, he was in a semi-comatose condition; complete paraplegia; sensation perfect. There was some febrile action, and very severe diarrhoea. He passed his urine and foeces involuntarily; appetite very good; pulse full and bounding; emaciation slight. The temperature of the right leg was slightly higher than that of the left, but both were very cold; skin moist. The blistered parts on each leg were suppurating slightly. The parts in the region of the sacrum were in a gangrenous condition. Opiates were given at night and chlorides used to cleanse the gangrenous wounds over the sacrum. Under the administration of astringents the diarrhoea ceased by the 25th. The patient, however, continued to sink, and died on March 29th, 1865. At the autopsy, the first lumbar vertebra was found transversely fractured entirely through its body at its upper third, with each pedicle broken and the left transverse and spinous processes encroaching upon the cord, which was lacerated at the lumbar and dorsal junction. The membranes were torn entirely across, except a few fibres anteriorly and posteriorly, and were congested above and below the seat of injury. Clots of diffused blood were found near the fracture. The lower portion of the cord, severely lacerated, was drawn up into a bundle at the seat of injury, entirely deprived of the membranes. The pathological specimens are Nos. 149 and 150, Section I, A- M. M.. and were contributed, with a history of the case, by Acting Assistant Surgeon XV. Dusenbury. Case.—Private Joshua C------, Co. H, 4th Ohio Volunteers, aged 23 years, received an injury of the spine, December 21st, 1863, from a tree falling across him, in camp. On January 27th, 1864, he was admitted to the 3d division hospital, Alex- andria, Virginia, with entire paralysis of the lower extremities, both as to sensation and motion. He did not complain of any great amount of pain. His appetite was good. There was no movement of the bowels, except as the effect of a cathartic, and his urine had to be drawn regularly, otherwise it passed involuntarily from him upon the bladder becoming partly full. The muscles of the thigh and legs twitched involuntarily. Blisters were ordered to the spine in the neighborhood of the second dorsal vertebra, which was dislocated. February 10th: Counter irritation has been thoroughly tried, with no good result. Bed-sores formed on each hip, although an astringent wash had been used and pressure prevented as far as possible, and it was feared that the vitality of the parts was so low as to prevent their healing. Patient sank gradually; his appetite became poor; bed-sores worse and the discharge from them very abundant and offensive. Death resulted on April 28th, 1864. At the autopsy, forty-eight hours after death, the viscera was found apparently healthy; there was pressure upon the cord at the point of dislo- cation of the vertebra] column and effusion within the membranes. The pathological specimen is No. 2255, Section I, A. M. M., and shows the fifth, sixth, seventh, eighth, and ninth dorsal vertebrae, completely fractured through the eighth and displaced forward. The bones are partially retained in their abnormal relation by callus deposited in the neighborhood. The fracture passes transversely through the body and embraces the processes also. It was contributed, with a history of the case, by burgeon Edwin Bentley, U. S. V. Case.— Captain Thorwald J------, Commissary of Subsistence, U. S. V., was injured at Larkinsville, Alabama, on the evening of December 31st, 186:'. by the falling upon him ofthe front of a building. He was taken out in a few minutes. Upon examination, bruises were found on the head in the frontal and occipital regions, and on other parts of the body. No bones appeared broken or displaced. There was complete paralysis of the arms and legs, and extreme sensitiveness of the front of the neck and upper part of the thorax. He was not, at any time, insensible. Respiration was performed only by the diaphragm, causing, throughout the case, great suffering from dyspncea. The symptoms indicated dislocation or fracture of the cervical vertebrae below the phrenic nerve, and above the brachial plexus. No displacement of the spinous processes could be detected, and the patient was able to raise his head and move it from side to side. The treatment adopted was, of course, only palliative. The bladder was tmptied by means of the catheter. His condition continued with very little change, except greater or les3 difficulty of breathing, until death, which occurred on the evening of January 3d, 1864, about seventy-six hours after the accident, from asphyxia. A partial examination, next morning, revealed a fracture of the fourth cervical vertebra. The left lamina was in two pieces and depressed upon the spinal cord. The pathological specimen is No. 2080, Section I, A. M. M , and was contributed, with a history of the case, by Surgeon J. S. Prout, 26th Missouri Volunteers. CASE.-Private John A. T------, Co. I, 1st New York Engineers, aged 18 years, while bathing at Folly Island, South Carolina, July 27th, 1864, dived from the beach in two feet of water, striking upon the top of his head agaiust the hard sandy bottom. There was immediate loss of sensation and power of motion below the shoulders and in the upper extremities, except over and in the flexor muscles of the forearms, and, apparently, the deltoid, though the extension of the arm at the shoulder was rather feeble and indeterminate, and was probably performed by the long or scapular head of the biceps. Respiration was diaphragmatic; pulse but little accelerated; consciousness complete. There was some, though not excessive, pain in the lower cervical region. He was at once conveyed to the hospital for detachments and civilians at Folly Island, and laid on his back, on a mattress. An anodyne was given during the night Eighteen hours after the injury, a fever set in, followed by some CONTUSIONS AND MISCELLANEOUS INJURIES. 427 delirium; an enema was given, which soon procured a copious alvine discharge. From the fifty-fourth to the sixtieth hour, a similar fever prevailed, which was allayed by the application of ice to the head, and mustard to the feet and thighs, with wet cups along the spine. After the first operation, there was some incontinence of feces and of flatus, but not of urine, the sphincter of the bladder retaining its power to the last, although of course, the urine was drawn off by the catheter. Asphyxia did not become prominent until the sixty-second hour, but steadily increased until death, which occurred on July 30th, 1K54, sixty-eight hours after the reception of the injury. At the autopsy, two hours after death, the body of the sixth cervical vertebra was found vertically fractured, the posterior edges of the partially separated halves pressing upon the anterior surface of the cord, opposite the origins of the seventh and eighth cervical nerves, and the third and fourth of the brachial plexus. The crural arch of the sixth cervical vertebra was also broken down, and there was dislocation of tlie spinous processes of the fourth, fifth, and sixth cervical vertebne and sufficient fracture of their arches to injure the cord, including most ofthe roots of the sixth cervical, but not at all those of the fifth nerve. At these points of direct injury, the substance of the cord was inflamed and disorganized into a red pulp. The inflammation and disorganization had also extended upward along the gray commissures and the posterior horns of the gray substance almost to the medulla-oblongata. The origins of the phrenic nerve having been untouched by the original injury, the diaphragm was able to continue its function of abdominal respiration, until, perhaps, the advancing inflam- mation invaded its origins. The pathological specimen is No. 3159, Section I, A. M. M., and was contributed, with a history of the case, by Assistant Surgeon Burt G. Wilder, 55th Massachusetts Volunteers. Ahehx, J. A., Sergeant, Co. E, 31st Ohio Volunteers, aged 23 years. Concussion of spine. Atlanta, August 29th, 1864. Treated in Hospital No. 8, Nashville, Tennessee. Returned to duty on January 24th, 1805. Alexander, George W., Captain, 1st Michigan Cavalry. Injury of spine by fall from horse. Gettysburg, July 3d, 1863. Discharged from service. Allen. Asa, Private, Co. D, 60th New York Volunteers, aged 25 years. Contusion of spine by fall. Treated in Hospital No. 14, Nashville. Liniments^ Transferred to Veteran Eeserve Corps, October 18th, 1864. Bean, Josl\h, Private, Co. I, 31st Maine Volunteers. Injury of spine. Spottsylvania, Virginia, May 12th, 1864. Treated in Lincoln Hospital, Washington. Returned to duty on May 24th, 1865. Benham, Thomas, Private, Co. A, 150th New York Volunteers, aged 35 years. Spinal injury. Treated in hospital at Columbus, Ohio. Returned to duty on March 20th, 1865. Borf.n, J. H., Private, Co. D, 91st Indiana Volunteers. Contusion of spine. Treated in Hospital No. 19, Nashville. Mustered out on June 26th, 1865. Bowen, William H., Private, Co. C, 32d Iowa Volunteers, aged 38 years. Contusion of spine, lumbar portion, by fall from horse. Treated in Washington Hospital, Memphis. Cupping and blistering. Returned to duty on July 23d, 1864. Breese, John, Private, Co. H, 5th Illinois Cavalry, aged 17 years. Concussion of spine by being thrown from his horse. Treated in Adams Hospital, Memphis. Died on March 15th, 1865, from chronic peritonitis. Breesk, F. F., Private, Co. B, 83d Pennsylvania Volunteers. Injury of spine by fall of horse. Anodynes and counter irritants. Discharged from service on February 23d, 1865. Bright, Samuel, Private, Co. H, 124fh Indiana Volunteers, aged 18 years. Spinal concussion from fall. Treated in Cumberland Hospital and Hospital No. 8, Nashville. Simple dressings. Returned to duty. Brooks, W. J., Sergeant, Co. E, 77th Illinois Volunteers, aged 26 years. Spinal injury by fall from wagon. Treated in hospital at Quincy, Illinois. Died on January 8th, 1864, from small-pox. Bryant, Charles F., Corporal, Co. K, 33d Massachusetts Volunteers. Injury of spine. Treated in Mason Hospital, Boston. Simple dressings. Returned to duty on June 3d, 1864. Buck, Bowman H., Sergeant, Co. F, 3d New Jersey Volunteers, aged 35 years. Contusion of spine from limb of tree. Spottsylvania, Virginia, May 10th, 1864. Treated in Baltimore and Wilmington hospitals. Rest. Returned to duty on August 2d, 1864. Buick, Anthony, Bugler, Co. I, 12th Kentucky Cavalry, aged 34 years. Injury of spine by fall from a horse, May, 1862. Treated in hospital at Louisville, Kentucky. Tonics and stimulants. Returned to duty on August 10th, 1863. Burch, Bernard, Private, Co. I, 4th Michigan Cavalry, aged 20 years. Spinal injury by fall from horse at Mammoth Cave, October, 1862. Treated in hospital at Quincy, Illinois. Counter-irritation. Returned to duty on December 21st, 1863. Carpenter, James W., Private, Co. E, 1st Massachusetts Cavalry. Injury of spine. Treated at Mason Hospital, Boston. Simple dressings. Returned to duty on May 9th, 1864. Catherman, Lewis, Private, Co. E, 7th Pennsylvania Cavalry, aged 33 years. Injury of spine by fall from horse. Treated in hospital at Louisville. Cathartics. Returned to duty on July llth, 1863. Clarkson, George A., Private, Co. A, 5th Michigan Cavalry. Contusion of spine by fall from horse. Treated in hospital at Point Lookout, Maryland, and Washington and Baltimore. Liniments and counter-irritants. Returned to duty on October 28th, 1863. Clift, Amos, 1st Lieutenant, Co. F, 1st Connecticut Cavalry. Injury of spine by fall from horse. Discharged from service on August 2d, 1865. Cook, J. C, Private, Co. G, 8th Indiana Cavalry, aged 37 years. Concussion of spine. Treated in Hospital No. 8, Nashville, Tennessee. Returned to duty, September 24th, 1864. 428 WOUNDS AND INJURIES OF THE SPINE. Cooper, Albert, Sergeant Major, 1st Michigan Artillery, aged 35 years. Injury of spine. Treated in Hospital No. 8, Nashville. Returned to duty on August 8th, 1^64. Corey, Joseph R., Private, Co. L, 1st Rhode Island Cavalry, aged 56 years. Spinal injury. Treated at Satterlee Hospital, Philadelphia Tonics. Discharged from service on June 6th, 1863. Crupper, John, Private, Co. G, 64th Ohio Volunteers, aged 19 years. Contusion over spine, by limb of a tree. West- ville, December 16th, 1864. Treated in Hospital No. 14, Nashville. Liniments. Returned to duty on May 17th, 1865. Dodd, James L, Private, Co. A, 34th Dlinois. Contusion of spine. Treated in Hospital No. 8, Nashville. Discharged from service on July 12th, 1865. Farnsworth, H. M., Private, Co. C, 2d Massachusetts Cavalry, aged 42 years. Injury of spine. Treated at Turner's Lane Hospital, Philadelphia. Discharged from service on January 25th, 1865. Foley, Hugh, Private, 36th Company, 2d Battalion, Veteran Reserve Corps. Injury of spine and breast by fall from bridge. Treated in Harewood, Hospital, Washington. Stimulants and tonics. Discharged from service on December 9th, 1863. Frehse, Louis, Private, Co. B, 37th Ohio Volunteers, aged 26 years. Injury to spinal column. Treated in Crittenden Hospital, Louisville. Simple dressings. Returned to duty on August 1st, 1864. Fudge, Philip M., Private, Co. A, 74th Ohio Volunteers, aged 21 years. Concussion of spine. Treated in Hospital No. 8, Nashville. Discharged from service. Gay, Robert, Private, Co. I, 112th Illinois Volunteers, aged 39 years. Spinal concussion from fall. Treated in Hospital No. 8, Nashville. Returned to duty on January 26th, 1865. Glasshook, George N., Private, Co. D, 12th United States Infantry, aged 27 years. Spinal injury. Treated in Hare- wood Hospital, Washington. Returned to duty on June 21st, 1863. Greisinger, Alexander, Private, Co. K, 1st Ohio Artillery, aged 29 years. Contusion of spine. Treated in Cumber- land Hospital, Nashville, Tennessee. Rest and liniment. Returned to duty. Haler, William C , Private, 19th Indiana Battery, aged 34 years. Contusion of spine. Treated in Hospital No. 8, Nashville. Tennessee. Returned to duty on November 15th, 1864. Hersey, Josiah E., Private, Co. D, 17th Illinois Volunteers. Injury of spine. Shiloh, April 6th, 1862. Treated in hospital at Quincy, Illinois. Blisters. Discharged from service on May 26th, 1864. Herton, Henry R., Corporal, Co. B, 1st Michigan Sharp-shooters, aged 31 years. Injury of spine by falling tree. Treated in Mount Pleasant Hospital, Washington. Returned to duty on July 2d, 1864. Hervey, Willlvm, Private, Co G, 98th Illinois Volunteers. Injury of spine and chest. Treated in Hospital No. 9, Louisville, Kentucky. Liniments and cathartics. Transferred to Veteran Reserve Corps on July 20th, 1864. Hillabiddle, Daniel W., Musician, Co. G, 125th Ohio Volunteers, aged 46 years. Contusion of spine. Treated in Hospital No. 8, Nashville. Discharged from service. Hiram, Benjamin, Private, Co. B, 78th Ohio Volunteers, aged 40 years. Contusion over spine. Treated in Hospital No. 14, Nashville. Liniments. Returned to duty. Hoy, Joseph, Private, Co. D, 98th Illinois Volunteers, aged 31 years. Contusion over spine. Treated in Cumberland Hospital, Nashville. Simple dressings. Discharged from service on June 27th, 1865. Himlett, George, Lieutenant, Co. M, 2d New Jersey Cavalry, aged 23 years. Concussion of spine, March 30th, 1864, Treated in Officers' Hospital, Memphis, Tennessee. Returned to duty on April 18th, 1864. Hutsman, Charles, Corporal, 1st Iowa Battery, aged 25 years. Spinal concussion from blow. Treated in Adams Hospital, Memphis. Discharged from service. Ives, Richard F., Sergeant, Co. G, 7th Illinois Cavalry, aged 26 years. Spinal concussion. Treated in Hospital No. 8. Nashville. Returned to duty on December 21st, 1864. Jackson, James F., Corporal, Co. D, 36th Wisconsin Volunteers. Injury to spine. Treated in Lincoln Hospital, Washington. Returned to duty on December 28th, 1864. Kennedy, James T., Private, Co. C, 25th New York Cavalry, aged 36 years. Spinal injury by fall.from horse at Harper's Ferry, August, 1864. Treated in hospital at Philadelphia. Returned to duty on February 25th, 1865. KING, Isaac M., Private, Co. D, 3d New Jersey Volunteers. Spinal injury by blow from a musket. Chancellorsville, Virginia, May 3d, 1863. Treated in hospital at Philadelphia. Blisters. Discharged from service on February 2d, 1864. Leard, Samuel F., Corporal, Co. B, 129th Indiana. Injury of spine by fall. Treated in hospital at Madison, Indiana. Liniments. Returned to duty on November 21st, 1864. Leonard, Edward L., Private, Co., D, 24th Wisconsin Volunteers. Injury of spine by fall from bunk. Milwaukee, Wisconsin, September 1st, 1862. Treated in hospital at Quincy r Illinois. Counter-irritation. Discharged from service on February 17th, 1864. Now bit, Lora, Private, Co. I, 4th Maine Volunteers, aged 29 years. Injury of middle of spinal column, June 9th, 1^64. Treated in Lincoln Hospital, Washington. Deserted on December 5th, 1864. MISCELLANEOUS INJURIES. 429 McCLURE, Thomas, Private, Co. II, 6th Pennsylvania Reserves, aged 30 years. Injury of spine by fall. Treated at Satterlee Hospital, Philadelphia. Liniments. Returned to duty on January llth, 1864. McMasters, Thomas S.. Private, 5th Wisconsin Battery, aged 28 years. Concussion of spine. Treated in Hospital No. 8 Nashville. Returned to duty on November '25th, 1864. McPherson, C. C, Assistant Surgeon, 73d Illinois Volunteers, aged 27 years. Contusion of spine from railroad accident. Treated in Hospital No. 1, Chattanooga, and Officers' Hospital, Nashville. Simple dressings. Leave of absence on November 27th, 1864. Martin, Samuel, Private, Co. C, 98th Ohio Volunteers, aged 23 years. Injury of spine by fall. Treated in Hospital No. 8. Nashville. Returned to duty. May, Erastus J., Private, Co. C, 177th Ohio A'olunteers, aged 29 years. Injury of spine from fall. Treated in hospital at Madison, Indiana. Liniments. Deserted on April 6th. 1865. Mitchell, Joseph, Private, Co. D, 8th Kansas Volunteers, aged 21 years. Injury of spine by fall from bridge. Treated in hospital at Louisville, Kentucky. Tonics and stimulants. Discharged from service on August 5th, 1863. Moren. George W., Corporal, Co. C, 10th Indiana Cavalry, aged 43 years. Concussion of spine by railroad accident on May 6th, 1864. Treated in Hospital No. 2, Vicksburg. Simple dressings. Discharged from service. Parish, Mortimer, Private, Co. K, 1st Michigan Engineers, aged 24 years. Contusion of spine by fall. Treated in Hospital No. 14, Nashville, and Crittenden Hospital, Louisville. Discharged from service on May 9th, 1865. Parker, Willum W., Corporal, 176th Co., 2d Battalion, Veteran Reserve Corps. Injury of spine. Treated in Mason Hospital, Boston, Massachusetts. Simple dressings. Returned to duty on June 3d, 1864. Payne, M. C . Private, Co. A, 6th Illinois Cavalry, aged 23 years. Injury to spine by fall of horse. Treated in hospital at Quincy, Illinois. Rest. Discharged from service on November 24th, 1864. Rey, George, Lieutenant, Co. C, 100th Illinois Volunteers. Contused wound of the spine by limb of a tree. Stone River, Tennessee, December 30th, 1862. Treated in Hospitals No. 2, Nashville, and No. 14, Louisville. Returned to duty on January 18th, 1863. Richardson, Thomas C, Private, Co. D, 4th Illinois Cavalry, aged 30 years. Concussion of spine. Grierson's Raid, December, 1864. Treated in Hospital No. 2, Vicksburg. Simple dressings. Returned to duty. Ryno, Edward, Private, Co. L, 4th Michigan Cavalry, aged 22 years. Injury of spine by fall from horse. Treated in Cumberland Hospital, Nashville. Simple dressings. Discharged from service. Sabines. James, Sergeant, Co. K, 49th Ohio Volunteers. Injury of spine by falling from a wagon. Treated in general hospital at Madison, Indiana, by counter-irritation. Discharged from service on July 7th, 1864; case considered hopeless. Saunders, John B., Private, Co. K, 143d New York Volunteers, aged 47 years. Injury of spine at lumbar region by fall. Treated in Satterlee, West Philadelphia. Discharged from service. Shepherd, William, Private, Co. B, 6th New Jersey Volunteers, aged 23 years. Injury of spine in lumbar region. Treated in Mount Pleasant Hospital, Washington. Returned to duty on July 9th, 1864. Shirley, Milton D., Sergeant, Co E, 10th New Jersey Volunteers, aged 20 years, received an injury of the spine by a blow from a gun at Cold Harbor, June 3d, 1864. He was treated in Campbell Hospital, Washington. Returned to duty on August 24th, 1864. Shoemaker, Frederick, Private, Co. B, 37th Ohio Volunteers, aged 28 years. Contusion of spinal column. Treated in Crittenden Hospital, Louisville. Simple dressings. Returned to duty on August 1st, 1864. Slater, Frank, Private, Co. E, 6th New York Artillery, aged 21 years. Contusion of right side and spine by fall of horse, May 30th, 1*64. Treated in Mount Pleasant Hospital, Washington. Discharged from service on June 1st, 1865. Snelling, H. G., Private, Co. F, 9th Massachusetts Volunteers. Injury of spine. Treated at Fairfax Seminary, Virginia, and South Street Hospital, Philadelphia. Simple dressings. Transferred to Veteran Reserve Corps, June 6th, 1864. Snydeu, Columbus, Private, Co. D, 7th Ohio Cavalry. Injury of spine. Treated in hospital at Camp Dennison, Ohio. Discharged from service on June 5th, 1863. Taylor, Edward H., Private, Co. A, 37th Massachusetts Volunteers, aged 38 years. Sprain of spinal column at Cold Harbor on June 3d, 1864. Treated in Lincoln Hospital, Washington. Discharged from service on June 17th, 1865. Tilse, Willlvm, Private, Co. B, 37th Ohio Volunteers, aged 26 years. Contusion of spinal column. Treated in Crit- tenden Hospital, Louisville. Simple dressings. Returned to duty on October 4th, 1864. Travelstean, D. W., Private, Co. C, 100th Illinois Volunteers, aged 38 years. Injury of spine by a barrel falling on him at Lumsville, Kentucky, October, 1862. Treated in hospital at Quincy, Illinois. Counter-irritants, shower baths, and tonics. Discharged from service on February 17th, 1864. Wariner, James A., Private, Co. D, 16th Pennsylvania Cavalry. Injury of spine by fall from horse. Treated in hospital at Philadelphia. Cold applications. Returned to duty. White, W. J., Private, Co. E, 46th Illinois Volunteers. Injury of spine and rheumatism, by falling into a ditch Treated in hospital at Quincy, Illinois. Discharged from service on June 15th, 1865. Whitehouse, Benjamin, Private, Co. C, 1st Ohio Artillery, aged 16 years. Contusion of spine and lumbar region. Treated in Asylum Hospital, Knoxville, Tennessee. Returned to duty on May 30th, 1865. Wood, Haver D., Private, Co. F, 2d New York Heavy Artillery, aged 25 years. Contusion of spine, June 12th, 1864. Treated in Lincoln Hospital, Washington. Deserted on July 7th, 1864. 430 WOUNDS AND INJURIES OF THE SPINE. Section II. GUNSHOT WOUNDS. Cases of gunshot injury of the vertebrae were commonly fatal; yet a few examples were recorded in which the transverse or spinous apophyses only were injured, in which more or less complete recovery ensued, and fewer still in which the patients survived for a protracted interval, after fractures of the bodies of vertebra?. The following abstracts are not grouped very accurately, but are generally placed according to region and result: Fractures of the Cervical Vertebras.—In the five following cases, the patients recov- ered ; but with stiff necks or palsied arms: Case.—Private John Mason, Co. D, 17th Vermont Volunteers, aged 43 years, was wounded at Spottsylvania, Virginia, May 12th, 1864, by a conoidal ball, which entered behind and below the left ear and emerged at the base of the neck two inches to the right of the spine, injuring the spinous processes of the vertebra. He was treated in field hospital until May 23d, when he was admitted to Mount Pleasant Hospital, Washington. On May 27th, he was transferred to the hospital at Chester, Penn- sylvania. There was partial paralysis of the left arm. On June 18th, he was transferred to the Sloan Hospital, Montpelier, Vermont, and, on September llth, to Baxter Hospital, Burlington, whence he was transferred to the Veteran Reserve Corps on April 27th, 1865. Pension Examiner H. H. Atwater reports, July, 1866, that the left arm is numb and weak, and that the pensioner suffers from stiffness and pain in the upper part of the spine. Case.—Lieutenant T. L. Whitakcr, Co. D, 24th North Carolina Regiment, aged 31 years, was wounded near Richmond, Virginia, May 16th, 1864, by a round ball, which entered at the angle of the inferior maxilla, fractured the transverse processes of the fourth and fifth cervical vertebrse and lodged. He was conveyed to Richmond and admitted to Chimborazo Hospital. There was paralysis of the left arm and partial paralysis of the left leg and right arm. Cold applications were made. He was furloughed on June 7th, 1864, having partially recovered the use of his right arm and left leg. Case.—Private John Monday, Co. E, 47th Pennsylvania Volunteers, aged 19 years, was wounded at Pocotaligo, South Carolina, by a bullet, which entered the left side of the neck two inches from the spine, passed transversely across the neck through the spinous process of the sixth cervical vertebra and emerged at a point corresponding to point of entrance. He was conveyed to Beaufort and admitted, on October 24th, to Division No. 1 Hospital. The patient was unable to bend his neck, but moved the spine as a whole. A poultice and rest were ordered and half diet. On November 10th, some pieces of bone having come away, and suppuration having nearly ceased, the poultices were discontinued and cerate dressings used. He was discharged from hospital on November 16th, at which time the wounds had nearly healed, but the neck remained stiff. Case.—Private Charles G. Cleland, Co G, 7th Wisconsin Volunteers, aged 20 years, was wounded at Gettysburg, Penn- sylvania, July 2d, 1863, by a conoidal ball, which entered the right upper lip at the second incisor, destroyed all the teeth save the last molar on the same side of the upper jaw, passed below the soft palate and penetrated the posterior pharynx and the body of the third cervical vertebra. He was treated in field hospital until July 10th, when he was sent to Satterlee Hospital, and, on August 7th, transferred to Christian Street Hospital, Philadelphia. Here the presence of the ball was determined by a Nelaton probe and extracted. There was paralysis in all four limbs, from which, however, he rapidly recovered and, for a time, did duty as hospital attendant. He was transferred to Turner's Lane Hospital on March 14th, 1864. Acting Assistant Surgeon W. W. Keen, jr., on duty at that hospital, states that "nearly the entire body of the third cervical vertebra has come away, including the anterior half of the transverse process and the vertebral foramen. No injury to the vertebral artery has been disclosed. What supports his head, anteriorly, I can't conceive. On May 3d, 1864, he was transferred to Washington to be assigned to a company in the Veteran Reserve Corps. The only remnant of his paralysis is some of sensation over a surface, say three by four inches, at the back of right neck. Some bone still occasionally discharges.-' Examiner Joseph Gadd reports, April 1st, 1871, that the right side of the tongue is distorted, leaving his speech affected; that the right side of his throat ia contracted, and that the right shoulder and arm are diminished in size and partially paralyzed. Disability three-fourths and permanent. WOUNDS OF THE CERVICAL VERTEBRA. 431 Case.—Private Peter C. Miller, Co. K, 7th, Wisconsin Volunteers, aged 36 years, was wounded at the Wilderness, Virginia, May 5th, 1864. by a conoidal ball, which passed transversely beneath the trapezius muscle and emerged at its anterior margin, fracturing the spinous process of the seventh cervical vertebra. He was taken to the field hospital of the 4th division, Fifth Corps, where pieces of bone were removed and simple dressings applied. On May llth, he was sent to Douglas Hospital, Washington; on May 18th, to Satterlee Hospital, Philadelphia, and, on July 9th, to Harvey Hospital, Madison, Wisconsin, whence he was discharged from service on December 17th, 1864. Tim motion of the cervical region was imperfect and painful. The nine following abstracts relate fatal gunshot injuries of the cervical vertebrae: Case.—Private George A. A------, Co. C, 20th New York Volunteers, aged 40 years, was wounded at Gettysburg, July 2d, 1863, by a conoidal ball, which fractured the right lowur jaw and the sixth and seventh cervical vertebrae. He was admitted into the Satterlee Hospital, Philadelphia, on July 9th, 1863. On July 14th, 1863, pyjemia developed. Quinine and iron, in large doses, were administered; stimulants and generous diet were given. The patient died on July 21st, 1863. The necropsy showed the right side of the lower jaw to be fractured and comminuted midway between the symphysis and angle, and the parts in the vicinity somewhat gangrenous. The connective tissue on the right of the pharynx and descending behind the oesophagus was blackened and gangrenous. The body of the sixth cervical vertebra was broken through, and a frag- ment was chipped from the seventh. The ball was not found; it was stated that the patient had ejected it from his mouth. The (esophagus, the trachea, and the bronchial mucous membranes were inflamed. The right lung was in a recent pneumonic condition, and filled with a multitude of small abscesses. The pericardium was distended with serum, but the heart and all the other organs appeared healthy. It was stated that the patient had difficulty of breathing, but had no paralysis; he walked about until a few days before his death, and had only complained of a slight uneasy feeling when turning his neck, the fracture of which was not suspected during life. The specimens are No. 1881, Sect. I, A. M. M., a wet preparation of the lower jaw, and No. 1867, Sect. I, A. M. M., vertebrae "foiowiig gunshot fnj^y?61^! the last four cervical and first dorsal vertebra?, and were contributed, with the history, 18t>7. Sect, I, A. M. M. by Acting Assistant Surgeon Joseph Leidy. Case.—Corporal Mark D------, Co. D, llth United States Infantry, was wounded at sunrise, August 31st, 1864, while on picket duty near the Weldon Railroad, Virginia. He was soon afterward brought to the field hospital of the Fifth Corps, where, on examination, it was found that a musket ball had entered the right side of the neck, at the posterior border of the sterno-cleido-mastoid muscle near its middle, and passed inward, downward, and backward. Some swelling and discoloration existed upon the left side of the neck, at and above the clavicle, but the ball could not be felt. Paralysis of motion was complete in the extremities and sensation was lost in them except in the arms near the shoulders, where it still existed to a slight degree. Nearly the entire trunk was without sensation and its only motion was that of respiration, which was performed by the diaphragm. The bladder was paralyzed, and the urine drawn off with a catheter. The bowels were not under the control of the will. Deglutition and respiration were slightly obstructed by swelling of the tissues near the track of the bullet. The patient could whisper, but spoke aloud with difficulty. His pulse was at first nearly normal, but afterward became weak and frequent. The lividity of the countenance indicated a want of aeration of the blood. The shock from the receipt of the wound seemed to be slight and he retained his intellectual faculties until death, which took place at eleven o'clock p. m., September 1st. At the post mortem examination, the ball was found in the subscapular muscle in contact with the scapula of the left side. It had taken a direct course from its entrance, and passed diagonally through the bodies of the fifth and six, and fractured the laminae and transverse processes of the sixth and seventh cervical vertebrae, slightly lacerating the spinal cord and forcing it to one side of the canal and compressing it seriously in its passage. The pathological specimen, consisting of portions of the last four cervical vertebrae, was contributed to the Army Medical Museum by Assistant Surgeon Edward Brooks, U. S. A., and is numbered 4157 of the Surgical Section. Case.—Lieutenant George C------, Co. K, 20th North Carolina Regiment, aged 24 years, was wounded at Monocacy Junction, Maryland, July 9th, 1864, by a conoidal ball, which entered the anterior part of the neck immediately to the left of the thyroid cartilage, passed through between the roots of the seventh and eighth cervical nerves, and emerged between the spinous processes of the seventh cervical and first dorsal vertebrae, a little to the left of the neck. He was taken to Frederick, and admitted on the next day to the 1st division hospital. Simple dressings were applied. By August 4th, the wounds of entrance and exit had entirely healed. Large bed-sores had formed on the back, arms, and legs. There was entire paralysis, with involuntary discharge of urine and feces and a profuse diarrhoea. He was placed upon a water-bed and tonics and stimulants, in connection with opiates and astringents, given internally, but the diarrhoea obstinately persisted, and the patient sank exhausted and died on August 12th, 1864. The autopsy revealed a slight effusion of blood between the membranes and cord on the right side and external to the membranes on the anterior part of the spinal cord. There was no direct injury to the cord. The pathological specimen, consisting of a wet preparation of the bodies and transverse processes of the last cervical and first two dorsal vertebrae, with the corresponding portion of the cord, were contributed to the Army Medical Museum by Assistant Surgeon R. F. Weir, U. S. A., and is numbered 3976 of the Surgical Section. Case.—Sergeant J. H. R------, Co. H, llth Pennsylvania Reserves, was wounded at Fredericksburg, Virginia, Decem- ber 13th, 1862. The ball entered near the inferior angle of the scapula, fracturing the anterior border, neck, and coracoid process; it then passed through the left clavicle, causing a fracture of the outer and middle thirds; then behind the scaleni muscles, carrying away the transverse processes of the third and fourth cervical vertebrae, laying bare the vertebral artery, 432 WOUNDS AND INJURIES OF THE SPINE. opening the sheath of the carotid, and finally lodged behind the symphysis of the inferior maxilla. He was conveyed to Wash- ington, and, on December 16th, admitted to Carver Hospital. Death resulted on December 22d, 1862. The autopsy revealed great infiltration of blood in the cellular tissues of the neck and in the mediastinum. The pathological specimens, consisting of the fractured clavicle and scapula, with the third, fourth, and fifth cervical vertebrae, are numbered 640, 641, and 901, Surgical Section, Army Medical Museum, and were contributed, with a history of the case, by Surgeon O. A. Judson, U. S. V. Case.—Private W. P------, jr., Co. F, 114th Pennsylvania Volunteers, was wounded at the battle of Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which entered about an inch below and back of the left mastoid process, passed inward and upward, and lodged. He was treated in the field hospital for several days, was then put on board of the steamer State of Maine, and conveyed to the 1st division hospital, Annapolis, Maryland. On June 2d, the wound was enlarged and the ball discovered, supposed to be sticking about the mastoid process, and an unsuccessful effort made to extract it. On June 3d, the wound was still further enlarged, and a few small pieces of lead removed with the bullet-forceps, the ball still remaining in the head. About an hour after the operation, the patient complained of a severe chill, from which he soon recovered upon the administration of brandy. June 5th, pulse 160. Nervous twitching of the upper lip. Urine difficult to pass and highly colored. On the morning of June 6th, he vomited a greenish fluid; an enema was administered, which produced a free evacuation of the bowels and the vomiting ceased, but he became delirious and weak, and failed rapidly until June 8th, when death supervened. At the autopsy, the ball was found lodged against the occipital and atlas, producing a fracture of the atlas and a fissure of the left portion of the occipital. It is supposed that the attempts made to extract the ball were unsuccessful on account of the contraction of the muscles of the neck. The pathological specimen is No. 1710, Section I, A. M. M., and was contributed, with the history, by Surgeon B. A. Vanderkieft, U. S. V. Case.—Private Leverett E------, Co. A. 8th Connecticut Volunteers, aged 22 years, of small stature and feeble build, was wounded at Antietam, Maryland, September 17th, 1832. by a musket ball, which entered the open mouth about the middle of the left anterior pillar of the fauces and emerged at the back of the neck two inches from the spinous process of the second cervical vertebra, on its left side. He was treated in field hospital until the 22d, when he was admitted to the hospital at Frederick, Maryland. He stated that, upon the reception of the injury, he lost considerable blood, producing faintness for several hours. After admission, patient did well until October 31st, when arterial haemorrhage occurred to the amount of a wine-glassful, recurring slightly two days after. On November 13th, after eating breakfast, his mouth was observed to turn inward; all facial expression on the left side was gone. In an hour, muttering delirium occurred. Death resulted on November llth, 1862. The autopsy revealed that the internal artery was cut by the ball and closed by a strong coagulum. The remainder of the artery had disintegrated and had passed away in the discharge. The haemorrhage was from small openings in the external carotid. The pathological specimen is numbered 778. Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon Redfern Davies. Case.—Private David A. C------, Co. D, 4th New York Heavy Artillery, aged 27 years, was wounded at Petersburg, Virginia, March 31st, 1865. by a conoidal ball, which entered on the left side of the neck and passed through the vertebra, producing paralysis of the lower extremities and left arm and hand. He was taken to the field hospital of the 1st division, Second Corps, where simple dressings were applied to the wound, and he was sent, after several days, to Harewood Hospital, Washington. On admission, the condition of the injured parts appeared to be tolerably good, but the constitutional state of the patient was very low; he was entirely unable to move his limbs, and, at times, to retain his urine and feces. He remained in this condition, notwithstanding the free use of tonics, stimulants, and a supporting treatment throughout, and gradually sank and died on April 29th, 1865. from exhaustion. The pathological specimen is No. 4346, Section I, A. M. M., and was contributed, with a history of the case, by Surgeon R. B. Bontecou, U. S. V. Case.—Private E. W. V------, Co. K, 1st Virginia Cavalry, received a gunshot wound ofthe neck at Suffolk, Virginia, April 13th, 1863. He was conveyed to Baltimore, where death resulted on May llth, 1863. The pathological specimen, No. 1791, Section I, A. M. M.. consists of several cervical vertebrae, showing the bodies of the third and fourth entirely carried away by gunshot and subsequent suppuration. The borders of the cavity are necrosed, and the membranes have ulcerated sufficiently to expose a large extent of the cord. The specimen illustrates how life may be preserved for a long time after extensive injury to the spinal cord. It was contributed by Surgeon B. Beust, U. S. V. Case.—Sergeant George E------, Co. A, 2d Texas Cavalry, an unusually robust and healthy man, was, on June 4th, 1865, shot twice by a comrade. He was immediately taken to the hospital at Brownsville, Texas. One ball entered one-fourth of an inch below the frontal sinus, fractured the nasal bones and the internal angular processes of the os frontis, and passed downward and backward, but could not be found. The other ball entered about half an inch below the clavicle, passed to the opposite side of the body, and lodged about half an inch below the middle of the posterior border of the left scapula, whence it was removed immediately after admission to the hospital. His sufferings from the effects of the second ball were great during the first month and a half. He was kept in a semi-recumbent posture, as the prone or supine condition would greatly increase the pain. On August 23d, he was removed to camp, a distance of three-fourths of a mile. The wound of head had apparently healed, and the wound beneath the clavicle suppurated slightly; the pulse was feeble and rapid. He was kept under the influence of morphia, and expressed a constant fear lest he might be freed from the power of the narcotic, and left exposed to the violence of pain in his chest. He was somewhat emaciated, but his appetite was good. Simple dressings were applied to the wound in the clavicular region. On September 5th, he was, apparently, fast sinking. Stimulants were given, which he was unable to bear. Even wine caused increased circulation and greater dyspncea from coughing. The morphia was continued. On the 9th, diarrhoea set in, which was checked with diarrhoea mixture. On the 16th, patient was nervous and anxious ; otherwise he was as usual. On September 25th, the wound of chest sloughed more freely, and the pain and dyspnoea had become intense. Morphia and balsam, with cough mixtures, were given. He complained a few times of pain in the head and neck. On Septem- ber 30th, he was disconsolate and requested to be discharged "that he might go home to die.'' He was able to walk a few yards FRACTURES OF THE DORSAL VERTEBRA. 433 from his bed and return. On October 10th, he had become perceptibly weaker, and died on October 20th, having survived his injuries four months and sixteen days. At the autopsy, the internal organs of the thoracic cavity were found in a normal condition, with the exception of the right lung, which was very much disorganized. The ball had broken off a splinter of the lower border of the clavicle, at a point below the outer attachment of the deltoid muscle, also a small portion of bone from the outer border of the first rib, and passing through the apex of the right lung in an oblique direction, made its exit between the fourth and fifth ribs, both of which were fractured near the spine. The ball in the head had fractured the ethmoid bone, and had extensively comminuted the sphenoid bone in its passage to the third cervical vertebra, where, impinging upon the right trans- verse process, it was found lodged and encysted in the muscular fibres of the rectus and scaleni muscles. The substance of the brain had not been injured in any way. The ease is reported by Acting Assistant Surgeon A. L. Norris, who also contributed the specimen, No. 3851, Section I. A. M. M., a wet preparation of the third, fourth, and fifth cervical vertebrae, of which the anterior portion of the body of the fourth, on the left side, is fractured by a bullet. Fractures of the Dorsal Vertebral caused by gunshot were generally mortal, unless the lesion was confined to the apophyses. Wounds of the bodies of the vertebrae were usually associated with penetrating wounds of the chest or abdomen. Abstracts of a few cases of recovery after injury of the spinous, transverse, and articular processes are appended: Case.—Private William Moran, Co. F, 22d Kentucky Volunteers, aged 28 years, was wounded, at Champion Hills, Mississippi, May 16th, 1863, by a ball from a canister-shot, which entered beneath and about the middle ot the spine of the scapula, passed through the infra-spinatus muscle, came in contact with the spine, which it fractured, and entered the supra- spinatus muscle. He was treated in the field until June 4th, when he was taken on board the hospital steamer R. C. Wood, and conveyed to Memphis, entering Union Hospital on the 8th. The wound was explored in search of the ball, but it could not be found; fragments of comminuted spine were extracted. Large fragments still remained, attached by soft tissues, which were not removed. About June 26th, gangrene set in. Wound about two inches in diameter; edges black and sloughy; large slough quite deep in the wound. Nitric acid and poultices were applied, and large doses of morphine given to quiet the nervous system and procure sleep. Under this treatment the condition of the wound improved, and, by July 12th, was granulating finely. August 1st. wound filled with granulations to a level with the skin, and became much smaller. October 1st, wound completely healed. Patient in excellent health. He was returned to duty on December 7th, 1863. Cask.—Lieutenant James Sample, Co. B, 118th Illinois Volunteers, aged 35 years, was wounded at Edward's Station, Mississippi, July 1st, 1863, by a musket ball, which entered near the upper portion of the left scapula, passed between the first and second dorsal vertebrae, shattering the processes and injuring the spinal column, passed through the upper portion of the right scapula, entered the right cavity of the chest, and following the course of tbe first rib, passed through the right shoulder joint and emerged at the axilla. He was discharged from service at New Orleans on December 1st, 1863. Pension Examiner Charles Hay reports, on October 25th, 1865, that a gradual improvement is slowly taking place. The next case is, if the diagnosis was indubitable, a very remarkable instance of recovery: Case.—Corporal W. B. Weldon, Co. A, 13th Massachusetts Volunteers, aged 24 years, was wounded at Gettysburg, Pennsylvania, July 2d, 1863, by a conoidal ball, which entered the left -side between the eighth and ninth ribs, passed through the spine, touching the spinal cord, and emerged between the fourth and fifth ribs. He was treated in the field hospital until August 21st, when he was sent to the hospital at Camp Letterman. The wounds had nearly healed. September 12th, paralysis of the right leg. Stimulants were given and the limb rubbed with liniments from hip to ankle. On October 9th, he was trans- ferred to Turner's Lane Hospital, Philadelphia, and, on January 13th, 1864, to Lovell Hospital, Portsmouth Grove, Rhode Island, whence he was discharged fi-om service on February 2d, 1864. Acting Assistant Surgeon H. H. Dutton reported the case. Pension Examining Surgeon Geo. Stevens Jones reported, April 28th, 1861. that "the ball entered at the bend of the tenth rib, passed obliquely upward and out of left axilla, where it entered the left arm in its upper aspect, and was extracted at the middle of the arm. In consequence ofthe injuries to the back, he has some pain, besides suffering from other inconvenience. Disability one-half, not permanent." Case.—Private Luther Weaver, Co. B, 126th New York Volunteers, aged 27 years, was wounded at Gettysburg, Penn- sylvania, July 3d, 1863, by a conoidal ball, which entered the right lumbar region on a level with the tenth rib, passed across the spine, fracturing the spinous and transverse processes ofthe tenth dorsal vertebra, and lodged in the muscles on the left side. He was treated in the field hospital until July 24th, when he was sent to Camp Letterman Hospital. On admission, his general health was feeble. Cold-water dressings were applied to the wound and stimulants administered. Under this treatment, the patient improved very much. On August 5th, several spiculae of bone were removed. He was transferred to Mower Hospital, Philadelphia, on September 15th, and returned to duty on November 25th, 1863. Case.—Corporal W. A. Freeman, Co. B, 13th North Carolina Regiment, aged 24 years, was wounded at Williamsburg, Virginia, May 5th, 1862, by a musket ball, which entered two inches below the spine of the left scapula, passed upward and inward, and escaped midway between the spine of the right scapula and the right clavicle. He was admitted, on the 12th, to Cliffbum Hospital, Washington. A counter opening had been made in the track of the ball to the left of the vertebral column, 55 434 WOUNDS AND INJURIES OF THE SPINE. and from this and the orifice of exit the discharge of pus was profuse. Digital examination through the counter opening showed a shattering of the spinous processes of two of the dorsal vertebrae, and the existence of a large abscess over the muscles to the right of the vertebne. A free transverse incision was made over the spine, the splinters of bone removed, sharp projecting points snipped off, and the carious portions gouged away. The cavity left was stuffed for two days with lint soaked in laudanum and subsequently with dry lint. The wound did very well. By July 3d, the wound had healed; the bullet holes were cicatrizing, and the cavity left by the operation was filling up with granulations. It was dressed lightly from the bottom with dry lint, the edges of the wound being approximated and supported by adhesive straps. By June 30th, the wounds had entirely healed. On July llth, 1862, he was transferred to Old Capitol Prison? Case.—Private Frederick Newman, Co. F, 81st New York, aged 18 years, was wounded at Drury's Hluff, Virginia, May 16th, 1864, by a fragment of shell, which fractured the spinous processes of the dorsal vertebrae. He was treated in the field, and, on May 19th, sent to Hampton Hospital, Fort Monroe. Simple dressings were applied to the wound. On July llth, he was transferred to McDougal Hospital, Fort Schuyler, New York Harbor, and, on April 6th, 1865, to the hospital at Rochester, New York, whence he was discharged from service on June 12th, 1865. There was partial paralysis of the lower extremities. Case.—Private Isaac N. Mitchell, Co. G, 8th Pennsylvania Reserves, received a gunshot wound directly across the back, injuring the dorsal muscles and spinous processes, and causing concussion of the spine, at Gaines's Mill, June 27th, 1862. He was treated in the field until August 26th, when he was transferred to the 1st division hospital at Annapolis. Returned to duty on January 30th, 1863. Case.—Private William B. Morse, Co. A, 40th New York Volunteers, aged 20 years, was admitted to Stanton Hospital, Washington, June 15th, 1863, from the field hospital of the Army of the Potomac, at Potomac Creek. He said that he had been injured in the battle of Chancellorsville, May 3d, 1863, by the explosion of a shell; that he was lying on the ground on his right side, in line of battle, under a heavy artillery fire, when something hit him violently on the left side and knocked him senseless. When he came to, his mouth was filled with clotted blood. He spat blood for two days, with a cough which had not yet entirely left him. His left side was swelled up, and was tender from the armpit all the way down to the hip. He could not move the left leg at all, the thigh included, and had but partial use of the right one. Sensation also was nearly abolished in the left lower extremity. The motion and sensation of the left upper extremity were considerably impaired. He had not had any difficulty in holding or voiding his urine. He stated that the left side appeared to be badly bruised, but the skin was not broken. When admitted to hospital, the partial paralysis still continued and was most marked in the left lower extremity. He had dyspncea and cough, but no expectoration. The left thorax was much shrunken and tender under pressure. The left shoulder had fallen down a good deal below the level of its fellow on the opposite side. There was lateral curvature of the spine, and his posture in bed bore a strong resemblance to that produced by pleurosthotonos of the left side. Nothing abnormal was detected by auscultation and percussion. There was no swelling or ecchymosis ofthe injured side, or evidence that the ribs had been fractured. He complained of much soreness in the walls of the left thorax and left side generally, and the motion of the left arm seemed to be much impaired on that account. His intellect was clear, and he presented no symptoms whatever diagnostic of a cerebral lesion. He was thin and rather pale; bowels constipated. He was manifestly suffering from the consequences of extensive contusion of the left side and concussion of the spinal cord. J)ry cups were ordered to be applied daily over the spine and the bowels to be kept open with laxatives. He was allowed full diet. The dry cupping seemed to benefit him very much and the paralysis was rapidly disappearing. By August 15th, he was up and going about on crutches. The cups were discontinued, and acetate of strychnia prescribed in small doses. This remedy was discontinued at the end of a month, as it appeared to do him but little, if any, good. During the fall and winter he continued to improve slowly, and, by the middle of March, threw his crutches aside, preferring to walk with the.aid of a cane only. April 10th, 1864 : He stands erect; the falling down of the left shoulder, the shrinking of the left side, and the posture simulating pleurosthotonos have entirely disappeared. The left thigh is a trifle smaller and more flaccid than the right one. At times, he has a feeling of numbness and tingling in the left arm, but none in the right, and the same abnormal sensations in the left thigh and leg, but not in the right. He presents a curious limp in his gait in walking. His body sinks very low on placing its weight on the left limb, from deficiency in the power of the extensor muscles, as compared with that of the flexor muscles of the limb, to support the body at its proper height in walking, and thus a strange hobbling is produced like that in some cases of rupture of the ligamentum patellae. He was discharged from service on April 18th, 1864. Of fatal cases of gunshot injury of the dorsal vertebrae, there were numerous illus- trations, with great variety in the character of the lesions, as the processes, laminae, bodies, or spinal canal might be involved. Reasoning only from the cases that came under treat- ment, it would be admitted that gunshot fractures of the dorsal vertebrae had hardly a larger fatality than amputations of the thigh; but the many examples of immediate death on the field would then be overlooked. It will be remarked, in the abstracts that follow, that although those cases complicated by wounds of the great cavities often terminated fatally at an early date from the reception of the injury, those in which the spinous processes and laminae were alone implicated were usually lingering and fatal from secondary causes. FRACTURES OF THE DORSAL VERTEBRAE. 435 Illustrations of these injuries are fully afforded by the specimens in the Army Medi- cal Museum, and the abstracts of histories of over an hundred additional cases. Some of the more remarkable are here cited: Case.—Corporal William J. F------, Co. B, 1st Michigan Volunteers, was wounded at Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which fractured the second dorsal vertebra. He also received a wound of the left eye, and a scalp wound of the left side. He was admitted, on the same day, to the field hospital of the 1st division, Fifth Corps, and transferred, on May 9th, to Armory Square Hospital, Washington. The sight of the left eye was gone, and there was paralysis of the lower extremities. Death occurred on May 13th, 18i*>3. At the necropsy, the ball was found to have lodged in the spinal canal. The right rib was shattered in its head. The right lung was very much congested. The pathological specimen is No. 1114, Section I. A. M. M., and was contributed, with a history of the case, by Assistant Surgeon C. C. Byrne, U. S. A. Most of the fractures of the third dorsal vertebra were complicated by wounds of the thorax, as in the three following cases: Case.—Private William L. B------', Co. I, 21st Georgia, aged 22 years, received a gunshot penetrating wound of the chest at Fort Stevens, District of Columbia, July 12th, 1864. 1 le was admitted, on the 14th, to Lincoln Hospital, Washington. When admitted, he was suffering intense pain in the chest; retention of urine and faeces; total paralysis, in lower extremities, of both motion and sensation; breathing, labored and painful; pulse, 100. Cold water dressings were applied, and opiates administered. He died on July 15th, 1865. At tlie autopsy a wound was found directly over the center of the left clavicle, made, apparently, by a bullet, but, on attempting to introduce the finger, it was found to be closed. The first rib was fractured at its greatest curvature, but was not entirely broken across. There was one hundred and eight ounces of bloody fluid in the thoracic cavity. The right lung, with the exception of a few recent adhesions on the posterior aspect of the lower lobe, was healthy. The left lung had a hole through it about one inch from the apex, through which the linger could be introduced. It was very much compressed by the fluid. The ball entered at the attachment of the rib to the third dorsal vertebra, the left transverse process of which it fractured, and was found lying against the left lamina of the fourth dorsal vertebra, which it had fractured from its pedicle, and by pushing it outward and backward had fractured the lamina of the opposite side and the' spinous process. The pathological specimen is'numbered 2S43, Section I, A. M. M., and was contributed, with a history of the case, by Acting Assistant Surgeon H. M. Dean. Case.—Private Nathan P------*, Co. G, 121th New York Volunteers, aged 18 years, was wounded at Spottsylvania, Virginia, May 10th, 1864, by a conoidal ball, which caused a penetrating wound of the chest. He also received a shell wound over the renal region. He was taken to the hospital of the 3d division, Second Corps; and, on May 16th, transferred to Lincoln Hospital, Washington, where he died on May 17th, 1834. At the autopsy, the ball was found to have entered two and one-fourth incbe3 posterior to the right acromion process, and one inch below the spine of the scapula, causing extensive comminution of the spinous and transverse processes of the third, fourth, and fifth dorsal vertebrae of the right side, and corresponding ribs posterior to their angles, penetrated both lungs, and destroyed that portion of the spinal cord lying between the third and fourth vertebrae. The cord was also diffluent for one-half an inch above the third dorsal vertebra. Above and below these points it was entirely healthy. The fourth rib of the opposite side was fractured at its vertebral attachment. The ball was found in the posterior fold of the axilla. The pathological specimen is No. 2330, Section I, A. M. M., and was contributed by Acting Assistant Surgeon A. Ansell. Cask.—Private James T. L------, Co. G, 18th Massachusetts Volunteers, aged 18 years, received a gunshot penetrating wound of the chest at Bull Run, Virginia, August 30th, 1862. He was treated in the field until September 12th, when he was sent to Master Street Hospital, Philadelphia. Death resulted on September 17th, 1862. Necropsy: The missile had entered over the head of the right humerus, splitting off a fragment of it, passed through, fractured the spine of the scapula, coracoid, and acromion processes*, wounded the lung, driving spiculae of bone into it, thence fractured the spine of the second and the right transverse process of the third dorsal vertebrae and emerged through the deltoid muscle, having passed through the left scapula at the base of its spine. The pathological specimen is No. 843, Section I, A. M. M., and consists of the second, third, and fourth dorsal vertebrae; the fragments are partly agglutinated by new cteposit and the spiculae are necrosed. It was contributed, with a history of the case, by Surgeon P. B. Goddard, U. S. V. In the three following cases of gunshot fracture of the fourth dorsal vertebra, the usual symptoms of paralysis and functional disturbances of the alimentary canal and urinary organs were observed: Case.—Private Frank N. H------, Co. G, 101st Illinois Volunteers, aged 24 years, a muscular man, in excellent health, was wounded on board the ram " Switzerland," at Simmsport, Louisiana, June 3d, 1863, by a conoidal ball, which, passing through an oak plank two inches in thickness, entered the body about two inches above tlie inferior angle of the left scapula, and passed transversely upward and a little forward. Complete paralysis of the lower portion of the body immediately ensued. A small quantity of air escaped from the wound during the first hour, but none subsequently. The external haemorrhage was slight, and but about four ounces of blood were ejected from the mouth. The respiration was but little affected, and the action of the heart somewhat increased. The introduction of a probe wan quite impossible, the tendons and aponeurotic tissue present- ing an impassable barrier. The patient was placed in bed in a sitting posture, supported by pillows and seemed to be quite comfortable. There was retention of urine and involuntary evacuations fi-om the bowels on the following day, as also slight 436 WOUNDS AND INJURIES OF THE SPINE. fever. The expectoration of blood and mucus continued about twenty-four hours, becoming gradually less. On the 5th, the fever had somewhat abated and he expressed himself as feeling comfortable. On the 6th, he was transferred in an ambulance, over a wry rough corduroy road, to the hospital steamer Woodford. A few hours after his transfer, he became delirious, and died on the morning of June 7th, 1863. At 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. M. M., 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 day, 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 fourth dorsal vertebra. Stimulants and tonics, with nourishing and sustaining diet, were given. On May 12th, pneumonia of the left lung set in, which rapidly passed into the third stage. His tongue was clean and appetite tolerably good, but his 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 foeces passed continuously and involuntarily, the urine displaying the turbid appearance and strong ammoniacal odor so characteristic of lesions of the spinal cord. He continued to grow worse and died on May 27th, 1863. At the autopsy, 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 obliquely downward and forward, and lodged in the body of the fourth rib, fracturing, in its course, the spine of the fourth dorsal vertebra. 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.—Private Oliver A. N------, Co. B, 13th New York Cavalry, aged 21 years, was wounded at Aldie, Virginia, July 6th, 1864, by a conoidal 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 was 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 right lung, and the ball imbedded in the fourth dorsal vertebra. The pathological specimen is No. 3333, Section I, A. M. M., and was 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 pleura] cavity. The 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: Case.—First Lieutenant J1. 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 pneumonia and secondary haemorrhage. At the autopsy, the track of the ball was shown to have been in the long axis of the arm and down the chest. The pathological specimen is No. 3515, Section I, A. M. M., and shows portions ofthe dorsal vertebrae, with a pistol ball firmly imbedded in the body ofthe 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 Wisconsin, aged 20 years, was wounded in the left chest and left leg at Peters- burg, Virginia, April 6th, 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, passed inward and downward, and slightly backward, lodging between the laminae ofthe fourth and fifth dorsal vertebrae, the apex of the ball entering the spinal canal, but not pressing upon or interfering with the theca. The pleural sac had been opened between the angles and heads of the fourth and fifth ribs, left side. Outside of this point of opening, the callus had formed an arch between the angles, so that the finger passed over a smooth surface in approaching from the outside the point of opening 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, March 25th, 1865, by a conoidal ball, which entered midway between the centre of the left clavicle and the sterno- cleido-mastoid 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 vertebrae, and was found lying loosely on the sixth rib, riglit side. He was treated in the field hospital, and, on the 30th, was sent to Lincoln Hospital, AVashington. Tonics and stimulants were FRACTURES OF THE DORSAL VERTEBRiE. 437 administered. Death occurred on April 5th, 1865. The necropsy revealed the course of the ball. The upper lobe of the left lun<* and the lower lobe of the right were found to be very much congested. There was some effusion on the right side. The patholos- A. The specimen is figured in the adjoining cut. Fio. 200.—Fourth lumbar vertebra, with fragments of a ball impacted. Spec. 683, Sect. I, A. M. M. FRACTURES OF THE LUMBAR VERTEBRA. 449 Of gunshot fractures of the fifth lumbar, two cases may be recorded, in which the specimens have been preserved: Case.—Private James D------, Co. B, 5th Minnesota Volunteers, aged 'Jl years, received a gunshot penetrating wound of the abdomen at Nashville, Tennessee, December 15th, 1864; he also received a gunshot fracture of the bones of the face. He was admitted, on the same day, to Hospital No. 8, Nashville. When admitted, a large piece of the omentum, four inches in breadth by five inches in length, protruded from the abdominal wound. There was great depression and constant vomiting. The hernia of the omentum was reduced. He died on December 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 ofthe ilium, passed inward, penetrated the ilium at two points, slightly fractured the body of the last lumbar vertebra, and lodged in the right iliac fossa. There was intense peritonitis everywhere prevalent, the membrane being injected and of a red and green color, and, at many points over the viscera, layers of lymph were found. Fcecal matter, mixed with escaped blood, was found about the spinal column and in pelvic cavity. The right ilium was roughened 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 Surgeon H. C. May. Case.—Private Michael H------, Co. 1). 13th New York Volunteers, received a gunshot penetrating wound ofthe lumbar region at Gaines' Mills, Virginia, June 27th, 186.2. 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 September 5th, he 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 inconvenience; the wound healed slowly but entirely, and the general symptoms were not sufficient to attract attention. On October 20th, after dissipation, he complained 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 developed 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 readily an eyed probe. About December 20th, both legs had 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 diarrhoea, and the stomach generally retained the anodynes, stimulants, and nourishing 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 plastic matter. The ball was found lodged in the spinal canal, opposite the fifth lumbar 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 the first sacral and fifth lumbar vertebrae. The left lamina of the first sacral bone was carried away. 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 the 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 plexus of the left side was 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 membranes without affecting the movement or sensation of the lower limbs. The complete closure of the wound, and the development of the disease in the bony structures that had received the shock of the ball, three months after the injury, was also worthy 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 Surgeon George R. Morehouse. A very complicated case, in which the lumbar vertebra? were implicated, but the thoracic and abdominal viscera as well, will be reverted to under the head of thoracentesis: Case.—Corporal Samuel Foulkrod, Co. G, 56th Pennsylvania Volunteers, aged 34 years, Avas 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, and, on May 12th, sent to the 3d division hospital, Alexandria. It was thought that some of the vertebral processes were shattered. Several fragments of bone came away, and the wound healed very slowly. After the wound healed, abscesses formed in the sacral region from time to time, which gave vent to considerable purulent collections. He was transferred, on October 8th 1834, to the 102d company, 2d battalion, Veteran Reserve Corps. On February llth, 1835. the patient had an attack of acute pleurisy Wet cups were applied to the right chest, and six or eight ounces of blood withdrawn. This was followed by fomentations and purgatives, with an anodyne at night. February 12th : Abatement of febrile action. Effusion in right pleural sac, extending up to the fifth rib anteriorly. Patient placed in an upright position. February 20th, accumulation in right pleural sac has increased. Flatness, on percussion, as high as the third rib anteriorly; no respiratory act audible below this point. No dyspncea. Decubitus on right side. Appetite fair; pulse 90, and soft. Patient complained of weakness. February 28th, marked increase of fluid inchest. On March 2d, a rapid accumulation was noticeable; complete flatness on right side, extending under. Liver depressed three or four inches. Apex of heart, two inches to the left of the nipple. Great dyspncea; pulse, 130. Hectic fever, followed by profuse perspiration. The operation of thoracentesis was decided upon, and was performed by Assistant Surgeon Samuel B. Ward, U. S. V. A straight trochar was passed 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 patient experienced no faintness during the operation and felt greatly relieved. After the operation, the heart and liver returned to 57 450 WOUNDS AND INJURIES OF THE SPINE. FIG. 202. — Transverse simple fracture of first lumbar vertebra. Spec. 149, Sect. I, A. M. M. their positions. The condition of pneumo-hydro-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 dullness extending as high as the fourth rib. On April 1st, the incision of opeiation 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 16th, 1865. The case is reported by Surgeon Edwin Bentley, U. S. V. Before summing up the results of the entire series of cases of injuries of the spine, wood- cut illustrations may be 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 Sergeant C-----, 26th Massachusetts, detailed on page-447. The ball, penetrating the thick lumbar muscles, shattered the right upper 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 Rich, Co. B, 55th Pennsylvania Volunteers, aged 21 years, having been wounded at the battle ot 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 spine 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 vertebrae are tender to the touch, as are also the upper dorsal vertebra. October 26th: Much in the same condition; antimony continued; low diet, and poultice to wound. October 27th : Respira- tion 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 assistance. 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, Fio. 201.—Lower part of spinal cord lacerated at the dors-o-lumbar junction. Spec. 150, .Sect. I, A.I.I. M. Fig. 203.—Third and fourth lumbar vertebrae, with a conoidal ball imbedded in the inter-vertebral d isk. Spec. 3796, Sect. I, A. M. M. FRACTURES OF THE LUMBAR VERTEBRA. 451 November 4th, but the stiffness of spine and inability to move the arms remain. November 18th : The poultice was discon tinned yesterday, and cerate dressings ordered. The patient can now move his arms somewhat, and sits up an hour or two dailv. 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 1 st, 1862: Rich has been walking around the ward since the 20th of November, and complains only of a feeling of stiffness 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 tlie 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 16th, 1865, and pensioned, his disability being rated total and permanent. Pension Examiner C. II. Rahter reports, under date of November 20th, 1868, that the patient's respiration is hurried, and he complains of constant pain in the chest. On May 3d, 1871, Pension Examiner S. M. Finley reports that "the wounds discharge freely every four or five months. There is great tenderness over the second rib ; is much troubled with cough and breathes hurriedly. There is dullness 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 York 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 the left scapula, below the supra-spinous process, and emerged posteriorly 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 6th, 1865. Pension Examiner A. P. Cook reports on August 5th, 1869, that there is inability to elevate the arm 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, aud compressed the spinal marrow. The man is a great sufferer, and is incurable. Disability total. The following abstracts relate to fatal complicated gunshot injuries of different parts of the vertebral column. It is unusual to find balls perforating the laminae and dividing the cord with comparatively little injury to the osseous structures. The following is an example of such an injury: Cask.—Corporal W. N------, Co. C, 142d Pennsylvania Volunteers, having been wounded at Fredericksburg, December 13th, was admitted to hospital at Alexandria, December 19th, 1862. A ball had entered one inch and a half above the outer third of the right clavicle and lodged. The patient was weak, and had an anxious countenance; there was considerable dyspncea, 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 patient remained unchanged. The diarrhoea became worse by the 28th, and dyspnoea increased, the breath passing through the wound. The patient died on December 31st, 1862, with very great dyspncea. 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 ofthe stomach. There was red hepitization ofthe injured lung, and a little pus was found iu the thorax. There was nothing to indicate the occurrence of Fig. 204.—Conoidal haemorrhage. The treatment of this case was expectant. The missile was contributed to the Army JJurved, with the apex Medical Museum, with the foregoing account, by Acting Assistant Surgeon G. F. French. It is repre- obliquely flattened and a „ * j • ,i ,. . . ,^ „„ fragment rent off. Spec. sented in the adjoining cut (Fig. 204.) 4483, Sect. I, A. M. M. Case.—Private Ii. 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 June 1st, 1864, the ball entering the first lumbar vertebra and ranging upward. He died June 3d, 1864. Paralysis did not occur. Surgeon P. F. Brown, P. 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 May 24th, 1865. A rifle ball had entered immediately below the spine of the right scapula, passed obliquely downward and inward, and entered the thorax through one of the riglit 4^2 WOUNDS AND INJURIES OF THE SPINE. ribs two inches from the vertebral column. The chief symptoms were inflammation of the right lung, high fever, and bloody expectoration. The treatment pursued was strictly antiphlogistic; bleeding, purging, sedatives, and spare diet. Death occurred on Mav 28th, 1865. 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 reported 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, 1862, by a conoidal ball, which entered near the clavicle to the left of the sternum, and lodged near the spine on the same side. On April llth, he was admitted to the hospital at Mound City, Illinois. Haemoptysis for first four days. Severe pain in lung and labored respiration. Arterial sedatives were 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 16th, hsemorrhage occurred from the large vessels in upper part 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 column. The case is reported by Surgeon E. C. Franklin, U. S V. Case.—J. W. 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 riglit 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 Sped men 4037, Sect. I, A. M. M.) The ball then shattered the bases of the left fourth and fifth lamina?, driving bony fragments among the muscles, and made its exit at the left 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 April 28th. Immediately after the reception of the injury, there was very general paralysis. The phrenic nerves performed their functions; but the respiration was diaphragmatic, of course, and labored and slow. Deglutition was impracticable, and one or two attempts at articulation were unintelligible. Death, from 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 Eatteo, 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 displacing 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 ofthe abdominal muscles and diaphragm set in, which continued steadily increasing in intensity. Anaesthetics were administered, and the urine was drawn off by a catheter. On the evening of the next day, he fell into a sleep, upon awaking from which the spasms returned, and continued until death, which occurred at eleven o'clock p. at., July 7th, 1863. Gunshol. 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 XIX. Results of Six Hundred and Forty-two Cases of Gunshot Injuries of the Vertebra. Fk;. 205.—Third, fourth' and fifth cervical vertebrae, showing gunshot fracture of the fourth and fifth. Spec. 408b\ Sect. I, A. M. M. REGION. Cervical. Dorsal. Lumbar........... Cervical and Dorsal. Dorsal and Lumbar. Vertebrae not stated. Aggregate. Cases. 91 137 149 2 3 260 642 Discharged. Duty. Unknown. 63 19 8 1 87 32 18 66 51 28 4 1 1 3 129 72 50 9 349 175 104 14 Per centage of Mortality. 70.0 63.5 45.5 | 50. ! ioo. 51.4 55.5 REMARKS ON GUNSHOT INJURIES OF THE VERTEBRA. 453 Among the cases enumerated in the foregoing table,—which includes those of which abstracts have been given,—the following complications were noted: Musket balls lodged in bodies or apophyses of vertebrae 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 Figures 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; twenty-one of the lumbar region, with sixteen deaths and five discharges for disability; six in which the region was not specified, with three deaths, two 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, with 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 which 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 upward "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, where injury of the cord is mentioned, cannot possibly include all in which that complication existed In the Army Medical Museum alone, there are fifty-two specimens of gunshot injuries of the spine involving the cord, nearly all procured from cases included in Table XIX. The Museum contains seventy-six specimens showing the results of gunshot fracture of the vertebrae.* In nineteen cases primarily fatal, the cord escaped injury in four only; in fifty-seven examples of secondary pathological conditions, the cord was involved in thirty-seven. Estimating the relative frequency of injury to the cord, in gunshot fractures of the vertebrae, by the fatal cases alone, the percentage would be 71.0. Paralysis is mentioned as a prominent symptom in only one hundred and fifty-one of the six hundred and forty-two cases enumerated in the table. Making every allowance for the considerable proportion of cases in which the lesions were confined to the apophyses, it must be regarded as probable that this complication was not always noticed when present. There were not a few instances in which paralysis was absent even where the cord was injured. (See Cases of J R-----, p. 444; J. D——, p. 447; M. H----- p. 449; R. H. Godwin, p. 451.) All of these were examples of injury of the lumbar vertebrae.f In the case of Bowers (p. 444), there was no paralysis, except of the bladder. The occurrence of bed sores is noted in twenty-two of the six hundred and forty-two cases, eleven terminating fatally. In fourteen cases, of which twelve terminated fatally, injuries of the vertebrae were complicated by wounds of the -lung. In fifteen cases the abdominal cavity was penetrated; there was 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, liver, spleen, or kidney, were implicated. *See Cat. of Surg. Sect. A. M. M. p. 57, et seq. t See Mr. Shaw's paper in Holmes's System (Op. cit. Vol. II p. 388) for four interesting cases of total absence of paralysis in fractures ofthe lower lumbar region. 454 WOUNDS AND INJURIES OF THE SPINE. Tetanus supervened in seven cases of gunshot injury of the vertebral column. Chloroform, hypodermic injections of morphia, and the extract of Calabar bean internally, with stimulants and nutritious enemeta, were the medicinal agents generally employed. Pyaimia is noted as a complication in eight of the three hundred and forty-nine fatal cases recorded in Table XIX. Dyspnoea is alluded to, either directly or by implication, principally in cases of gun- shot injury of the cervical vertebras, and in many of those of the dorsal. Mr. Shaw1 in his able paper on injuries of the spine, calls attention to the fact that respiration is not exclusively diaphragmatic in injuries of the cervical portion of the cord, for although the intercostal and abdominal muscles are paralyzed, the serratus magnus, supplied by the external thoracic nerve (Bell's external respiratory), and other muscles of the outside of the chest, are powerful auxiliaries in inspiration, and, indeed, in expiration also; for the action of these muscles is to elevate the upper ribs to which they are attached, and to expand the chest, and, when they relax, the ribs falling from the elasticity of the thorax, the lungs are compressed and both actions of respiration are thus aided. Brodie2 explains the occurrence of dyspncea in injuries of the dorsal spine by the removal of the power of the abdominal muscles to aid in expiration. The air not being completely expelled, mucus accumulates and cannot be expectorated, and the blood is imperfectly oxygenated. Mr. Shaw points out the additional reason that distension of the hollow viscera by gases is permitted by the deprivation of the compression normally exercised by the muscles, and that tympanitis thus produced disturbs the respiration mechanically. Dysphagia is noted in a number of cases, the complication being generally dependent upon wounds of the muscles of deglutition rather than injury of the nerve trunks. Costiveness was the general rule in these injuries, in the early stages; but when the lower portion of the cord became disorganized, paralysis of the sphincter and involuntary faecal discharges were common, a phenomenon clearly explained by Mr. Hilton.3 Disorders of the urinary organs are frequently referred to. Retention of urine, requiting the habitual use of the catheter, was often followed by incontinence, if the patients lived long. The occurrence of suppression of urine or of diabetes, referred to by authors, was not noted. Hsematuria is reported in a single case, in which the kidney had shared in the injury of the vertebra. The secretion of mucus and ammoniacal urine is often alluded to, and in two instances cystitis was pronounced the proximate cause of death. Priapism is reported in three cases only, all of the cervical region.4 It will be readily understood that the figures cited here and throughout this analysis of the table by no means furnish an exact estimate of the number of instances in which a given rational symptom was present; but state simply how often it was noted. The reports were generally, of necessity, too brief to admit of a full review of the clinical phenomena. 1 On Injuries of the Back. In Holmes's System of Surgery, 2d ed., 1870, Vol. II, p. 392. ^ It would appear that this remark can only apply to cases of injury below the origin of the sixth cervical nerve.—Comjriler. SGuy's Hospital Reports, Vol XI, 3d series. •"Another case is reported in Circular 3, S. G. O., 1871, p. 129. OPERATIONS. 455 Section III. OPERATIONS A few cases of ligations, on account of secondary haemorrhages, a number of ball extractions, and removals of fragments of bone constituted the examples of operative interference resorted to in the wounds and injuries of the spine. The number and results are exhibited in the following table : Table XX. Results of Sixty-two Operations after Gunshot Fractures of the Vertebrce. OPERATION'. Ball removed.......................... C ervical - - Do. do............................ Dorsal___ Do. do............................ Lumbar... Do. do............................ Not stated. Bone removed.......................... Cervical.. Do. do............................ Dorsal___ Do. do............................ Lumbar... Do. do............................ Not stated Ligations.............................. .......... Total. 1 12 16 5 5 6 9 4 4 62 Died. Discharged. Duty. Unknown. 1 4 7 7 1 3 5 1 3 1 1 2 2 1 2 1 4 3 1 4 2 2 4 27 22 H 2 Ligations.—The complications of injuries of the spine by haemorrhage were not numerous. In seventeen only, of the six hundred and forty-two cases enumerated in Table XIX, is this complication noted as of importance; fourteen ofthe cases had a fatal termination. In a complicated case, not included in the table, of gunshot wound of the lower jaw, tongue, and pharynx, the first on page 355, the left transverse process of the third cervical vertebra was fractured. The coats of the vertebral artery wore away against the jagged margin of the fracture; on the eleventh day there was copious haemorrhage, for which the common carotid artery was tied. Seven days subsequently haemorrhage recurred and was promptly fatal, the bleeding point being vainly sought for. It would be difficult to adduce a more striking illustration of the soundness of Guthrie's precept on this subject. Apart from this case which has been recorded in a previous category on account of its complications, in four other instances only were important vessels secured : Case.—Ligation of Occipital Artery.—Private Joseph Horton, Co. D, 57th Massachusetts Volunteers, aged 23 years, was wounded at North Anna, May 18th, 1864, by a conoidal ball, which entered the external ear, and passing inward and downward, 456 WOUNDS AND INJURIES OF THE SPINE. lodged in the first dorsal vertebra. He also received a gunshot wound ofthe right hand. lie was conveyed to the field hospital of the Ninth Corps, where the thumb and forefinger were amputated. On May 24th, he was transferred to Harewood Hospital, Washington. Secondary haemorrhage occurred from the right occipital artery on May 31st; the artery was ligated by Surgeon R. R Bontecou, U. S. V., on the same day. The haemorrhage recurred on June 2d, when re-ligation was perfonned. Death resulted in about three hours after the second operation. The case is taken from the Harewood Hospital reports. Though the surgeon followed the generally accepted practice:|: in the following case, one cannot refrain from a feeling of regret that an attempt, at least, was not made to place a double ligature on the internal carotid at the part wounded. If successful, it would have been a glorious achievement, and it could not have had a worse result than the Anellian operation that was adopted : Case.—Ligation of Common Carotid for Gunshot Wound of the Internal Carotid—Orderly Sergeant Vincent L. Keiflin, Co. K, 105th 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 York. 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 haemorrhage occurred from the wound, and could not be controlled by the ordinary means. The right common carotid artery was tied by Surgeon Henry Palmer, U. S. V., 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 pieces of the ball were extracted. The case is reported by Acting Assistant Surgeon H. F. Bowen, in charge of the case books of York Hospital. The medulla appears to have escaped all injury. In the next case there is no indication of the source of bleeding; but it was probably a leison of some of the vessels in the axilla, as the operator would hardly have tied the left subclavian within the scaleni, without specifying the fact: Cask.—Ligation of Left Subclavian.—J. C. Howard, Confederate, aged 19 years, received at Fair Oaks, a gunshot wound on May 31st, 1862, 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 Aledical and Surgical Journal, Vol. I, p. 186.t] The following case, reported by Assistant Surgeon Robert F. Weir, U. S. A., is very instructive: Case.—Diffuse Traumatic Aneurism ; Wound ofthe Spinal Cord ; Ligation of the Carotid ; Death; Autopsy.—"In the afternoon of September 30th, 1862, I Avas requested to see in consultation, by Surgeon Thurston, U. S. V., and Acting Assistant Surgeon C P. Herrington, at Frederick Hospital No. 4, Private Henry Herman, 12th Pennsylvania Reserves, aged 23 years, who was wounded at the battle of Antietam, by a buckshot, which had entered on the right side of the neck on a level with the upper portion of the thyroid cartilage and on the anterior margin ofthe 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 29th instant, some haemorrhage had occurred, twelve days after the reception of the injury. The bleeding had been checked, as was thought, by plugging the small opening of the wound with lint saturated with liquor ferri persulphatis. 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 trouble. At the hour of consultation the tumor was reported to have increased much in size 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 plug of lint remains in yet, held firmly by clotted blood. The mean pulse was 65 and irregular, but became quiet—probably from the amount of rcratrum viride that had been given him, to wit: from eleven o'clock A. m. (it now being five o'clock p. M.), 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 Avas 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 plug 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 that it is unfortunate that the last edition of Gray's Anatomy (2d Holmes, i.ondon, 1866, p. 356), a work in the hands of so many students, should recommend the ligation of the common carotid for wounds of the internal carotid.—Compiler. t In connection with this case, Dr. Thomas, who did much cf the statistical work in the Confederate Surgeon General's Office, remarks: " In many of the reports the data are so meagre as not to furnish any satisfactory conclusions with regard to the gravity of the case. Brevity is a very commendable feature in clinical reports, but should not be pushed to the extent of robbing the case of its intarest. ' Alexander died—Alexander was buried;' but there are some people who would be curious to know how he died and when he was buried; and it is a lean obituary that does not give these small items." REMOVAL OF FRAGMENTS OF VERTEBRAE. 457 first had been quite profuse, though of short duration. Throughout the whole of the protracted operation, it was noticed with what ease the bleeding from the artery was checked—so little pressure was required. 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 displacement of the parts from pressure, 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 by 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. Tlie ligature of the distal portion was then applied, which entirely checked the bleeding. At tlie time the first ligature was applied, great disturbance in the respiratory movements occurred, 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 been applied, that hemiplegia of the left side had taken place, with tendency to sleep; patient was easily aroused, and that the riglit 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, pulse 66, 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 unimpaired, though the left pupil did not contract upon exposure to strong light; the condition of the pupils, prior to the operation, had not been noticed. Seven and a half o'clock p. m.: The trachea had returned to its normal 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 ferri 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 regularly when exposed to light, at twenty-five minutes past two o'clock p. M. 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 greatly 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 proper 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 wound, but the upper one was somewhat loose, perhaps enough so as to account for the recurrence of the haemorrhage 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 sheath 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 the wound. The three lower cervical and two upper dorsal vertebrae and the cord were exposed by sawing through the laminae. The shot had entered the spine anteriorly, and at the lower edge of the sixth cervical vertebra of the right side, just internal to the vertebral ai'tery, 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 lodgement ofthe ball were found inflamed. The brain was found, in the middle lobe of the right side, to be softer than that of the left. Just to the right of the lamina cinerea, where the middle lobe overlaps the anterior, was a spot, of about one inch in diameter, where the substance ofthe brain was greatly disintegrated, and in a liquid condition. It had almost formed an abscess—otherwise healthy. The specimens were preserved." Removal of Fragments of Vertebrae.—Of formal trepanning of the vertebrae no instances were reported, but a few examples of the extraction of recent spiculae 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 Moran, 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 large 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 18th, he was admitted from Westchester to the Haddington Hospital, Philadelphia. The wound was painful and discharged freely, and 58 458 WOUNDS AND INJURIES OF THE SPINE. the patient was much debilitated. The hall Avas removed through the point of entry after slightly enlarging tlie wound. The entire riirht lateral process of the vertebra Avas removed in four separate pieces, one of Avhich adhered to the flattened ball. Simple dressings were applied, and by November loth the wound was nearly healed. The patient was unable to bend his body antero posteriorly; but this disability impro\Ted after the application of frictions Avith volatile liniment. On March 21st, 1S6I, lie avus transferred to the Christian Street Hospital, Philadelphia, and on September 21st was sent to Kingston, New York, to be mustered out of service. The case is reported by Acting Assistant Surgeon R. J. Lewis. Pension Examiner R. Loughlan of Kingston, N. Y., reported, on October 3d, 1871, that there is no especial paralysis, but a geneial physical weakness. The wound occasionally becomes inflamed, opens and discharges. The pulse is regular and respiration free. Disability one-half, and permanent. Cask.—Private Peter Chester, Co. K, 6th Maine Volunteers, aged 22 years, Avas wounded on November 7th, 1861, by a conoidal ball, which entered over the fourth dorsal vertebra and fracturing its spine passed upward toward the right shoulder, and lodged. There was also a flesh Avound ofthe middle third ofthe left thigh. He was sent to Washington, and, on November 9th, was admitted into the Stanton Hospital. There was inflammatory fever, with a quick pulse, and the wounds suppurated freely. Simple dressings were applied; anodynes and stimulants were administered, and a full diet Avas allowed. On November 13th, some pieces of the spine of the vertebra were removed from the Avound. By November 19th, the patient was free from pain, and the wound Avas healing. On January 5th, the ball Avas extracted from under the edge of the trapezius muscle by counter incision. The patient Avas returned lo duty on April 24th, 1864. He is a pensioner. Pension Examiner T. A. Foster reports, May 18th, 1866, that there is loss of power in arms. His disability is rated total and permanent. Cask.—Private William C. Patrick, Co. E, 104th NeAV York Volunteers, aged 22 years, avus Avounded at Gettysburg on July 1st, 1863, by a conoidal musket ball, Avhich passed across the lumbar region from right to left, fracturing the spinous and transverse processes of the fourth lumbar vertebra, and lodging in the lumbar muscle. He was admitted to the field hospital, and thence Avas transferred to Camp Letterman on July 24th. Spiculae of bone Avere removed on July 31st; simple dressings Avere applied to the wound; tonics Avere administered, and a full diet was allowed. The patient Avas transferred to a convalescent hospital on September 25th, the Avound being entirely healed,, and on June 25th, 1884, he was discharged the service. Pension Examiner L. W. Fasquelle reported, January 29th, 1867. that the ball has iecenfly been removed, leaving a large fistulous opening, Avhich still discharges a large amount of pus daily. His disability is total but not permanent. Cask.—Private William Ambrosher* Co. C, 49th Ohio Volunteers, aged 25 years, was Avounded on May 27th, 1864, near Dallas, Georgia, by a conoidal musket ball which entered the lumbar region and injured one of the vertebrae. On July 1st, lie was admitted to the West End Hospital, Cincinnati. His condition Avas scorbutic and anaemic, and there were bed-sores over nearly every prominent part of the body that came in contact with the bed. Three days after admission, some necrosed portions of the spinous processes Avere removed, and two days afterward, the patient had much fever; the parts around tlie wound became inflamed and SAVollen, and an abscess formed, the contents of which escaped through a fissure running to the posterior surface of the left thigh. A large sloughing ulcer, four inches in diameter, took the place of the abscess and Avound, and sloughing also commenced in the bed-sores. Yeast and charcoal poultices were applied, also oil of turpentine twice daily. The turpentine arrested the sloughing, and, after the fourth application, was discontinued. The subsequent treatment was expectant, and by October the patient was nearly Avell. He was transferred to the Veteran Reserve Corps on April 4th, 1865. The case is reported by Acting Assistant Surgeon R. Bartholow. Cask.—Private Benjamin Smith, Co. K, 12th Alabama Regiment, aged 22 years, Avas wounded at Gettysburg on July 1st 1863, by a conoidal musket ball, which fractured a process ofthe third lumbar vertebra. He was sent to the field hospital, and, on August b'th, was admitted to Camp Letterman Hospital. Simple dressings Avere applied to the Avound, and a full diet was allowed. Several pieces of bone were extracted. The pa'tient recovered, and Avas transferred, for exchange, on September 6th, 1863. Acting Assistant Surgeon XV. W. Welch reports that there were no serious symptoms at any time. It was the spinous process that Avas splintered. Cask.—Private Benjamin Wright, Co. K, 42d Illinois Volunteers, aged 26 years, was Avounded at Chickamauga, Georgia, on September 20th, 1863, by a conoidal musket ball, which fractured the fourth lumbar vertebra, injured the spinal cord, and lodged. He Avas sent to the field hospital, and, on November 23d, was admitted to Brown Hospital at Nashville. Here the ball and a fragment of the spinous process Avere extracted by Surgeon M. M. Chambers, U. S. V. He was subsequently transferred as follows: February 15th, 1864, to Hospital No. 19, Nashville; March 16th, 1864, to Louisville, Kentucky; April 7th, 1864, to Madison, Indiana; July 24th, 1864, to Quincy, Illinois; September 20th, 1864, to Springfield, Illinois, where he Avas mustered out of service on September 28th, 1864. Cask.—Private Charles Carlen, Co. I, 3d Pennsylvania Reserves, aged 24 years, was wounded in the back at Bull Run, August 30th, 1862, by a musket ball, Avhich fractured the third lumbar vertebra, and lodged. On August 31st, he was admitted from the field to Ascension Hospital, Washington. Some paralysis ofthe lower extremities and the bladder followed the injury, but the boAvels remained normal. The patient was admitted to the Episcopal Hospital, Philadelphia, on November 12th, 1862, and on December 5th a small piece of bone Avas removed. Several pieces of bone are reported to have come away at previous times. The patient complained of pain in the back of the neck; the ball remained within the Avound. By December 13th, there was no change in the patient's condition. He Avas discharged the serA'ice on February 9th, 1863, and pensioned. His pension Avas increased on September 4th, 1865. A communication from Pension Examiner T. B. Reed, dated September 16th, 1865, states that the ball has not been extracted. The pensioner suffers from stiffness and neuralgia of the muscles of the back of the neck and head, and from dysuria. His disability is rated three-fourths. Cask.—Private John Stichler, Co. G, 184th Pennsylvania Volunteers, aged 18 years, was Avounded at Deep Bottom, Virginia, August 14th, 1864, by a conoidal musket ball, which entered to the right of the last dorsal vertebra, passed inward and doAvnward, and lodged in tl e right iliac fossa. He Avas sent to AVashington and admitted to Emory Hospital on the 17th. On the 19th, ether and chloroform Avere adminislered, and the ball Avas removed from the right iliac fossa through an incision tAvo inches in length. A small portion of the right transverse spinal process and a splinter from the crest of the ilium were also REMOVAL OF FRAGMENTS OF VERTEBRAE. 459 removed. Adhesive strips Avere applied to coapt the lips of the Avound; tonics, stimulants, and a nutritious diet constituted the remainder of the treatment. This man was returned to duty on 1 )ecember 1st, 1864. The ball Avas presented to the Army Medical Museum, Avith the above account, by Acting Assistant Surgeon Jos Walsh, and is No. 4623 of the Surgical Section. Stabler Avas discharged the service on July llth, 18(15. and on December Pith, 1870, was pensioned. A communication from Pension Examiner G. Harris, dated March 12th. 1872, states that there is a depressed angular cicatrix about one inch square over the original seat of injury; the patient is unable to do any heavy work, but bis general health is good. His disability is rated one-half and permanent. Cask.—Private Peter C. Miller, Co. K, 7th Wisconsin Volunteers, aged 36 years, was wounded at the Wilderness, May 5th, 1864, by a conoidal musket ball, which passed transversely beneath the trapezius, fracturing the spinous process of the seventh cervical vertebra, and escaped at the outer margin of the muscle. He Avas admitted from the Army of the Potomac to the Douglas Hospital, Washington, on May llth. Simple dressings were applied to the Avound, and pieces of the spinous process were removed. The motion of the cervical region Avas imperfect and painful. The patient was subsequently transferred to the Satterlee Hospital, Washington, thence on July 9th, 1861. to the Harvey Hospital, Madison, Wisconsin. He Avas discharged the service on December 17th, 1864. Examining Surgeon I). D. T. Hamlin, of Elkhorn, Wisconsin, reported, on March 12th, 1865, that the " applicant is laboring under necrosis of the two lower cervical vertebrae, producing partial loss of motion of both arms, vertigo, and constant pain in head and shoulders ; unable to labor. Disability total and permanent." CASE.-Private John Quaid, Co. F, 6th Michigan Cavalry, aged 18 years, of sound constitution, was hit in the loins by a conoidal musket ball, in an action near Salem Church, Virginia, May 28th, 1864. He was sent to the hospital ofthe 1st division, Cavalry Corps, and bis Avound was examined and dressed by Surgeon XV. H. Rulison, 9th New York Cavalry. The ball had entered two inches to the left of the spinous process of the second lumbar vertebra, passed transversely to the right, inclining forward through the lumbar muscles, and emerged five inches from the median line. There Avas complete paraplegia. The catheter Avas required for three days, and there was obstinate constipation. On June 2d, the paralysis began to disappear, and the patient was sent to Washington, and entered Stanton Hospital, under the immediate charge of Assistant Surgeon G. A. Mursick, U. S. V. His general condition was good; but there was still partial paraplegia. He complained of pain in the right hip, and the paralysis Avas most marked on that side. On June 19th, Dr. Mursick removed a small detached fragment of the spinous process of the second lumbar. On July 12th, he removed another fragment. At this date, the patient Avould move about ou crutches ; he could move his lower limbs freely in bed; but had difficulty in standing upright. He complained of a queer benumbed sensation in the right hip and thigh. On July 21st, the exit wound was nearly healed ; but the entrance Avound was sloughy. A permanganate of potassa lotion was prescribed. On July 28th, the wound Avas granulating finely, and the patient could Avalk pretty Avell Avith the aid of a cane. On August 18th, the Avounds had healed, and, Avith the exception of slight weakness of the lower extremities, he Avas Avell. He was furloughed from the hospital at this date, and failing to return, Avas recorded as a deserter, October 31st. 1864.* His name is not on the Pension List, nor have his heirs made application for pension. Case.—Private David Campbell, Co. A, 29th Pennsylvania Volunteers, aged 38 years, was wounded at Gettysburg, Pennsylvania, July 3d, 1863, by a conoidal ball, which entered just above the acromion process and passed deeply into the neck. He was taken prisoner and remained in the enemy's hands until July 17th, when he Avas admitted to hospital at Annapolis, Maryland. On October 3d, he was transferred to Satterlee Hospital, Philadelphia. Simple dressings Avere applied. On November 1st. the Avound was opened by free incision; the transverse process of the fifth cervical vertebra Avas found corroded, and was scraped. Some necrosed portions of bone were brought away. He Avas transferred to Veteran Reserve Corps on December 31st, 1863. Referring to the figures in Table XX, it will be found that there were twenty-four cases of removal of fragments of the vertebrae after gunshot fracture, with fatal results in only ten instances. The gratification that such a favorable statistical exhibit would other- wise produce, is much diminished by a close examination of the fourteen examples of complete or partial recovery mentioned in the foregoing memoranda. In nine instances the spinous process alone or portions of it only were removed, and that the injuries to the vertebral column could not have been of a very serious nature is shown by seven of the patients having been speedily returned to duty or exchanged. Dr. Lidell (I. c. p. 327) has remarked of one of these cases that it afforded "strong evidence of the small amount of danger which usually attends gunshot fractures of the spinous process of a vertebra." The evidence is not weakened by the eight additional cases. In the five cases of recovery in which portions of the laminae or of the transverse processes were removed, the results were much less satisfactory, and nearly all of the patients still suffer from serious disabilities. * This is one of the cases cited, under tlie head of Concussion of the Spine, by Surgeon .John A. Lidell, U. S. v., in his admirable paper: On Injuries of the Spine, including Concussion of the Spinal Cord, in the American Journal of Medical Sciences, for October, 1V(A, Vol. XLVIII, p. 305. 460 WOUNDS AND INJURIES OF THE SPINE. Of the ten cases of extractions of recent portions or sequestra? of the arches or processes of the vertebra? that terminated fatally, the details furnished are very scanty. The following may serve as examples : Case.—Private XV. B------, 23d Pennsylvania Volunteers, Avas Avounded at Fair Oaks, Virginia, May 31st, 1862, by a round musket ball, which entered the left side below the scapula, and lodged. There was no haemoptysis, but the patient was very Aveak, and sensation below the knees Avas impaired. On June 27th, a probe passed four inches into the AA-ound came in contact Avith the tenth vertebra, from which a piece of loose bone was removed. Death occurred on July 31st, 1862. The ball Avas removed from the body of the tenth vertebra at the post-mortem examination. The cord Avas free from compression. The ball was presented to the Army Medical Museum, and is No. 4945 of the Surgical Section. Assistant Surgeon William Thomson, U. S. A., reports the case from Portsmouth Hospital, Virginia, Avhither the patient had been sent soon after the reception of the wound. Case.—Private Joseph Pollock, Co. E, 2d Missouri Militia, Avas admitted to hospital at Kansas City, Missouri, on May lstt 1863. A ball had fractured the spinous process of the last dorsal vertebra and buried itself in the body of the bone. Complete paralysis ensued. The ball and the spinous process were removed. There Avas a slight return of sensation after the operation. The patient died on October 19th, 1863. Acting Assistant Surgeon J. Thorpe reports the case but not its fatal issue Case.—Private David C. Laird, Co. A, 4th Michigan Volunteers, aged 20 years, was Avounded at Gettysburg, Pennsyl- vania, July 2d, 1863, by a conoidal ball, Avhich entered the lumbar region one inch to the left of the spine, passed dowmvard and forward to the right side, fractured the transA'erse process of the fourth lumbar vertebra, and emerged near the right ilium. He Avas treated in the field until J dy 31st when he entered the hospital at Camp Letterman. When admitted, his general health was good. The discharge from the Avounds Avas profuse. The patient experienced great difficulty in micturition, and the urine Avas streaked Avith pus. Tonics, stimulants, and diuretics, Avith nourishing diet, were administered and cold-water dressings applied to the wound. On August 7th, several spiculae of bone were removed. A large abscess fonned on the 10th, which, being incised, discharged a large quantity of pus. The discharge of pus from the wound increased and the strength of the patient began to fail. Death resulted on September 24th, 1863. The case is reported by Acting Assistant Surgeon W. B. Jones. Case.—Private W. H. Whitney, Co. K, 7th Maine Volunteers, having received a gunshot fracture of the spine at Cold Harbor, Virginia, June 3d, 1864, was sent to the field hospital of the Sixth Corps. Fragments of bone were removed, and the wound Avas dressed simply. He died on June 7th, 1864. Case.—Captain W. H Shoppee, Co. B, 31st Maine Volunteers, having received a gunshot fracture ofthe spine at Peters- burg, Virginia, on June 26th, was admitted from the field to the Armory Square Hospital, Washington, on July 1st, 1864. The ball and spiculae of the bone Avere removed, and the Avound was dressed simply. The patient died on July 2d, 1864. Removal of Balls.—Abstracts of several cases of gunshot fracture of the vertebrae, in which the missiles were extracted during life, either alone or in connection with bone- splinters, have already been cited. (See cases of MacDonald, p. 441 ; Hogan, p. 442; Flaherty, p. 442; all three examples of recovery after removal of musket balls from the transverse processes of the second lumbar. See also case of Joseph R-----, p. 444, for a difficult extraction of a ball from the second lumbar; the cord was injured and fatal tetanus resulted. See also fatal case of Sergeant E-----, p. 446, and case of W. C. Patrick, p. 45S.) The following is an interesting case, the patient having been under observation for more than seven years after the reception of the injury: Case.—Private James M. Carter, Co. F, 14th Iowa Volunteers, aged 20 years, was wounded at Yellow Bayou, Louisiana, on May 18th, 1864, by two missiles, one a fragment of shell, the other a ball, both of Avhich entered the back in the dorsal region. On June 2d, he was admitted from Red River to the Jefferson Barracks Hospital, St. Louis. The spinous process of the third dorsal vertebra was fractured. The fragment of shell Avas removed on May 18th, the ball on June 20th, 1864. The patient was transferred to Keokuk, Iowa, on November 3d, 1864. He Avas discharged the service on January 28th, 1865, and pensioned. His pension was increased on June 6th, 1866. Pension Examiner A. XV. McClure reports, under date of December 27th, 1866, that this man is partially paraplegic. He is able to walk on level ground, but cannot run; sensation in the legs is. imperfect; the urine and fecces pass involuntarily. The patient's disability is rated as equal to the loss of a leg, and permanent. His pension Avas last paid on December 4th, 1871, when his condition was unchanged. The ten following abstracts are of cases of partial recovery after ball-extractions in spinal injuries. Nearly all the patients are pensioners, suffering from paralysis in various degrees: Cask.—Private Albert C. Williams, Co. I, 53d Ohio, aged 24 years, Avas Avounded at Kenesaw Mountain, Georgia, June 27th, 1864. by a conoidal ball, Avhich entered the right shoulder one inch and a half above the joint, and emerged at the centre of the dorsal vertebra?, fracturing the process. He was at once admitted to the field hospital ofthe 2d division, Fifteenth Corps, where the ball was extracted and simple dressings applied. He Avas furloughed on August 18th, 1864. On April 9th, 1865. he REMOVAL OF BALLS. 461 was admitted to the hospital at Gallipolis, Ohio, and discharged on June 25th, 1865. The case is reported by Surgeon Lincoln R. Stone, U. S. V. On June 6th, 1866, Pension Examiner J. P. Bing reports as follows: "Ball entered top of riglit shoulder fracturing the neck of the scapula, and passing dowmvard and backward, was extracted near the right side of eighth dorsal vertebra. The arm is constantly supported in a sling, and is quite painful and nearly useless." CASE.-Private Seth Golden, Co. H, 55th Ohio Volunteers, aged 18 years, was wounded at Peach Tree Creek, Georgia, July 20th, 1864. A buckshot struck the shoulder and lodged against the spinal column, injuring the borders of the lower dorsal vertebra?. He Avas taken to the field hospital. Here the ball was extracted, and he was treated until August 12th, Avhen he was returned to duty. Being unable to march, he was conveyed by ambulance to Savannah, Georgia, and admitted to general hospital, whence he was discharged on May 20th, 1865. In his declaration for pension he states that after reaching home paralysis ofthe loAver extremities gradually came on. Tension Examiner A. II. Agard reports, September 1st, 1870, that necrosis, abscess, and angulation of the spinal column followed, Avith complete paralysis of the lower extremities, rendering him so helpless as to need the daily attention of an assistant to dress and care for him. This man received a pension of $25 per month. The case is reported by IT. W. Sawtelle, M. D. Cask.—Adjutant James B. Storer, 29th Ohio Volunteers, aged 25 years, received a gunshot fracture of the spinous process of the fifth dorsal vertebra at Buzzard Roost, Georgia, on May 8th, 1864. He was treated in the field hospital until the 12th, when he entered the Officer's Hospital at Nashville. On May 28th, 1864, the ball Avas extracted The patient Avas discharged from service on November 30th, 1864. Tlie case is reported by Surgeon J. K. Ilerbst, U. S. V. On November 24th, 1866, Pension Examiner W. Bowen reported that the pensioner bad paralysis of the right loAver limb, and partial loss of power of the left, also incontinence of the urine and faeces. His disability is rated total and probably permanent. Cask.—Private Nelson Tiffany, Co. A, 25th Massachusetts Volunteers, aged 20 years, Avas wounded at Petersburg, Viiginia, May 9th, 1864. by a conoidal ball, Avhich struck the spine near the loAver dorsal A'ertebra, passed into the abdomen, and lodged in front of the right iliac fossa. He was taken to the field hospital, Avhere the ball Avas cut out, and simple dressings applied. On May 12th, he Avas transferred to Hampton Hospital, Fort Monroe, and, on June 7th, to Knight Hospital, New Haven, Connecticut, Avhence he Avas furloughed on June 17th, 1864. On August 8th, he reported to Mason Hospital, Boston. He was finally discharged from service on May 15th, 1865. Pension Examiner Oramel Martin reports, June, 1865, that the skin adheres firmly to the vertebrae, and that the patient bends his body with pain and difficulty. He is not ooav a pensioner. Assistant Surgeon E. McClellan, U. S. A., reports the case. Case.—Private Patrick Spillane, Co. D, 3d Wisconsin Volunteers, aged 23 years, was wounded at Smithfield, North Carolina, March 16th, 1865, by a conoidal ball, Avhich entered about three inches to the left of the spinal column and two inches above the crest of the ilium, and lodged. He was at once conveyed to the field hospital of the 1st division, Twentieth Corps, where the ball Avas removed at a point corresponding Avith the free extremity of the twelfth rib on the riglit side, and simple dressings were applied. On April llth, he Avas transferred to Foster Hospital, New Berne; on April 16th, to DeCamp Hospital, New York Harbor, and, on June 1st, to SAvift Hospital, Prairie Du Chien, Wisconsin, whence he Avas discharged from service on September 1st. 1865. Assistant Surgeon J. W. Brewer, U. S. A., reports the case. Pension Examiner W. A. Gordon reports, May 31st, 1866: "Exercise produces slight tremor of the left-leg. There is manifest stiffness of the back and weakness across the lumbar region. General health good; disability one-third." The spinous process ofthe second lumbar was probably fractured. Case.—Private C. A. Haywood, Co. E, 114th NeAV York Volunteers, aged 20 years, Avas Avounded at the battle of Winchester, September 19th, 1864, by a conoidal musket ball, Avhich fractured the spinous process of a lumbar vertebra, and lodged in the left iliac region. He Avas admitted from the field to the hospital ofthe Nineteenth Corps on September 22d. Simple dressings Avere applied to the Avound, and, on October 8th, the ball was extracted. There was partial paralysis of the left side. The patient was transferred on October 30th, 1864, to Jarvis Hospital, Baltimore, thence, on December 10th, 1864, to Cuyler Hospital, GermantoAvn. He Avas discharged the service on March 17th, 1855. Pension Examiner A. Willard reported, December 27th, 1865, that the patient has so far recovered as to be able to do light work. Any active, laborious exercise produces pain at the point of injury. Exercise or exertion in a bent position is nearly impossible. The lower limbs are still weak, and easily give Avay on walking either up or down hill. He rates his disability three-fourths and probably not permanent. Case.—Second Lieutenant William A. C. Ryan, Co. G, I32d NeAV York Volunteers, aged 21 years, Avas wounded at Bachelor's Creek, North Carolina, February 1st, 1864, by a conoidal ball, which fractured the last lumbar vertebra and lodged in the sacrum. He AA-as at once conveyed to the Foster Hospital, New Berne, Avhere simple dressings were applied to the wound. On April 30th, he Avas transferred to Ladies' Home Hospital. New York City. On June 12th, 1861, the wound discharged very freely, and the patient Avas in a very good condition, but feeble; an ulcer had formed across the sacrum, about three inches long and about one inch and a half wide, with a sinus leading to the ball. Surgeon Alexander B. Mott, U. S. V., slightly enlarged the sinus, and, with some difficulty, removed the ball, Avhich he found firmly imbedded in the bone. The patient improved after the operation. The treatment consisted of tonics, with a generous diet. The wound healed rapidly, and, on October 9th, 1864, the lieutenant was dismissed the service. There is no record of him at the Pension Office. Case.—Private William Heald, Co. K, 3d Maine Volunteers, aged 45 years, was wounded at Gettysburg, July 2d, 1863, by a conoidal ball, Avhich fractured the lumbar vertebrae and left iliac bone of the pelvis, and lodged. Another ball fractured the right wrist-joint, and a third passed through the fleshy portion ofthe left thigh, posterior to the femur. He Avas conveyed to the Seminary Hospital, Avhere the ball Avas extracted from near the lumbar vertebrae, and the fore-arm amputated at the middle third. Simple dressings were applied to the wounds; on August 3d, he was transferred to Camp Letterman Hospital, and on November llth, to the hospital at York, Pennsylvania, Avhence he was discharged from service on June 27th, 1864. Pension Examiner Edmund Russel reports, December 4th, 1866, ''the Avound is still suppurating. Disability total and permanent." Case.—Private Samuel F. Sexton, Co B, 19th Ohio Volunteers, aged 22 years, was wounded at Dallas, Georgia, May 27th, 1864, by a conoidal ball, Avhich entered the back three inches to the left of the spine, crossed the spinal column diagonally, injured the spinous processes of the first and second lumbar vertebrae, and lodged three inches to the right of the spine, lie 462 WOUNDS AND INJURIES OF THE SPINE. was taken to the field hospital of the 3d diAdsion, Fourth Corps, and simple dressings were applied to the Avound. On June 3d, he was transferred to the hospital at Chattanooga; on June 22d, to Hospital No, 19, Nashville; on June 29th, to Jefferson Hospital, Indiana, and on July 25th, to the hospital at Cleveland, Ohio, whence he Avas discharged from service on June 3d, 18ii5. Pension Examiner E. Mygatt, reports, May llth, 1866: " The ball Avas removed by incision six months after the recep- tion of the injury. - There is great loss of substance by sloughing. The re-ion of the wound is tender, and becomes inflamed and painful from any ordinary or continued use of (he muscles. Disability one-half, probably not permanent." Case.—Private Thomas Berry, Co. C, 14th Indiana Volunteers, received a gunshot fracture of the spine at Antietam, Maryland, September 17th, 1862. The ball entered at the lower and outer surface of the crest of the ilium and imbedded itself deeply in the side of the last lumbar vertebra. He Avas treated on the field until October 6th, when he entered Summit House Hospital, Philadelphia, where the ball Avas extracted muskL't banTrooved on the same day. On December 12th, 1862, he Avas returned to duty. The man is not a pensioner. The bv impact with bone. missile is preserved in the Museum, and is figured in the wood-cut. The case is reported by Acting Assistant Spec. 44ti7, Sect. I, £.. A. m. M. Surgeon YY inthrop Sargent. The nine following abstracts relate to fatal cases of extractions of missiles after rrunshot fractures of the vertebras: o Case.—Private XV. Hedden, Co. D, 3d NeAV Jersey Volunteers, aged 32 years, Avas Avounded at Chancellorsville, May 3d 1863, bv a conoidal musket ball, which entered the right side, passed deeply beneath the muscles of the lumbar region and betAveen the first and second lumbar vertebrae, fracturing both, and completely dividing the cord. He was admitted from the field to Stanton Hospital, Washington. There Avas complete paralysis of the loAver extremities, relaxation ofthe anal sphincter, and retention of urine. The temperature of the body Avas below the normal standard; the respiration laborious, and the circulation feeble, Avith a tendency to congestion. The ball was extracted; the patient Avas placed upon a Avater-bed, and the urine Avas drawn off with a catheter. Cold-Avater dressings Avere applied to the Avound, and tonics, stimulants, etc., were administered. On Mav 13th, the patient greAV Avorse. He complained of pain in the track of the ball, fever and great rest- lessness. The wound did not discharge feely, and the urine dribbled aAvay. On May 15th, there was an augmentation of the above svmptoms, Avith low muttering delirium. By May 17th, the delirium increased, with a tendency to convulsions, and the patient died. The case is reported by Assistant Surgeon P. C. Davis, U. S. A. Case.—Private John H. Dowling, Co. E, 2d Colorado Cavalry, was Avounded at Camp Babbitt, Colorado, December 27th, 1863. by a ball from a revolver in the hands of a felloAV soldier. The missile entered the right side of the neck, Ioav doAvn, rather in front of the median line, grazed the vertebrae, and lodged in the other side, nearly opposite the point of entrance. An hour or tAvo after the reception of the injury he Avas admitted to the Post Hospital, complaining of paralysis of the extremities; the ball Avas removed. The paralysis increased in intensity until death, Avhich occurred on December 29th, 1863. Case.—Corporal Frederick Ruhling, Co. I, 56th Massachusetts Volunteers, aged 40 years, received a gunshot Avound of the left shoulder, Avith injury to the spine by a ball from a grapeshot, at North Anna River, May 24th, 1864. He was taken to the field hospital of the 1st division, Ninth Corps, where the ball was extracted and simple dressings applied to the Avound. He died on May 24th, 1834. The case is reported by Surgeon M. K. Hogan, U. S. V. Case.—Private Samuel Jessup, Co. C, 4th Georgia Regiment, received a gunshot Avound of the back and shoulder by a conoidal ball at Petersburg, Virginia, March 25th, 1865; the vertebral column Avas fractured. He was taken to the field hospital of the 2d division, Ninth Corps, Avhere the ball Avas extracted. On the 27th, he Avas sent to the general field hospital of the Ninth Corps, and, on April 9th, was put on board the steamer State of Maine, to be transferred to Washington. He died on the next day. Acting Assistant Surgeon W. H. Finn reported the case. Case.—Private John Fisher, Co E, 2d Missouri Militia, was shot in the back at Independence, Missouri, on August llth, 1862. He avus sent to Kansas City, and admitted to hospital on August 23d. The ball ay as extracted from the first lumbar vertebra. The patient recovered from the operation, but sank into a typhoid condition, and died on September 6th, 18(12. There Avere immense bed-sores on the back and hips. Case.—Private L. T. JeAvett, Co. A. 1st Maine Heavy Artillery, aged 23 years, was Avounded at Spottsylvania, Virginia, May 18th, 1864. The missile entered the left side, near the first lumbar vertebra, and emerged on the opposite side, near the angle of the eleventh rib. He Avas treated in the field, and, on May 22d, Avas admitted to Emory Hospital, Washington, D. C. On admission, there AA'as palsy of the lower extremities, retention of urine, and peritonitis. The ball was extracted, AA'ater dressings were applied to the Avound, and the urine Avas drawn off by the catheter. Death resulted on May 25th, 1864. Case.—Captain Charles Harris, Co. H. 7th Michigan Volunteers, received a penetrating Avound of the spinal column by a conoidal ball at Spottsylvania, Arirginia, May 12th, 1864. The ball lodged. He Avas conveyed to the hospital of the 2d division, Second Corps, where the ball Avas extracted from the spinal column and cold-water dressings applied. He was after- Avard treated in private quarters in Washington, and was furloughed on May 27th, 1864. The Adjutant General states that he died on November 4th, 1864. The case is reported by Surgeon J. F. Dyer. Case.—Private Eugene R. Buckman, Co. C, 8th Pennsylvania Cavalry, aged 19 years, received a gunshot Avound of the back, at the junction of the dorsal and lumbar regions, by a conoidal ball at Jettersville, Virginia, April 5th, 1865 ; the bal lodged. He wa6 conveyed to the field hospital of the Cavalry Corps. AA'here the ball Avas extracted and simple dressings applied to the wound. On April 15th. he entered the 1st division hospital, Annapolis. There Avas complete paralysis of the loAver extremities, and extensive bed-sores over both trochanters, which sloughed so far as to expose the femurs for near their entire upper third, especially the right one. Dry oakum dressings were applied and charcoal poultices to the bed-sores; anodynes were given. His appetite Avas very poor, and he could retain no solid food. The wound improved until about the 20th, when it commenced sloughing. Death resulted on April 25th, 1865. Acting Assistant Surgeon William Pitt Willis reports the case. EXCISION OF PORTIONS OF THE VERTEBRAE. 463 CASE.-Private Arthur Kay. Co. F, 62d Pennsylvania Volunteers, Avas Avounded at Fredericksburg, Virginia, December 13th, 1862. by a grapeshot. Avhich entered the back at the left shoulder and lodged in the left hip. He Avas taken to the field hospital ofthe 1st division, Fifth Corps. Avhere the ball Avas removed and Avater dressings applied to the wound. Death resulted on December 19th, 1862. Assistant Surgeon A. J. llobart, 1st Michigan Volunteers, reports the case. The question of the propriety of trephining the spine, or. more properly speaking, of excising portions of the vertebral, was discussed by Pan'', Heister, and many of the older authors, and, with great acerbity, early in this century, when Henry Cline1 first performed the operation at St. Thomas's Hospital, June 16th, 1814, in the case of a man of 26 years, who had fractured the spinous processes of the seventh eighth, and ninth vertebral, by a fall from a second story on the previous day. The arches of the upper two vertebra? were crushed in upon the cord, and were removed by aid of a trephine, Machell's circular saw, chisel and mallet. The patient lived seventeen days, and Mr. Cline candidly admitted that the operation hastened his end. Tyrrell2 twice repeated the operation, in 1822, and in 1827, with unfavorable results, and mentions that Wickham, of Winchester, and Atten- burrow, of Nottingham, had anticipated him, with no better fortune. No particulars are given of Attenburrow's case, and it may be identical with that of Oldknow,3 of Notting- ham (1819). The operation was first undertaken in this country by John Rhea Barton4 (1824) and was repeated by Dr. A. G. Smith5 in 1829, and by Dr. D. L. Rogers6 in 1834. In Germany, Holscher7 in 1828, was as unsuccessful; as was Mayer,8in 1846. In France, Laugier9 operated unsuccessfully in 1840. Meanwhile, in Great Britain, the operation was occasionally advocated and performed. South10 had a fatal case, and Edwards11 of New South Wales, claimed a success, but the ultimate result is not given. Ballingal12 relates that Dr. Blair, formerly a surgeon in the Royal Navy, had performed according to Dr. Monro, secundus, this operation successfully on a seaman; but adds that " very few cases occur in which the operation of trepanning the spine ought to be performed." The opera- tion has, of later years, been resorted to in this country, twice by G. C. Blackman,13 thrice by Dr. H. A. Potter,14 of Ontario County, New York, also by Dr. Stephen Smith,15 Dr. J. C. Hutchison16 and Dr. Goldsmith,17 and abroad by Dr. G. M. Jones,18 Dr. R. McDonnell,19 Dr. H. J. Tyrrell, Dr. Gordon, and M. Tillaux,20 M. Felizet,21 Mr. Maunder,22 and Mr. Willett.23 i See New England Journal of Medicine and Surgery, Vol. IAr, No. 1, Jan. 1815; also a full account In South, Notes to Chelius. Am. ed. 1847, p. 590, and nearly all works on resection. 2Notes to Lectures of Sir Astley Cooper, London, 1829, Vol. II, p. 11 (case of Buckley, at St. Thomas's), and London Lancet, Vol. XI, p. 685 (case of Mahony, arch and spinous process of twelfth dorsal removed). 3 See Bransby Cooper's edition of Sir Astley Cooper's Treatise on Dislocations and Fractures, London, 1842, Vol. VIII, p. 5G0. 4 Godman's edition of A. Cooper on Fractures. (•North Am. Med. and Surg. Jour., Vol. VIII, p. 94, 1829. BAm. Jour, of Med. Sci., O. S., 1835, Vol. XVI, p. 91. " Hannoversche Annalenf. d. ges. Heilkunde, B. I\r, 1839, S. 330. 8 v. Walther und v. Ammox's Journal der Chirurgie, Bd. XXXVIII, 1848, S. 178. ^Bulletin Chirurgical, T. I. p. 401, and Des Lesions traumatiques de la Moelle epiniere. These de Concours, 1848, p. 133, Obs. 52. ">Notes to Chelius. Vol. I. p. 540, Eng. ed. H British and Foreign Med. Rev., Vol. VI, 1838, p. 162. 12 Outlines of Military Surgery, 5th ed. 1855, p. 321. 13 Ed. of Mott's Translation of Velpeau's Operative Surgery, Vol. II, p. 392, and Am. Med. Times, July 13, 1861, p. 21. u Hued, in New York Journal of Medicine, Vol. IV, March, 1845; and POTTEK, Am. Med. Times, 1863. >s New York Journal of Medicine, Vol. VI, p. 87. IB Transactions of New York State Medical Society, 1861. 17GKOS6, S. D. (Op. cit., Vol. I, 2d ed.), according to Dr. Ashhurst. I cannot find the reference in the 3d or 4th eds., and have not access to the 2d, at this moment. is London Medical Times and Gazette, 18.56, Vol. II, p. 86. '9 Dublin Quarterly Journal, Aug. 1865, and Aug. 1866, Vols. 51 and 53. In the latter of these excellent articles by Dr. McDonnell, the cases Drs. Tyrrell and Gordon are recorded. -" Bulletin general de Thirapeutique, Mars 15, 1866. il Archives generates de Med., VIml! serie, T. VI, pp 439, 572, 683. w London Medical Times and Gazette, 1867, Vol. I, p. 195. ~> London Medical Times and Gazette, 1867, Vol. I, p. 129. 464 WOUNDS AND INJURIES OF THE SPINE. The subject of the so-called trepannation of the spine has latterly attracted much attention, mainly through the strenuous advocacy of the operation, on physiological grounds, by Dr. Brown-Sequard ;l the publication in the Archives generates by Mr. Felizet, of three extended papers, and the reports of the discussions in the British medical societies on the partially successful operation by Dr. Gordon, the pamphlets published by Dr. McDonnell, Mr. Nunnelly's2 address, and Dr. Ashhurst's monograph.3 After Cline's unsuccessful case, Sir Astley Cooper assured his class that it would be unmanly to refuse the operation, and undertook it himself, found his diagnosis wrong, after the incision was made, the spinous process only being involved, and did not conclude the operation.4 Mr. Solly5 remembers that Travers, who was present at Tyrrell's first operation, in 1822, expressed the opinion that the operation never would succeed; and it is noticeable that, in his second case, Tyrrell consulted with his other colleague, Green. No improve- ment followed the operation ; the patient survived eight days. The cases of Wickham, Attenburrow,6 Oldknow, Barton, Rogers, Holscher, Mayer, Laugier, South, Blackman, S. Smith, Hutchison, Jones, McDonnell, Tyrrell, Willett, Maunder, and two of H. A Potter terminated fatally. The advocates of the operation will hardly rest their argument on Monro's vague recollection of Blair's case, or on Gold- smith's case, in which "no particular benefit" was obtained, or on that of Edwards, in which the "patient did well" for a time, but no result is given, or in the third case of Dr. H. A. Potter, with no improvement after the operation, or in Dr. A. G. Smith's case, which Dr. Brown-Sequard defends against Malgaigne's telling criticism, and in which the operator saw the patient for the last time a week after: " since then, I have not seen him, but I entertain considerable hopes." (Op. cit. p. 96 ) But those who favor the operation, may justly claim that the partial recovery of Dr. Gordon's case was due to it, and that in many of the fatal cases, temporary alleviation of distressing symptoms was obtained.7 The operation has not found favor with military surgeons. Surgeon J. A Lidell (/. c, p. 320), "after considerable investigation * * has failed to find one completely successful case on record " Legouest8 discountenances the operation, and thinks it wiser not to interfere with gunshot fractures of the spinous processes even, unless the fragments are detached and large. Jobert9 is unmeasured in his condemnation, character- izing the operation as " barbare et ridicule." Dr. E. Gurlt10 replies seriatim to Dr. Brown- Sequard's arguments, and to that derived from experiments on animals,—from which Professor Brown-Sequard pronounces it "quite evident that the laying bare of the spinal cord is not a dangerous operation," but few animals dying,—Dr. Gurlt opposes the experience of Dr. Bernhard Heine,11 who resected vertebrae of twenty-four cats and twelve dogs. i Brown-Sequard, Course of Lectures on the Physiology and Pathology of the Central Nervous System, Phila., 1860, Appendix, p. 244. - Xuxxelly, Address in Surgery at the Thirty-seventh Meeting of the British Medical Association. Held in Leeds, July, 1869. 3 Ashhup.st, Injuries of the Spine, with an Analysis of nearly Four Hundred Cases, Phila., 1867. A carefully written work, to which I have had frequent occasion to refer in compiling this chapter. •» South's Notes to Chelius, Vol. I. r.Medical Times and Gazette, 1865, Vol. II, p. 639. BO. Heyikldei!, Lehrbuch der Resectionen, Wien, 1863, S. 313, says that this was a fatal case. I cannot trace the source of his information. 71 have not included the case of Dr. John B. Walker (Catalogue of the Anatomical Museum of the Boston Society for Medical Improvement. By J. B. S. Jackson, M. D., Boston, 1847, p. 31), in which the spinous process of the sixth cervical vertebra, "quite loose though not driven in," was twisted off. 8 Chirurgie d'Armie, pp. 341, 352. h Plaies d'Armes a feu, Paris, 1833, p. 125. "> Handbuch der Lehre von den Knochenbruchen, Hamm, 1864, p. 186. n Wagner, A., Vber den Heilungsprocess nach Resection und Extirpation der Knochen. Berlin, 1853, 3. 45. EXCISION OF PORTIONS OF THE VERTEBRA. 465 All of the cats died and only two dogs survived. The result in the case of a calf was also fatal. Malgaigne calls the operation a "desperate and blind one."1 The successful instances that have been adduced in this chapter of removal of frag- ments of vertebra) after gunshot fracture nearly all resemhle the operation of Louis,2 in 1762, sometimes cited as the first example of resection of the spine, but in reality an extraction of loose fragments, seme of them, it is true, "aswz considerables." Such operations are perfectly rational, and have resulted, as has been shown, in a fair measure of success. It may be permissible to go a step farther, and to excise with bone-forceps or gouge any sharp projecting points of the broken arches; but it is questionable if the danger of wounding the membranes does not counterbalance the advantages to be derived from this procedure. Formal trephining of the spine has hitherto given such unfortunate results, that without much more positive favorable evidence, it cannot be accepted as an established operation. Of Concussion and Commotion of the spinal cord very little is said in the reports, though these accidents are noted in many of the cases briefly cited in the first section of this chapter.3 Dr. John A. Lidell, in the excellent memoir already referred to, relates the histories of several eases that came under his observation during the war, and discusses the subject fully. He found the use of dry cups very advantageous. Dr. Chisholm,4 who has epitomized the theory and practice on gunshot wounds of the spine, generally accepted by the Confederate military surgeons, treats of concussion of the spinal cord, and of myelitis and intervertebral extravasation as its occasional consequences. He speaks of the explosion of a shell in the immediate vicinity of the back as a not infrequent cause of such results! He recommends extract of belladonna, in half-grain doses, in congestions of the spinal cord, and advises the internal use of strychnia to hasten convalescence from paraplegia. In gunshot fractures of the vertebral column, accompanied by lesions of the cord, his prognosis is gloomy: "the patient dies, no course of treatment offering any prospect of success." Another Confederate surgeon, Dr. P. F. Eve,5 in a paper read before the Tennessee Medical Society, is of a different opinion, and cites two cases of balls lodged in the vertebral column, in which the patients survived for a long time. Luxations of the Vertebras will be considered in a separate chapter on simple frac- tures and luxations.6 l Packard, Translatioir'of Malgaigne's Treatise on Fractures, Phila., 3 859, p. 345. 2 Louis, Remarques et Observations sur les Fractures et la fuxation des Vertebres. Mc in. Posth. Arch. Gin. de Med., 1836, T. XI, 2e Serie, p. 417. Captain Villedon received a gunshot fracture of a dorsal vertebra, Nov. '20th, 1762, and fell completely paraplegic. M. Duplessis, his regimental surgeon, made free incisions and extracted the ball. Louis saw the patient on the fourth day, and passing his finger to the bottom of the wound found splinters and some rather large fragments of bone. Louis drew a parallel between the case and a depressed fracture of the cranium. Duplessis was convinced, and the next day the fragments were removed. The paralysis gradually subsided, and twelve years afterwards Captain Villedon was living on his estate in Poitou, in good health, walking with the aid of a cane, though his limbs were feeble and shrunken. 3Consult Mr. Shaw's able paper (op. cit., p. 370); Mr. Erichsen, On Railway and other Injuries of the Nervous System; Dr. Buzzard, On Cases of Injury from Railway Accidents, Lancet, 1867, p. 389; Dr. Bastian (Med. Chir. Trans., Vol. I, p. 499), and the systematic writers on surgery. 4 Op. cit., p. 333. a Amer. Jour. Med. Sci., N. S., Vol. LVI, p. 103. (>On the subjects considered in this chapter, consult farther: Blasius, E., Die traumatischen WirUclverrenkungen ; Bell, C, On Injuries of the Spine and Thigh-bone, London, 4to, 1824; Beutheau, R., Uber einige F'dlle von Verletzungcn der JIalswirbelsiiulc, Diss. Gottingen, 1869 ; Boykk, Traite des Maladies Chirurgicales, 5 6d., Paris, 1846, T. Ill, p. 132; Bueka, Delia Rachialgite Cenni Pathologici, Livonia, 1810, 4to, pp. 30; BKODIE, Med. Chir. Trans., Vol. XX, 1837, p. 118, and Works collected by C Hawkins, London, 1865, Vol. II, p. 319, and Vol. Ill, p. 85; Beck, Kriegs- chirurgische Erfahrungen wdhrend des Feldzuges 1866, in Siiddeutshland, Freiburg, 1867, p. 195; Casper, J. L., Uber die Verletzungcn des Rucken- marks in Hinsicht auf ihr Lethalitdts- Verhaltniss, Berlin, 1823; CuiixOTTE, F. A. F., Dissert, sistens casum subluxationis vertebrse dorsi cumfractura complicatx post factam repositionem, etc., Argent. 1761; Erichsen, Science and Art of Surgery, London, 1869, Vol. I, p. 411; Fisher, Militdr- drztliche Skizzen aus Silddeutschland und Bohmen, Aarau, 1867, j>. 64; FALLOriUS, Opera gennina omnia, Venet. 1606, T. II, p. 379; Gray, Amer. Jour. Med. Sci., Vol. LII, p. 109, and Circular No. 3, 5. G. O., 1871, p. 133; ILekner, Disscrtatio de medullse spinalis inflammation^ Marbourg, 1792; Heistek, Institutiones Chirurgicie, Amstelodami, 4to, 1739, T. I, p. 199; HEVIX, Cours de Patliologie et de Therapeutique Chirurgicales, Paris, 1785, T. II, p. 390; HL.TON, Guy's Hospital Reports, 3d ser. Vol.11; LOHMEYER, Die Schusswunden und ihre Behandlung, Gottingen, 1859, p. 112; LE Gkos Clark. F., Lectures on the Principles of Surgical Diagnosis, London, 1870, p. 187; MORGAGNI, De sed. etcuusis morb., ed. Patav., 1765, T. I, p. 27:5; McCoitMACK, \V., On a case of Injury of the. Spine in the Cervical Region, Dublin, 1867; RAUCH, J. F. L., De oertebrarum cervicalium luxatione, Berolini, 1828 ; Stromeyer, Maximen der Kriegsheilkunst, Hannover, 1861, p. 473. 5!) CHAPTER V. WOUNDS AND INJURIES OF THE CHEST. The number of cases reported of wounds and injuries of the chest is large, and the aggregate would appear still greater, had not the wounds of the soft tissues covering the chest posteriorly been classified with the wounds of the back. The punctured, incised, and miscellaneous wounds and injuries will first be briefly noticed,—the simple fractures and other of the more important of the miscellaneous group being discussed elsewhere;— the second section will be devoted to gunshot wounds of the thorax and its contents, and the third to the operations required by the effects of injuries of this division of the body. Section I. INCISED WOUNDS, CONTUSIONS, AND MISCELLANEOUS INJURIES. Excluding gunshot contusions of the walls of the chest, burns and scalds, and simple fractures of the clavicle, scap da, ribs, and sternum, the returns of this Office exhibit only two hundred and ninety cases of injuries of this group. Of these nine were sabre wounds, and twenty-nine bayonet wounds. Sabre Wounds.—Only one of the nine cases that came under treatment, proved fatal; although several were examples of penetrating wounds of the chest: Case.—Private Leander Clark, Co. G. 123d Indiana Volunteers, aged 40 years, a recent recruit, two days before the action of Rocky Face Eidge. was accidentally wounded in the right che«t by a sabre. The extent of the injury is not noted. He was admitted on May 9th, 18t>4, to Clay Hospital, Louisville, Kentucky. He was here treated for severe bronchitis until June 25th, when he was transferred to the hospital at Jeffersonville, Indiana, and registered as ill of chronic bronchitis. Subsequently Surgeon H. P. Stearns, U. S. V., diagnosticated phthisis, and the patient is recorded as having died on August llth, 1864. of phthisis pulmonalis. The sabre wound could hardly have been regarded as an exciting cause of the tubercular affection, as it is not mentioned in the later reports. Case.—Private James McCauley, Co. C, 1st United States Cavalry, aged 21 years, received a sabre thrust of the chest at Upperville, Virginia, June 21st, 1 803. The point entered about two inches above and to the inner edge of the inferior angle of the right scapula, passed directly through the upper lobe of the right lung from behind forward, and made its appearance beneath the integument two inches above the right nipple, producing a discoloration at that point. He also received four sabre cuts of the head, one of which, over the right parietal bone, fractured the skull; the others were scalp wounds. He was treated in the field, and, on the 24th, was sent to Emory Hospital, AVashington. On admission, he complained of very slight dyspncea and some constipation, which was obviated by a potion of castor oil. Pulse 84 ; tongue clean; appetite good. A bandage was placed around the chest and cold-water dressings applied. A fragment of bone was removed from the right parietal bone. He BAYONET WOUNDS. 467 was furloughed on July 17th, and returned to duty to Carlisle Barracks, September llth, 1863. Pension Exammer J. O. Stanton reports, under date of August 3d, 1871: "The pensioner states that he frequently has haemorrhage from the lungs. There seems to be considerable irritability of the throat and fauces. He is strong and muscular; circulation good." Cask.—Private Joseph Dangel, Co. B, 9th New York Cavalry, aged 21 years, received a perforating sabre wound of the chest at Upperville, Virginia. June 21st, 18i>3. The weapon entered between the ninth and tenth ribs, left side, beneath the axilla, passed inward and backward through the lung and pleural cavity, and emerged two inches below the inferior angle of the left scapula. He also received a gunshot compound fracture of the vertex of the skull, a penetrating wound of the abdomen, a wound on the dorsal aspect ot the left foot, a wound of the right hand, carrying away the little finger, and a wound ofthe back. He was taken prisoner and conveyed to Andersonville, where he remained a period of seventeen months. He was finally paroled and sent to Baltimore, entering Jarvis Hospital on April 5th, H(>5. On May 29th, 181)5, he was discharged from service, at which time Assistant Surgeon DeWitt C. Peters, U. S. A., who reports the case, states that he had entirely recovered, with the excep- tion of some pleuritic, adhesions and contractions of the left side, which, to a great extent, disabled him. He is not a pensioner. Cask.—Private Robert McReery, Co. F, 1st Michigan Cavalry, aged 33 years, was wounded at Gettysburg, Pennsylvania, July 3d. 1863. by a sabre, which entered the posterior boundary of the left axilla, and passed upward some four inches through the serratus magnus and pectoralis muscles. He was conveyed to the field hospital, where he remained until August 20th, when he was transferred to the hospital at Camp Letterman. When admitted, his general health was feeble, and the wound discharged ichorous pus. An emollient poultice was applied, and the discharge soon assumed a healthy appearance. Under the adminis- tration of nouishing diet and stimulants, his general health improved slowly. An abscess formed on September 5th, which was opened. The patient was transferred, on October 9th, to the Cotton Factory Hospital, Harrisburg, Pennsylvania, and discharged from service on January 6th, 181)4, at which time he suffered from phthisis puhnonalis. He is a pensioner. Case.—Private William Cherry, Co C, 2d New York Cavalry, aged 25 years, was wounded at Claiborne, Alabama, April llth, 1865, by a sabre, which entered the body at a point five inches below the nipple, in a line perpendicular to it. On April 25th, he was admitted to the Marine Hospital, New Orleans, and, on the 29th, was transferred to New York; in the hospitals of which State he remained until finally discharged from service. He is not a pensioner. Nickney, Anton, Private, Co. B, 12th Illinois Volunteers. Severe sword wound of right axilla. Culpeper, Virginia, October, 1SG3. Treated in hospital at Quincy, Illinois. Simple dressings. Discharged on April 18th, 1864. Loss of power in arm. Not a pensioner. Earles, James. Corporal, Co. G, 61st New York Volunteers, aged 44 years. Sabre cut over sternum. May llth, 1864. Treated in Stanton Hospital, Washington. Eeturned to duty on June 17th, 1864. Not a pensioner. Britsch, Christian, Private, Co. B, 82d Pennsylvania Volunteers, aged 50 years. Sabre wound of left side. Treated in hospital at Chester, Pennsylvania.' Eeturned to duty, Not a pensioner. Clark, Gavin, Private, Co. I, 1st Illinois Artillery, aged 27 years. Sabre wound right side. Treated in Clay Hospital, Louisville, Kentucky. Returned to duty. Not a pensioner. Bayonet Wounds —There were twenty-nine cases of this group reported. Nine proved fatal, six were discharged, twelve were returned to duty, and in two cases the results could not be ascertained. If there was no error in diagnosis, the abstracts of the two following cases furnish examples of punctured wounds of both lungs, when life was prolonged for two days after the reception of the injury: Case.—Private Nicholas Schenecker, Co. E, 35th Massachusetts Volunteers, aged 25 years, was wounded at Petersburg, Virginia, September 30th, 1864, by a bayonet, which entered the left side, between the second and third ribs, penetrated the lungs, and emerged anteriorly near the sternum. He was treated in the field, and, on October 5th, was transferred to Finley Hospital, Washington. Simple dressings were applied to the wound. Death occurred on October 7th, 1864. The case is reported by Surgeon G. L. Pancoast, U. S. V. Ray, William, Private, Co. E, 1st Washington Territory Volunteers. Perforating bayonet wound of both lungs. December 3d, 1865. The weapon entered anteriorly to the lower portion of the left lung, penetrating the diaphragm, passing- upward and backward, making its exit through the right lung posteriorly. Died, December 5th, 1865. The case is reported by. Assistant Surgeon Clinton Wagner, U. S. A. In the four following cases, bayonet stabs in the chest were followed by fatal inflam- mation of the lung : Phillips, Crawford, Private, Co. A, 44th Georgia. Bayonet wound of riglit chest and arm, and gunshot wound of neck. Wilderness. Virginia, May 9th, 1864. He was admitted to Douglas Hospital, Washington; transferred to Lincoln Hospital, May 14th, and died on May 29th, 1864. Cuomney, Owen, Private, Co. K, 2d Connecticut Volunteers, aged 19 years. Bayonet entered above outer third of left clavicle and passed downward. Cold Harbor, June 3d, 1864. Treated in 3d division hospital, Alexandria. Lung affected. cough, and slight expectoration. Died on July 29th, 1864. The case is reported by Surgeon Edwin Bentley, U. S. V. 408 WTOUNDS AND INJURIES OF THE CHEST. Frazer, Edward, Private, Co. G, G4th United States Colored Troops. Bayonet wound in right side; the weapon entered the pleural cavity one inch below the mamma. May 2-th, 18G4. Treated in hospital at Natchez, Mississippi. Died on June 2d, 1H>1, of inflammation ofthe pleuia extending to the lung. The case is reported by Assistant Surgeon W. H. Miles, 63d C. S. C T. Dehxy, Michael, Color Sergeant, 27th Illinois, was wounded at Marietta, Georgia, June 14th, 1864, by a conoidal ball, which fractured the right arm and jaw. He also received a bayonet penetrating wound of the chest. He was sent to Ackworth, Georgia, on June 28th, and thence to Chattanooga on June 30th. He died on July llth, 1864. Surgeon Francis Salter, l.T. S. V., reports the case. In the three succeeding fatal cases, death resulted promptly from lesions of tlie large vessels of the thorax: Jeffords, Harrison H., Colonel, 4th Michigan Volunteers. Bayonet thrust through chest. Gettysburg, Pennsyl- vania, July 3d, 1863. Died on July 3d, 1863. Mitchell, Louis F., 1st Minnesota. Two bayonet wounds through chest. Edward's Ferry, October 21st, 1861. Died on the same day. The case is reported by Surgeon D. XV. Hand, U. S. V. Case.—Private B. H-----, Co. A, Cobb's Georgia Legion, a prisoner of war at Newport News, Virginia, received a penetrating bayonet wound of the chest, May 7th, 1865. Acting Assistant Surgeon William H. Helm, who reports the case, states : '' At half past ten o'clock p. m., May 7th, I was sent for to see a prisoner who had been wounded by a sentinel. I found him lying on his left side, with his knees drawn pretty well up, and his body bent forward. He complained considerably of pain in any position and begged for some morphia. On examination, I found a triangular-shaped opening on the posterior portion of the thorax, two inches below the inferior angle of the scapula and four inches to the right of the spine. On examination with the probe, I found that the probe ran down beneath the skin for two or three inches, but was unable to detect any opening into the thorax. Pulse good but slightly accelerated. Respiration very iittle if at all affected. Expression of countenance slightly uneasy. There was a very slight oozing from the wound. After a consultation, it was concluded that it was a non-penetrating wound of the chest. The wound was covered by a piece of dry lint fastened by adhesive plaster. A grain of morphia was given him, with directions to give him half a grain in an hour if he was not relieved. Toward morning he became delirious and died about sunrise, without the ward-master having sent for any ofthe surgeons. Necropsy: On tracing the path ofthe bayonet it was found to have gone downward and to the left, some two inches beneath the skin, when it entered the ninth intercostal space. Upon opening the thorax nearly its entire cavity was found filled with clots and semi-fluid blood, of a dark-red hue. The opening in the ninth intercostal space was found and the further course ofthe bayonet was traced, where it had torn through the muscles to the outer and right edge of the intervertebral disk, between the ninth and tenth dorsal vertebra?. The lungs were found to be uninjured. The pericardium contained a clot of bright-red hue, about the size of a large hen's egg, and several ounces of bloody serum. A small triangular spot was seen on the posterior portion of the base of the left ventricle. The probe sank into the triangular spot by its own weight merely, and, on opening the left ventricle, it was found to be a pene- trating wound of the heart. The opposite surface of the ventricle was entirely uninjured. The vena cava ascendens was probably pierced by the bayonet, though it was impossible to find the opening, owing to the dense fibrous clots surrounding the vessels, and pervading the cellular tissue. This supposition accounts for the large venous hsemorrhage and is entirely probable, as the vena cava ascendens was in the course of the bayonet." Of the six men discharged for disability on account of bayonet wounds of the chest, only one is a pensioner. The other five had wounds that probably seriously implicated the external soft parts only: Case.—Corporal Thomas Powers, Co. G, 2d United States Infantry, aged 40 years, was stabbed by a bayonet in the hands of a refractory prisoner on December 2d, 1862. The bayonet entered one-half inch to the right of the median line of the chest, immediately next to the middle of the xiphoid cartilage, penetrated four inches in a direction downward and outward, entering the chest over the costal cartilages of the eighth, ninth, and tenth ribs. On receipt of the injury there was prostration, vomiting for two days, difficulty of breathing, incapacity to draw a long breath, total absence of movement of ribs of lower part of right chest, and decubitus on injured side; no respiration heard on lower part of right chest; puerile respiration above and over the whole of the left chest, mixed, however, in some parts of the left chest, with mucous sounds of bronchitis. Gentle stimulants and essence of beef were given. On December 5th, the vomiting had ceased. He was transferred to Stanton Hospital,. Washington, on December llth; at that time, the wound was closed and the orifice of it covered over by a small, dark-colorfd, triangular-shaped scab. He complained much of darting pains and stitches in the right side. He exhibited dyspncea and increased frequency of the respiratory movements. At times, the dyspncea was so great as to compel him to sit up in bed. There was a moderate amount of effusion in cavity of right pleura, with friction sounds higher up on the same side. He was directed to keep quiet in bed, to be supported by a nourishing diet, to take fluid extract of cinchona, combined with iodide of potassium, and, with a view to still further promote absorption and combat the traumatic pleurisy, to have a succession of blisters applied to his right chest. About Christmas, he had a severe exacerbation of all his symptoms, which was combated by the application of wet and dry cups. A fresh pleurisy was lighted up in the early part of January, 1863, which was treated in the same way. Under the tonic and supporting plan of treatment, he mended slowly in spite of the relapses, and by January 25th, was able to sit up most of the time. He was discharged from service, at his own request, on February 2d, 1863. He was still very feeble and wan, had dyspncea, and percussion showed that the pleuritic effusion, although diminished in quantity, still remained, but the dyspncea appeared to be much greater than could be accounted for satisfactorily by the amount of the effusion. Examining BAYONKT WOUNDS. 469 Surgeon Frank S. Porter reports, October 30th, 1S67: The bayonet entered the chest on the median line, at the lower end ofthe sternum, and, ranging downward and backward, wounded the diaphragm and liver. The result is enlargement of the left lobe of the liver, severe cough, bloody purulent expectoration, haemorrhage of the bowels, with great emaciation. Disability total. Coscjrove, Jesse D., 1st Maryland. Bayonet wound of chest. Gettysburg, July, 1863. Discharged from service. Not a pensioner. Eddie, Samuel E., Private, Co. D, 37th Massachusetts Volunteers, aged 42 years Perforating bayonet wound of chest. Treated in Harewood Hospital, Washington. Discharged from service on June 12th, 1865. Not a pensioner. Hani.Y, Timothy, Private, Co. E, 52d New York Volunteers, aged 35 years. Perforating bayonet wound of chest. White Oak Swamp, Viiginia, June 30th, 1862. Treated in Frederick and Philadelphia hospitals. Bloody expectoration for two weeks. Discharged from service on September 27th, 1862. Not a pensioner. Kirker, Ira, Private, Co. F, 140th Pennsylvania Volunteers, aged 21 years. Bayonet wound of right breast. Spott- sylvania, Virginia, May 12th, 1864. Treated in Harewood Hospital, Washington. Discharged from service. Not a pensioner. Mohawk. S., Corporal, Co. C. 7th Maine, aged 28 years, Bayonet wound of left breast. Wilderness, Viiginia, May 6th, 1864. Treated in Emory and Lincoln Hospitals, Washington. Discharged from service. Not a pensioner. The termination of the two following Confederate cases could not be traced; but it may be hoped, from the condition of the patients when last reported, that they could ultimately have been counted in the list of recoveries: Case.—Private William Tinkler, Co. G, 3d Battalion, South Carolina Infantry, was wounded in a bayonet charge at Spottsylvania, May 8th, 1864. He was conveyed to a Confederate hospital an hour after the reception of the injury. On exam- ination, two apertures were discovered, one a triangular, ragged opening in the back, about one-half inch to the right of the tenth dorsal vertebra, and the other a small puncture, three inches below the right nipple, near the angle of the ninth rib. The patient stated that while in a stooping posture he was transfixed by a bayonet, and he asserted positively that he distinctly felt the withdrawal of the weapon. When admitted to hospital, his face was pallid and anxious and nostrils distended. Skin cool, pulse weak, but somewhat excited, breathing difficult and labored. There was slight oozing of blood from the posterior orifice, which was contracted, and bloody expectoration similar to that occurring in gunshot injuries of the lungs. These symptoms, conjoined with the direction of the wound, led to the belief that the right lung was transfixed. May 9th : Patient expectorates bloody mucus, complains of pain in right lung; has but little cough. Shock has passed off and he is tranquil. May 12th: Bloody expectoration ceased, but pain still continues. May 13th, posterior wound is healed over by scabbing. On May 16th, the patient was doing finely. There was some acceleration of the circulation and dyspncea, but no physical symptoms of lung disease. He was sent to general hospital, May 17th, in fine spirits. Perciral, G., Corporal, Co. F, 5th South Carolina Battery. Perforating bayonet wound of chest. Spottsylvania, Virginia, May 8th, 1864. Treated in Confederate hospital. Dyspncea and bloody expectoration. Doing well. Of twelve men returned to duty or exchanged, one was afterwards pensioned. In three cases, the pleural cavity was believed to have been opened. The remaining cases were, probably, superficial flesh-wounds: Brady, Owen, Private, Co. E, 1st Connecticut Artillery. Bayonet wound of thorax, September 20th, 1863. Treated in 3d division hospital, Alexandria. Returned to duty on September 28th, 1863. Not a pensioner. Conroy, James C, Private, Co. G, 16th United States Infantry. Penetrating bayonet wound, right breast, August 30th, 1865. Treated in Cumberland Hospital, Nashville. Returned to duty on October 14th, 1865. Not a pensioner. Dorsey, Rush, Private, Co. E, 17th We>t Virginia Volunteers, aged 21 years. Bayonet wound, inferior angle of scapula. Cavity of chest not opened. Grafton, September 26th, 1864. Treated in hospital at Grafton. Returned to duty on October 2d, 1864. Not a pensioner. Garrett, J. W., Corporal, Co. E, 50th Pennsylvania Volunteers. Bayonet wound of left side, April 13th, 1863. Treated in St. Aloysius Hospital, Washington. Returned to duty on October 22d, 1863. Not a pensioner. Huber, Jacob, Private, Co. H, 13th Indiana Volunteers, aged 29 years. Perforating bayonet wound of chest. Fort Darling, May 20th, 1864. Treated in hospital at Point Lookout, Maryland. Transferred to Veteran Reserve Corps on April 12th, 1865. Not a pensioner. Johnson, John, Private, Co. K, 6th Pennsylvania Cavalry. Bayonet wound of lung, June 17th, 1863. Treated in 1st division hospital, Annapolis. Returned to duty on July 7th, 1863. Not a pensioner. Moore, W. J., Private, Co. C, 15th New York Engineers, aged 24 years. Bayonet wound of breast, May 6th, 1864. Treated in 3d division hospital, Alexandria. Returned to duty on August 29th, 1864. Not a pensioner. Murray, George, Private, Co. B, 39th United States Colored Troops, aged 24 years. Bayonet wound of left breast. Petersburg, July 30th, 1864. Treated in Summit House Hospital, Philadelphia. Returned to duty on September 27th, 1864. Not a pensioner. 47<> WOUNDS AND INJURIES OF THE CHEST. O'Connor, Timothy, Private, Co. G, 13-th New York Volunteers, aged 35 years. Bayonet wound of chest. Septem- ber lotri 1^(>4. Treated in Mansfield Hospital,-Morehead City, North Carolina. Returned to duty on March 27th, 1865. Not a pensioner. Smith, Griffith, Drummer. Co. D, 163th New York. Bayonet wound of right breast. Treated in Douglas Hospital, Washington. Returned to duty on August 22d, 1863. His name does not appear on the Pension Records. Squires, T. G., Private, Co. L, llth Pennsylvania Cavalry. Bayonet wound of left side, and gunshot wound of shoulder. Stony Creek, June 29th, 1864. Treated in 1st division hospital, Annapolis. Returned to duty on November 16th, 1-65. Examining Surgeon Martin Riger, of Brookville, Pa., reported, May 1st, 1866, that there was "nearly entire loss of motion in right arm from gunshot wound of right shoulder, entering just below the articulation, fracturing the spine of the scapula, passing out near the spine. Bayonet wound of right side, fracturing eighth rib. Remis's Station, June 29th, 1864. Disability one-half aud permanent." Case.—Private James H. W. Virl; Co. G, 8th Louisiana Regiment, aged 19 years, received a bayonet thrust in the left chest at Rappahannock Station, Virginia, on November 7th, 1863. He was sent to Washington, and admitted to Armory Square Hospital on November 9th. The left lung was penetrated one inch below the nipple, and the wound was three-fourths of an inch long. Bloody expectoration, November 8th, 9lh, 10th.—less on llth. Simple dressings were applied. The patient was transferred to the Old Capitol Prison on November 12th, 1863, for exchange, having completely recovered. A colored drawing of the recent wound was made by Hospital Steward W. Schultze. It is No. 79 ofthe Surgical Series of Drawings, S. G. 0. Punctured and Incised Wounds by Various Weapons.—Besides the sabre-cuts and bayonet stabs of the chest, there were reported twenty-seven instances of incised wounds and six examples of punctured wounds penetrating the thorax. Several of these recovered, though attended by lesions of the pleura and its contents: Case.—Corporal Philip Carr, Co. G, 7th Louisiana Infantry, Colored Troops, was admitted to the Corps d'Afrique Hos- pital, New Orleans, Louisiana, December 15th. 1863, with an incised wound of the chest, penetrating the lower lobe of the right lung, inflicted with a dirk knife. Patient anaemic. Prognosis unfavorable. Discharged from service on March 10th, 1864; lung unsound. Not a pensioner. Case.—Private M. P. Bailey, 2d Ohio Heavy Artillery, aged 21 years, was wounded at Lexington, Kentucky, in an affray in prison, July 26th, 1864, by a sheath knife inflicting a wound of the side and injuring the lower lobe of the left lung. He was sent to general hospital on the same day. Simple dressings were applied, and he was returned to jail on September 2d, 1864. The case is reported by Acting Assistant Surgeon Robert Peter. Cask.—Corporal Richard L. Gallatin, Co. B, 8th Iowa Volunteers, aged 23 years, was wounded at Memphis, February 9th, 1865, by a knife, which penetrated the right side below the twelfth rib. Admitted to Adams Hospital the following day, simple dressings were applied. He was returned to duty on April 20th, 1865. His name does not appear on the pension rolls. Acting Assistant Surgeon J. M. Study reports the case. Case.—Private Barney McGinnis, Co. H, 7th Kansas Volunteers, was admitted to the hospital at Leavenworth City, Kansas. August 13th, 1862, with a punctured wound of the right side, by a knife entering below the axilla. The wound was received in camp in a drunken row. He was discharged from service on December 29th, 1863, on account of chronic pleurisy, accompanied by empyema, resulting from the wound. Not a pensioner. But a large number of wounds of this group were fatal. It is common to entertain hopes of recovery when the patient has passed through the immediate danger of such wounds and safely survived the third day. But several of the following cases terminated fatally at a much later date: CASE.-Private Nathaniel Prather Co. A, 29th Illinois Volunteers, aged 21 years, was wounded in a brothel on December 14th, 1864. A knife penetrated the middle lobe of the right lung. He was admitted to Overton Hospital at Memphis, on the same day, and simple dressings were applied. Death resulted on December 17th, 1864. The case is reported by Assistant Surgeon J. C. G. Happersett, U. S. A. CASE.-Private James R. Brown, Co. E, 2d Mirnesota Volunteers, aged 27 years, was admitted to the Marine Hospital, Chicago. March 12th, 1864, with two severe incised wounds through the left mamma, inflicted two days previously with a dirk knife. Death resulted on March 18th, 1864, from penetration of lung and pleuro-pneumonia. Ralph N. Isham, M. D., reports the case. CASE.—Private William T. McLean, Co. F, 64th Ohio Volunteers, aged 23 years, on April 10th, 1865, was stabbed with a bowie knife, which entered to the right of the sternum between the eighth and ninth ribs, penetrating the right lung. On April 24th, he was sent to the Asylum Hospital, Knoxville, where simple dressings wTere applied. Pleuro-pneumonia ensued, and death resulted from empyema on April 28th, 1865. The case is reported by Surgeon F. Meacham, U. S. V. Case.—Private William L. Patch, Co. A, 10th Missouri Cavalry, aged 26 years, received, on November 24th, 1^64, a wound from a knife, penetrating the thorax on the left side. Five days subsequently he was conveyed to the Overton Hospital at Memphis, and simple dressings were applied to the wound. Death resulted on December 12th, 1864. Assistant Surgeon J. C. G. Happersett, U. S A., reports the case. INCISED WOUNDS, CONTUSIONS, AND MISCELLANEOUS INJURIES. 471 Case—Private John Purtell, Co. G. 16th Illinois Volunteers, aged 24 years, was admitted to the hospital at Quincy, Illinois, February 19th, 1864. from Quincy Barracks, with a punctured wound ofthe right side ofthe body, between the seventh and eighth ribs, inflicted with a common pocket-knife during a row, at Memphis, while on veteran furlough. On admission, he was exhausted from loss of blood; but reaction came on the next day. The wound never healed, but continued to discharge from two sinuses above and below. Severe cough and all the symptoms of consumption followed. He at one time improved under the use of expectorants and cod-liver oil. The wound ceased discharging and he voluntarily offered to go to duty. He went out in the city on the next day, indulged too freely in drink, grew gradually worse, and finally died on May 1st, 1865. The case is reported by Acting Assistant Surgeon J. T. Wilson. Case.—Private James T. Fulton, Co. A, 12th Kentucky Cavalry, aged 21 years, received an incised wound of the chest in an affray at Camp Nelson, Kentucky, January 29th, 1865. The weapon, a pocket-knife, penetrated the cavity of the pericar- dium and slightly wounded the heart. He was immediately carried to the Convalescent Hospital near the camp. There was not excessive primary hsemorrhage; but great prostration. Absolute rest and low diet were enjoined, and the movements ofthe chest were restrained by simple dressings. The patient died on February 18th, three weeks after the reception of the injury. Acting Assistant Surgeon A. C. Rankin reports the ease, giving no further details either in the register, monthly report, or burial certificate. Apparently no autopsy was made, and the diagnosis was hazarded without being verified. Miscellaneous Injuries,—Two hundred and twenty-five cases of injuries of the chest of various kinds, caused by railroad accidents, falls, kicks from horses and mules, and other accidents, are recorded. Only five cases proved fatal. It will be remembered that the grave cases of fracture of the thoracic walls have been separated from this group: Case.—Private William Henry, Co. F, 81st Illinois Volunteers, aged 30 years, was admitted to Lawson Hospital, St. Louis, Missouri, January 13th, 1864, with contused wounds of the chest and shoulder, caused by falling from a mule and being dragged and trampled upon. Simple dressings were applied. He was transferred to the Veteran Reserve Corps on March 4th, 1864. Not a pensioner. Case.—Private Isaac G. Farquhar, Co. F, 36th Indiana, received a severe contusion of the sternum, by being run over by a wagon at Chickamauga, Georgia, on September 20th, 1833. He was treated in the field, and afterwards sent to Nashville, in the hospitals of which city he remained until January 1st, 1864, when he was returned to duty. Not a pensioner. Case.—Private Charles Winston, Co. E, 33d United States Colored Troops, was admitted to the 2d division hospital, Beaufort, South Carolina, February 3d, 1865, from field, with a slight contusion of the right side caused by a limb of a tree. He was returned to duty on March 17th, 1865. Not a pensioner. Assistant Surgeon WT. P. Way, U. S. V. reports the case. Case.—Private William Weller, Co. C, 1st New Jersey Cavalry, aged 23 years, was admitted to Fairfax Seminary Hospital, Virginia, May 3d, 1864, with a contusion of the chest and back, received April 30th, by falling from a horse. On May ?th, he was transferred to Cuyler Hospital, Germantown, and returned to duty on May 7th, 1864. Not a pensioner. Assistant Surgeon Henry S. Schell, U. S. A., reports the case." Case.—Private Hiram Rosengrant, Co. D, 33d Illinois Volunteers, aged 27 years, was admitted to the St. Louis Hospital, New Orleans, March 2d, 1865, with a contused wound of the chest, received in an accident on the Opelousas Railroad the same day. He was returned to duty on March 7th, 1865. Not a pensioner. Surgeon A. McMahon, U. S. V., reports the case. Case.—Private Walter Baker, Co. D, 33d Illinois Volunteers, aged 22 years, was admitted to the St. Louis Hospital, New Orleans, March 2d, 1865, with an injury of the chest received in an accident on the Opelousas Railroad the same day. He was returned to duty on March 7th, 1865. Not a pensioner. The case is reported by Surgeon A. McMahon, U. S. V. Table XXI. /Statement of Sabre and Rayonet Wounds and Miscellaneous Injuries of the Chest. nature oe injury. Sabre Wounds.......................... Bayonet Wounds....................... Incised Wounds from various Weapons___ Punctured Wounds from various Weapons Contusions............................. Cases. Died. DISCHARGED. Duty. Unknown. 9 1 4 4 29 9 6 12 2 27 8 5 14 6 4 1 1 225 5 15 205 Aggregate 296 27 31 236 2 V(2 GUNSHOT FLESH- WOUNDS OF THE CHEST. Section II. GUNSHOT WOUNDS OF THE CHEST. These injuries are almost universally, and with great propriety, divided into pene- trating and non-penetrating wounds. Other subdivisions are necessary, however, in the study of a large number of cases. Among the non-penetrating wounds are to be distin- guished: first, those in which the skin, fasciae, and other soft coverings of the thoracic walls are alone interested, and from this large group are separated the flesh-wounds of the region defined by the trapezii and posterior thoracic portion of the latissimi; secondly, the wounds complicated by fracture of the clavicle, scapula sternum, and ribs, or by injury of the bones or cartilages, without injury to the pleural cavity; and lastly the injuries to the contents of the thorax produced by large spent projectiles causing solutions of continuity internally, without external breach of surface. Gunshot Flesh- Wounds of the Chest.—The returns of the flesh-wounds, though the entries of the individual cases were brief, were usually sufficiently detailed to permit an approximative estimate of the position and severity of the injury. There were eleven thousand five hundred and forty-nine cases of gunshot flesh-wounds of the thoracic parieties, exclusive of the dorsal portion. The results were ascertained in all but six hundred and fifty eight cases.* Of the remainder, eight thousand nine hundred and eighty-eight returned to duty in the Veteran Reserve Corps, or were exchanged after their recovery; seventeen hundred and ninety were discharged, the furloughed men who failed to return and the deserters from hospital being included in this aggregate;"}* and one hundred and thirteen died. In the one hundred and thirteen cases last mentioned, death was not always due to the immediate or even remote effects of the injury. Fifteen fatal cases of pyaemia, five of tetanus, eleven of hospital gangrene, eleven of hsemorrhage, one of erysipelas, and ten of pulmonary complications,—including six cases of pneumonia, two of hydrothorax, and one of empyema,—in these fifty-two cases, the injury and death were doubtless directly connected as cause and effect. Of fifty cases,—in which the latal issue w^as referred to diarrhoea and dysentery in nineteen cases, to typhoid fever in twrelve, to exhaustion in fifteen, to consumption in two, to anaemia and anasarca in two,—it is difficult to determine what relation, if any, existed between the injuries and deaths. Finally in eleven cases,—two of malarial fever, two of cerebritis, one of peritonitis, one of diphtheria, and five of small pox,—it is fair to conclude that the original injuries were less closely connected with the fatal results than were hospitalism and other morbific * The undetermined cases were chiefly taken from Confederate reports, and there were no means of tracing them. This observation applies to all classes of cases derived from this source. Only in important instances of extraordinary injuries or operations, information has been sought by special correspondence with the medical officer or the patient, and has commonly been freely communicated when possible. t See page 61, ante. gunshot flesh wounds. 473 causes. It appears, then, that in uncomplicated superficial gunshot wounds of the soft coverings of the chest the mortality is exceedingly small. They commonly cause but little pain, and seldom interfere with the exploration of the lungs by auscultation. They have the disadvantage, however, of healing very slowly, especially when they produce a long groove or canal, or a fistulous track beneath the skin or through the muscles, forming what the French denominate plaies en scion. Their tedious cicatrization is doubtless due to the want of that absolute rest and immobility requisite for prompt reparation,—the muscular movements, especially those of respiration, being with difficulty restrained. Foreign Rodies Lodged.—The lodgement of balls, bits of cloth, or other foreign bodies beneath the skin or in the muscles of the chest was not very infrequent. Tlie following may serve as examples: Case.—Private Gilbert McMurtree, Co. F, 25th New York Volunteers, was wounded at Fred- ericksburg, December 13th, 1862, by a conoidal ball, which entered just above the interclavicular notch of the sternum and lodged near the superior angle of the scapula. He was treated in the field until the 19th, when he was transferred to the 3d division hospital, Alexandria, where, on the next day, Assistant Surgeon XV. A. Conover, U. S. V., removed the missile. Simple dressings were applied to the wound. On January 9th, he was transferred to Lovell Hospital, Portsmouth Grove, Rhode Island, whence he was returned to duty on February 5th, 1833, and probably had no further incon- rounded at apex and deeply , ii- i ' i t» • i • mi • •! i grooved longitudinally.— vemence from the wound as his name does not appear on the Pension List. Ihe missile, represented spec.4400,Sect.I, A.M.M. in the adjacent cut (FiG. 207), was contributed to the Museum by the operator. The longitudinal groove may have been caused by contact with bone; but there was no symptom of injury of the osseous tissue. Case.—Private B. F. Pierce, Co. A, 6th New Hampshire Volunteers, was admitted to Filbert Street Hospital, Phila- delphia, September 3d, 1862. He had been hit in the side, at the second battle of Bull Run. August 30th, by a musket ball, which had run around under the fasciae, externally to the chest, and had made its exit at a point between the fifth and sixth ribs, about the junction of their anterior and middle thirds. The wounds of exit and extrance were dressed by compresses spread with simple cerate. A profuse discharge of thin yellowish pus persisted for several days, when a large piece of cloth was removed from the track of the ball. The wound now cicatrized readily, and, on October 2d, he was nearly well enough to leave hospital. But subsequently, there was some pulmonary difficulty, and the man was discharged from service on December 4th, 1862. Examining Surgeon Ira S. Chase, of Grafton County, New Hampshire, reported, on June 8th, 1863, that the man was in feeble health, with cough and hepatized lungs at the lower part on each side, with violent palpitation from the least exertion or labor of any kind. Disability total and apparently permanent. Case.—-Private Thomas Hagerty, Co. K, 3d Pennsylvania Cavalry, aged 37 years, was admitted to McVeigh branch 3d division hospital, Alexandria, Virginia, December 4th, 1863, having been wounded at the battle of Mine Run, November 27th, by a conical ball, which entered one inch to the left of and exactly in line with the point of the sternum, passed directly across the body and was extracted at the lower edge ofthe middle of the eighth rib. When wounded, he had in his coat-pocket a letter containing a quantity of hog's bristles, a looking-glass cased in a wooden frame, and a gutta-percha comb, portions of all of which were driven into, and were, at different times, extracted from the wound, large portions of the looking-glass case being extracted at four different points in the course of the ball. When admitted, the patient was much prostrated, having been exposed to all the inclemencies of the season, without rations for several days, and transported in an army wagon some forty miles. He lingered for a long time at the point of death, and exhibited some symptoms of pyaemia, of which there were many cases in the hospital at that time, but, aided by constant care, together with the liberal exhibition of tonics and stimulants, with extra diet, the powers of nature overcame the prostration, and he recovered so far as to receive a furlough to go to Philadelphia on the 18th of May, 1864. He returned from furlough in July somewhat improved, but suffering greatly from pain in the region of the wound on any sudden movement, or upon being obliged to stoop. He was discharged from service on August 8th, 1864. Surgeon Edwin Bentley, U. S. V., reports the case. Non-penetrating Injuries of Rones.—In this class, it has been sought to include only those gunshot wounds complicated by injury'of the bones, or cartilaginous portion of the parietes of the chest, but unaccompanied by opening of the chest cavity or direct lesion of its contents. Many such cases recover without serious symptoms, but in others, inflammation of the pleura is induced either by the concussion caused by the projectile or by depression of the bone upon the pleura, or disease of the bones may ensue, with abscess and necrosis, and consecutive pneumonic inflammation may be lighted up at a period remote from the injury. The following illustrations may be of interest: Case.—Corporal Walter Gregory, Co. F, 173d New York Volunteers, aged 22 years, was wounded at Pleasant Hill, Louisiana, April 9th, 1864, by a conoidal ball, which fractured the ninth rib. He was taken prisoner and remained with the 60 474 WrOUNDS AND INJURIES OF THE CHEST. enemy until June 16th, when he was paroled and sent to the University Hospital, New Orleans. Simple dressings were applied. He wa* transferred to Camp Parole on February 2d, 1864. and was mustered out of service on October 18th, 1H(5.">. The Pension Examining Board at Boooklyii, 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." Case.—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 trans verselv across the chest, fracturing the sternum, and lodged in the anterior fold of the right axilla. He was admitted, on the next dav, to the hospital at Frederick, Maryland, breathing rapidly and with considerable difficulty. The ball was immediately extracted. On the next day dyspncea set in, due to double pleurisy from contiguity of wound to the pleura and depression of the sternum. Stimulants and anodynes were administered, and dry cups applied on the right side of the chest. The patient improved rapidlv. By October 19th, the wounds were healed, and he was returned to duty. He was discharged on March 26th, 18o4. 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, 69ch 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 ofthe body of the sternum. Various efforts were made to remove it by counter openings, but in vain, and, after nine months in general hospitals in 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 appearances of old gunshot wounds. He was immediately sent to Riker's Island, New York Harbor where he underwent a great, deal of unnecessary exposure to the elements, and also to other deleterious influences 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 Nekton's probe, indicated the nature and position of the bullet, the existence of which had been previously doubted or denied. It was removed, without difficulty, by simple incision. No spiculae of carious 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 from the surrounding tissues. The missile 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. Fk;. 208.—A flat- tened conoidal musket ball successfully re- moved from the ster- num. Spec. 1558, Sect. I, A. M. M. C.\SE.—Private J. E. A- e~L~ -, Co. I, 32d New York Volunteers, having been wounded in front of Richmond, on June 25th, 1864, was sent to Washington, and admitted into Mount Pleasant 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 inflammation of the surrounding tissues. The administration of tonics and stimulants, and the application of cold-water dressings failed to avert the fatal issue, which occurred on August 1st, 1862. 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 hypertrophied, and showed evidences 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 Jersev Volunteers, aged 24 years, was wounded at Fredericksburg, December 12th, 1862, by a ball, which, entering the back on the ver2j' iSt^STy™ round right side, within a half inch of the vertebral column, opposite the spinous process of the sixth balL Spec.34, Sect. I, A. M.M. dorsal vertebra, and apparently passing 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 a 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, 1862, to Harewood Hospital, Washington, and, on January 31st, 1863, to Broad and Cherry Streets Hospital, Philadelphia. 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, aud 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. FiG. 210.—An elongated ball grooved by impact on the clavicle. Spec :;?8 S.'.-t. I, A.M. M. NON-PENETRATING INJURIES OF BONES. 475 Case.—Private WTilliam A. Furbush, Co. G, 16th Maine Volunteers, aged 18 years, was wounded at Fredericksburg, Vir.">, by a conoidal ball, which entered the left side near the spine, between the eighth and ninth ribs, penetrated the thorax, and lodged. He was taken from the field and sent by rail, with over two hundred other wounded ofthe corps, to City Point, to the field hospital of the Second Corps, under Acting Staff Surgeon John Aiken, V. S. V. He had rallied from the shock of the injury, but was depressed by haemorrhage, and had labored breathing and haemoptysis. Simple dressings were applied, and the patient was placed on an hospital steamer, and on April 5th was admitted to Armory Square Hospital, Washington. He died on April 6th, 1865, while the wound was being examined. Cask..—Private Leonidas Miller, Co. A, 26th Iowa Volunteers, was wounded at the battle of Big Shanty, Georgia, June 16th, 1864, the missile passing through the upper portion of the middle lobe of riglit lung, entering between the fourth and fifth ribs anteriorly, and lodging in the pleural cavity. He was admitted on the same day into the field hospital of the 1st division, Fifteenth Corps, in charge of Surgeon M. XV. 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 of supporting 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 applied to the wound, and a generous diet ordered. The patient died on July 3d, 1834. 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 conoidall 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 June 30th. On admission, the patient was suffering severely. His wound was dressed and an opiate given, after which 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 delirious." Case.—Private Jesus Garcia, Troop F, 1st New Mexico Cavalry, in attempting to escape,'after being apprehended 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 symptoms 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. Gunshot 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 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, 1833, 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 fracture 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 closes of morphia were given, with the effect of diminishing very much the frequency of the cough. The patient was feeble, and the discharge from the wound considerable, but no very serious symptoms presented themselves until the 16th, when the patient was seized with considerable oppression of breathing, and with pain on the wounded side. Dullness over the upper side of the right lung was observed on percussion. A discharge of blood and serum 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 copious discharge of serous pus remained, and the patient became gradually 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 Fig. 218.—Transverse fracture of the right cla- near its angle. The specimen figured in the adjoining cut (Fig. 218), was presented vicle, with a conoidal bullet attached. Spec. 1-^10, tl . ,, ,. , ' . , , J , \ . ... . o s.et. I, A. M. M. (Vertical view. Reduced to t() tne Army Medical Museum, with the above account, by Acting Assistant burgeon one-third.) p; p Crai". GUNSHOT FRACTURES OF THE CLAVICLE. 483 Case.—Private Andrew G- , Co. I, 5th Michigan Volunteers, aged 21 years,-was wounded at Fredericksburg, December 13th, 1862, by a missile, which fractured the clavicle, passed through the apex of the riglit lung, and emerged near the eighth dorsal vertebra. He was admitted to Harewood Hospital, Washington, on December 17th, suffering 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 applied; 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 Nashville 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 Regiment, aged 22 years, was admitted to hospital at Nashville, on January 27th, 1864, from another hospital, 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 simple dressings were required. On February llth, 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, tlie 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 R. T. Higgins, and is figured in the adjoining cut (Fig. 219) [This patient was, probably, wounded at Mission Ridge, November 25th, 1863, as he was received at Nashville from the hospital for prisoners at Stevenson, Alabama, December llth, 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.] Fig. 219.—Left clavicle, showing- a partially united fracture with shortening, posterior displacement, and necrosis. Spec. 2194, Sect. I, A. M. M. Case.—Private W. H. C- -, Co. H, 31st Georgia Regiment, wounded at Fredericksburg, December 13th, 1862, was admitted to Carver Hospital, Washington, and died exhausted on January 8th, 1863. A conoidal 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 between 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 downward 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 with pus, and clots of blood undergoing putre- 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. fig. 220.—Conoidal musket-ball, with a portion o The specimen is partly represented in the adjoining cut (Fig. 220). j*ectlef £*&" M .wbuai" has Perforate(1- sPec- 636- Case.—Private Edward Osborn, Co. H, 9th Pennsylvania Reserves, aged 24 years, was wounded at South Mountain, Maryland, September 14th, 1862, by a conoidal ball, which entered the riglit 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, 1863, 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 expectorants were administered. January 26th: 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 improving. When coughing, air passes through the anterior wound, and pus through the posterior one; discharge profuse but healthy. Cough worse when laying down and at night. February 10th r Expectoration diminished; air has ceased to pass through the wound. He continued to improve, and, by February 15th, was able to move about the ward. Wound look- ing healthy and suppurating freely. On March 30th, a piece of bone about the size of a hazel-nut came away from the clavicle, which had been splintered by the ball. April 18th : Right lung almost consolidated, and sinking away of chest very noticeable. He Avas transferred to Baltimore, and finally discharged from service on November 12th, 1863 Pension Examiner E. McCook ■1*4 WOUNDS AND INJURIES OF THE CHEST. reports. November lSth, 1863, ''arm useless, fingers partially paralyzed. Air still passes out of the posterior opening from the lung." The Pittsburg Examing Board reports, October 4th, 1^71: " 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 the 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. Gunshot Fractures of the Scapula.—Several illustra- tions of thisinjury have been cited among the non-penetrating gunshot 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 perforations of the lower plate, near its middle, connected by a fissure. The supra-spinous fossa has been chiefly carried away. The thin splintered laminae of the body of the bone are forced outward about the perforations. The specimen was contributed by Surgeon Jerome B. Green, 1st Rhode Island Volunteers. It was brought from the First Bull Run FIG. 221.—Gunshot perforation of the right scapula. Spec. 851, Sect. I, A. M. M. 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 impringing 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 haemorrhages from the trunk or minor divisions of the transversalis colli, suprascapular, posterior cervical, princeps cervicis, and subscapular were 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. Lodgement 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. 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 ICth, 1866, "there is an aneurism ofthe 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 Jonothan Morris. Ironton, Ohio, reports, March 1, 1867, that " upper portion ofthe 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 Jr. Oglcsby, 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 riglit breast between the first and second ribs, passing entirely through the lung and lower portion ofthe GUNSHOT FRACTURES OF THE SCAPULA. 485 Fig. 222.—Gunshot fracture of the riglit 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 being much prostrated. He rallied under treatment, which consisted of free bleeding from the arm and the antiphlogistic regimen generally, followed by liberal doses of tincture of iron. The wound assuming a healthy appearance, soon healed, and, on December 28th, the patient was almost entirely recovered. He was furloughed. The next case is from a prisoner wounded at Fort Donel- son, February 15th, 1862. He was 23 years of age, and tem- perate. A musket ball entered below the right clavicle and passing inward and backward injured the upper lobe of the lung and fractured the scapula (Fig. 222"): The patient survived the injury until after August 21st, 1862, when he was sent to the prison hospital at Alton, Illinois. In the specimen, a transverse fracture extends across the dorsum, parallel with the spine. From this a vertical fracture separates the superior anterior fourth from the remainder of the bone. A longitudinal fracture occupies the anterior border for one inch below the chief injury, and a fissure of similar length extends parallel to the posterior border. There are traces of periosteal disturbance. The specimen was contributed to the Army Medical Museum by Surgeon J. T. Hogden, IT. S. V. Cask.—Private G. W------, Co. E. 96th New York Volunteers, aged 24 years, was admitted to hospital at Philadelphia from Winchester, Virginia, on October 26th, 1864, for a gunshot fracture of the left scapula, received at the battle near Gedar Creek on October 19th. A conoidal musket ball had entered the left shoulder, just beneath the acromion process of the left scapula, passed transversely downward beneath the scapula, and imbedded itself just beneath its spine. The wound was quite unhealthy, the shoulder being enormously swollen and discolored, with a large amount of pus concealed beneath the scapula. The patient's breathing was oppressed; there was dullness on percussion, with absence of the vesicular murmur over the upper portion of the left lung, and the general health was much impaired. The expectant plan of treatment was pursued. On October 27th, the patient was etherized, and the ball remo\ed through a counter opening beneath the inferior border of the scapula. Some eight or ten ounces of very unhealthy pus and broken bone were evacuated at the same time. In the after- noon a severe chill occurred, followed by slight fever, profuse, cold, clammy perspiration, and low muttering delirium. Ten grains of bisulphite of soda, in an infusion of quassia, was directed to be taken every hour, in addition to tonics and stimulants. Delirium and chills continued on the 28th, with an increase of swelling and disorganization of the soft parts. On the 29th, none of these symptoms had abated. The patient sank rapidly, and died on the morning of October 30th, 1864. The autopsy revealed a bad fracture of the scapula, a disorganized condition ofthe subscapular and pectoral muscles, and an opening in the apex of the chest. The left lung was highly congested; the abdominal viscera healthy. There was congestion of the membranes of the brain, with effusion of serum at its base and in the ventricles. The pathological specimen was contributed to the Army Medical Museum, with the history, by Acting Assistant Surgeon A. A. Smith. (See Fig. 223.) Fig. 223.—Left scapula, showing frac- ture of the coracoid process. Spec. 3G38, Sect. I, A. M. M. Gunshot fractures of the scapula were often associated with those of the ribs and humerus, as in the following case: Case.—Private Thomas L- -, Co. K, 1st Massachusetts Volunteers, aged 42 years, having been wounded at Fredericks- burg, Virginia, on May 3d, 1863, was sent to Washington, and admitted to Carver Hospital on the 9th. An unknown missile had entered the right shoulder about two inches below the acromion process, and, passing backward and inward, had emerged above the inferior angle of the scapula. The patient's pulse was 120, and quite Aveak, and his skin was bathed in perspiration. Percussion over the right lung elicited considerable dullness. The treatment consisted in the frequent administration of anodynes, stimulants, and tonics, with a low diet. The patient suffered from anorexia and insomnia, and bloody serum was discharged through the pos- terior wound during inspiration. Air was also forced through at the same time. He died on the morning ofthe llth. The autopsy discovered a fracture at the surgical neck of the humerus; the sixth, seventh, and eighth ribs were comminuted, and portions of bone were forced through the pleura, the cavity of which contained a large quantity of bloody serum. The scapula was also fractured, and the tissues surrounding the wound were much inflamed. The costal surface of the pleura was coated with fibrinous exudations. The pathological specimen, consisting of the right scapula, upper third of the humerus, and sections of the fifth, seventh, and eighth ribs, was contributed by Surgeon 0. A. Judson, U. S. V., and is represented in the wood-cut (Fig. 224). Fig. 224.—Gunshot fracture of the humerus Spec. 1215, Sect. I, A. M. M. 486 WOUNDS AND INJURIES OF THE CHEST. In other instances the clavicle, scapula, and ribs were shattered by the same projectile, as in the case of Private J. M. W-------, illustrated by Spec. No. 1304 of the Museum; that of Private W. A. F-------, narrated on page 475, and in the following case: Case.—Private Edward L------, Co. A, 87th New York Volunteers, was wounded at Bull Run, August 27th, 1862, by a conoidal musket ball, which struck the left clavicle about three inches from its sternal extremity, passed through the cheBt, and emerged near the posterior border of the left scapula. Five days subsequently he was admitted into the Cranch Hospital at Washington, in a feeble condition. There was constipation and troublesome cough accompanied by haemoptysis. The bowels were relieved by sulphate of magnesia, and the cough was alleviated by ipecac and opium. An engorged condition ofthe injured lung, with sanguineous expectoration and dyspncea, continued for some twelve days, when the patient began to grow better. His general health improved, and, to all appearance, resolution was taking place in the lung. Improvement continued till October 12th, when the patient took cold through indiscretion, and had a chill. After appropriate treatment he had partially recovered by October 27th, when he again exposed himself unnecessarily, took a fresh cold, and had another chill, lasting an hour and a half, followed by fever and pneumonia ofthe right lung. Wet cups were now applied, and a dose of ten grains of calomel was administered. On October 30th, the cups were repeated, and another expectorant mixture was prescribed. There was no reaction, however, dyspncea continuing unabated, and terminating in death on November 3d, 1862. The autopsy showed the left clavicle fractured at the junction of the middle with the outer third, the distal portion being driven in. There was a formation of callus, but no union of bone. The third, fourth, and fifth ribs, of the left side, were fractured near their spinal articulations, and the dorsum of the left scapula was perforated. The apex of the left lung was grooved by the passage of the hall and appeared entirely solidified. The track of the wound through the lung was entirely cicatrized, and seemed cartilaginous to the touch. There were also pleuritic adhesions in the right side, and the right pleural cavity contained from two to three pints of fluid. The specimen, represented in the adjoining wood-cut, Fig. 225, was contributed to the Army Medical Museum, with the history, by Surgeon A. Wynkoop, U. S. V. Fig. 225.—Left scapula, clavicle and ribs fractured by a conoidal musket ball. Spec 245, Sect. I, A. M. M. Gunshot fractures of both scapula? by the same ball are occasionally seen. In such instances the projectile, passing parallel to the posterior plane of the thorax, usually fractures one or more vertebral spinous processes, as in the case of Private J. T. L------, Co. G, LSth Massachusetts Volunteers, recorded on page 435 ; see Spec. 699 of the Surgical Section of the Army Medical Museum. The specimen of fractured vertebrse is No. 843 of the same section. Cases of fractured scapula complicated by injuries of the vertebrae have been reported in the last chapter; see cases of Corporal G. W. M------, p. 438, Fig 190. The scapula is Spec. 3089, Sect. I, of the Museum. Also, the case of Sergeant J. H. R-------, page 431, and that of Private C B-------, Spec. 4092, Sect. I. The Museum possesses thirty-two specimens of gunshot fracture of the scapula. Besides those that have been cited, or that will be noted in the section on operations, interesting illustrations of attempt at reparation in the scapula are afforded by -(Specs. 2792, 218'\ 1211, from patients who survived their injuries thirty-three, sixty-three, and twenty-two days, respectively. Specs. 832, 2585, 2124, and 4862 show various forms of associated fractures of the shoulder-blade and ribs. Gunshot Penetrating Fractures of the Sternum.—A number of examples of recovery after this severe form of injury were reported.* One of the most interesting is that represented in the accompanying chromolithograph (Plate X) of a soldier wounded in the anterior mediastinum in General Sedgwick's movement, at the battle of Chancellorsville :f Case.—Private Charles P. Betts, Co. I, 26th New Jersey Volunteers, aged 22 years, was struck by a three-ounce grape- shot, on the morning of May 3d, 1863, in a charge upon the heights of Fredericksburg. The ball comminuted the sternum, at * For instances of non-penetrating gunshot fractures of the sternum, see page 474, ante. t The drawing was made at the Potomac Creek Hospital of the 2d division, Sixth Corps, and so faithfully was the likeness of the patient preserved, as well as the features of the wound, that Surgeon S. A. Holman, IT. ,S. V., medical director of the Sixth Corps, in 1865, turning over a portfolio at the Min^ro General's Office, and, observing this drawing, exclaimed : " I know that man ; that's Betts, 2d divisiou, Sixth Corps !" I'M. Sliiucli |,inx' .1.1!icii . clii'oiiiolilti PENETRATION OF ANTERIOR MEDIASTINUM BY CANISTER. GUNSHOT PENETRATIONS OF THE STERNUM. 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 collapsed. When sitting up there was but slight dyspncea. Several fragments of the sternum were removed, and the wound soon granulated kindly. On Mav 10th, a colored drawing of the wound was made. (No. ID, Surgical Series of Drawings, S. (1. O.) On July 5th, the patient was transferred to Washington, convalescent. He ultimately recovered perfectly. This man was discharged the service on June 27th, 186:1, 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 way that it is ragged and does not heal solid. My health is as good as I ever expect 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- FlG. 226.—Superior portion of sternum fractured by a ball which is attached. Spec. 1073. Sect. I, A. M. M. ■. Co. C, 147th Pennsylvania Volunteers, was wounded at Chancellorsville. May 2d, 1863, by a conoidal musket-ball, which entered between the second and third ribs, on the right side, two inches from the median line, fractured the sternum, and lodged beneath it. The wound bled profusely, but the haemorrhage was arrested by pressure The patient was conveyed to Douglas Hospital, Washington, on May 8th, and died the following day. He had haemoptysis and the symptoms of traumatic pneumonia. The pathological specimen, contributed to the Army Medical Museum by Assistant Surgeon W. Thomson, U. S. A., is figured in the adjoining wood-cut (Fig. 226.) Case.—Private H. B-----, 27th Michigan Volunteers, aged 21 years, was wounded at Spottsylvania, May 12th, 1864, by a fragment of shell, which contused the upper 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 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 15th, when there was anorexia, dry tongue, an apparently healthy discharge from the wound, troublesome cough, and muco-purulent sputnm. To combat these symptoms, tonics, stimulants, and an extra diet were directed. The patient sank gradually, and, by July 5tb, 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 dyspncea; 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 pleural 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 H. Allen, U. S. A., and is figured in the adjoining cut (Fig. 227). FIG. 227.—Upper portion of the sternum fraetured longi- tudinally and obliquely, with displacement. Spec. 2914, Sect. I, A. M. M. Case,—Private Edwin Steele, Co. A, 3d Missouri State Militia 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 llth, when he was sent to the post hospital at Cape Girardeau. Discharged from service February 27th, 1865. Pension Examiner E. W. Bartlett reports, June 22d, 1869, " the missile interferes with the motion of the arm and causes haemorrhage 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, passed through the mediastinum, and lodged beneath the posterior border of the left scapula. He was taken to the field hospital, where the wound was dressed with adhesive plaster. During the first twenty-four hours, the external haemorrage 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 R. C. Kedzie, 12th Michigan Volunteers. The internal hsemorrhage was considerable and frothy, and bloody expectoration continued for some three weeks. Morphia was administered regularly, and the patient was kept 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, Pittsburg. The wound finally healed about the middle of July, 1862. He was discharged from service on November 7th, 1862. Pension Examiner Ira C. Backus reports, December 1st, 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; dyspncea 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.' 488 WOUNDS AND INJURIES OF THE CHEST. Cask.—Private James Brownlee, Co. G, 134th New York Volunteers, aged 21 years, was wounded at Gettysburg, Julv 1st. 1863. by four balls and three buckshot. One ball, probably conoidal, entered the sternum about an inch below the jugular fossa, and passing downward and outward, underneath the second, third, and fourth ribs, perforated the upper lobe of the right lung superficially, and emerged between the fourth and fifth ribs, about three inches to the right of the nipple of the same side. Three buckshot took effect just above the pubes, some of them passing through the bladder. One ball entered the riglit thiadi and lodged; another (conoidal) entered the left thigh and passed nearly through. It was removed on the fourth day. A nearly spent conoidal ball entered the back of the sacrum, near its middle, and buried itself slightly beneath the skin, whence it was immediately removed by the patient. In addition to the injuries already stated the patient affirms that he was finally struck upon his knapsack, and knocked down by a piece of railroad iron about eighteen inches long, which was fired from one of the enemy's guns. Being made a prisoner soon after, a Confederate surgeon removed some fragments of the sternum from the wound of exit, and dressed the wound with pledgets of lint, removing them every hour or two. He observed that whenever the dressing was removed he breathed with difficulty, but on being replaced he felt immediate relief. The patient was admitted to Camp Letterman, Pennsylvania on August 6th, and was furloughed on October 30th, 1863. He was admitted to Central Park Hospital, New York, on December 9th, 1863, and came under the observation of Professor Frank II. Hamilton, who stated that " after the lapse of nine months there is a copious purulent discharge from both orifices, and the walls of the thorax upon the injured side have already contracted considerably. The posterior portion of the right lung admits air freely, nearly to its base. In front, no auscultatory sounds are detected. When he stands erect the right shoulder falls considerably. Most of the time he has a troublesome diarrhoea, yet under a generous diet he is gradually gaining in strength and health." On June 3d, 1865, Brownlee was admitted to Ira Harris Hospital, Albany. He was discharged the service on August 12th, 1865. Examining Surgeon William H. Craig states, August 22d, 1866, that "a fistulous opening remains in the breast, at which the air escapes in inspiration. About four ounces of pus is discharged from this opening each day. Disability probably permanent." On January 29th, 1867, Examining Surgeon E. S. Delavan, at Albany, reports: "Three buckshot entered in front near the symphisis pubis, perforating the bladder. Strange to say, he recovered from the wound. Ball entered the breast and sternum and passed out (probably, though he never saw the ball); it may be in the chest below the right nipple. The right lung is almost totally useless. I can detect no respiratory murmur, and he has cough and feeble pulse. In my opinion, the disability is permanent.'' Gunshot Fractures of the Ribs—The ribs are sometimes fractured, as has been seen (pp. 4'6I, by a conoidal ball, which entered the right side ofthe chest, fractured two ribs and lacerated the right lung. He was discharged from service on February 2d, 1835. Pension Examiner Charles Rowland reports, April 24th, 1865, that pulmonary consumption has resulted, confining the pensioner to his bed. The wound discharges freely. Dr. AV. E Mulhallen, of Brooklyn, New York, reports , September 21st, 1866 : I attended Lieutenant Henry for some twelve months previous to his death, which occurred at Brooklyn, August 16th, 1866. He was wounded near the sixth rib anteriorly; the wound healed up and inflammation set in, and it again opened in two places about the fourth rib and continued to discharge until his death. The right lung was affected by this wound, and became entirely useless aud wasted away. There can be no possible doubt but that his death was caused by the wound. Opportunities were sometimes, though rarely, afforded of observing the attempts at repair in fractured ribs, when young and robust patients survived their injuries for several weeks. The following is an instance, in which the pathological appearances of the lungs are described, and the collapsed right.lung imperfectly figured: CASE.-Private S. B------, Co. A, 83d New York, having been wounded at Fredericks- burg, December 13th, 1862, was admitted into Lincoln Hospital, Washington, on December 23d, 1862. A conoidal musket ball had entered the right chest posteriorly, over the attachment of the eleventh rib, and passed forward. The missile was extracted on the 26th, and simple dressings were applied. Pleuro-pneumonia ensued, and resulted in empyema. On January 3d, 1863, a pint of pus was evacuated from the pleural cavity. The case terminated fatally on January 21st, 1863. Nine hours subsequently a post-mortem examination was performed by Assistant Surgeon G. M. McGill, U. S. A. Rigor mortis was well marked. The brain weighed forty-five ounces and two drachms. A healthy fluid was found in the lateral ventricles. The bronchial glands were enlarged. The right lung was compressed and crowded into the superior, posterior, and internal part of its chamber. It was adherent to the costal parieties by fibrinous bands. Anteriorly, inferiorly, and externally, occupying the cavity left by the retreating lung, was found a collection of pus, between the two walls of pleura, measuring one pint and a half. This cavity was lined by a thick membrane presenting internally a mucoid appearance. The left lung showed gray hepatization in the upper and posterior portions, the inferior and anterior being congested, and thick, tenacious bronchial secretion exuded from the bronchial tubes. Anteriorly, this lung was firmly adherent to the pericardium. The right lung weighed fourteen, the left twenty-six ounces. The pericardium was filled with two ounces of yellowish fluid. The heart, with the pericardium, weighed ten and a half ounces. Firm fibrinated clots existed in both auricles, continuous within the auriculo-ventricular openings, and a black clot was found in the left ventricle and aorta. The liver, weighing sixty-four ounces, was " nutmegged." Each kidney weighed five and a half ounces. The spleen was firm, and weighed seven and a half ounces. The pancreas weighed four ounces. The greater omentum extended a short distance below the umbilicus; the intestines were much inflated; the lymphatics of the lumbar region and the mesenteric glands were enlarged. The stomach and duodenum were normal; patches of congestion were scattered through the jejunum and ileum; the mucous membrane of the small intestine was softened; the walls of the large intestine were thickened. Portions of the eleventh and twelfth ribs of the right side, completely fractured and surrounded at the points of solution with large irregular formations of callus, were contributed to the Army Medical Museum by Surgeon H. Bryant, U. S. V., and the particulars ofthe autopsy were furnished by Assistant Surgeon J. Cooper McKee, U. S. A. The specimens are figured in the accompanying wood-cuts (Figs. 232 and 233), on a much reduced scale, the cut used in Circular 6, and in the Catalogue, being utilized. Fig. 232.—Eight lung collapsed after gunshot wound. Spec. 846, Sect. I, A. M. M. Fig. 233. — Attempted repair after gunshot fracture of floating ribs. Spec. 845, Sect. I, A. M. M. Other illustrations of gunshot fractures of the ribs will appear in the sub-division on Hemorrhage, others again among the Operations in the next Section. The Army Medical Museum contains altogether thirty-three specimens belonging to this class. For fracture of the neck of the right first rib by a small round iron ball, see Specimen 1472. For a wrell-marked willow fracture of the left ninth rib, by a conoidal musket ball, striking side-wise, from a youth of twenty, see Specimen 1441. For an example of moderate osseous deposit in thirty-three days, in a fracture of the eighth rib in a boy of nineteen, see Specimen 1901. For examples of necrosis, see Specimens 2809 and 3843. For an instance of consolidated fracture, see Specimen 877. For a curious incomplete fracture, without penetration by the missile, see Specimen 3823,—from a cavalry soldier, aged 28 years, who died from pleuro-pneumonia five days after the reception of the injury. COMPLICATED WOUNDS OF THE LUNG. 491 Complicated Gunshot Wounds of the Lung.—The following abstracts comprise several remarkable instances of recovery after gunshot wounds believed to have involved the pulmonary parenchyma, and also accounts of interesting cases that had a fatal termination: Cask.—Color Sergeant Samuel McQuaid, Co. I, 124th New York Volunteers, aged 28 years, was wounded at Gettys- burg, Pennsylvania, July 2d, 1863, by a conoidal ball, which entered about an inch above the left nipple, passed entirely through the chest, fracturing two ribs in its passage, and lodged in the back near the lower edge of the scapula, from whence it was extracted. He was treated at the field hospital of the 1st division, Third Corps, and, on July 10th, transferred to Satterlee Hospital, Philadelphia. When admitted, the wound was of smaTl dimensions ; not painful. The discharge was very profuse and seemed to come from the thoracic cavity, great quantities being discharged when the body was bent forward so as to favor its free expulsion. On the morning of July 24th, symptoms of internal disturbance became manifest; faintness and depression, followed by coldness of the extremities, with dyspncea, indicated a collection of pus in the pleural cavity. His strength soon began to give away, and he was only kept alive by the free administration of stimulants and such nutritious diet as he could swallow.. The first attack lasted during the greater part of the day. growing gradually less severe until evening, when he had almost entirely recovered from its effects. Several slight attacks of the same kind were experienced during the next three days. The wound began to assume an unhealthy appearance and was soon covered with sloughs of a gangrenous character, which continued to extend until it became more than thrice its original size. A wash, composed of equal parts of creasote, alcohol, and water, was applied to the wound, which was afterward dressed with yeast poultice. Under this treatment the sloughs began to separate and come away, leaving a healthy granulating wound. The patient soon began to improve, and, on August 8th, was able to go home on furlough, the wound at that time being almost entirely closed. His respiration was perfect. He was trans- ferred to the Veteran Reserve Corps. January 30th, 1864. He is not a pensioner. Surgeon 1.1. Hayes, U. S. V., reports the case. Case.—Private Summcrlin Berrien, Co. G, 47th Georgia Regiment, aged 35 years, was admitted to the Institute Hospital, Atlanta, Georgia, May 18th, 1864, with a gunshot penetrating wound of the chest, received on May 13th, 1864. A conoidal ball entered the back, about two and one-half inches to the left and opposite the sixth dorsal vertebra, passed directly forward, and emerged four inches to the left of the median line and between the floating ribs. When admitted, the wound of entrance was clean and healthy, and suppurating kindly. The wound of exit had closed and had the appearance of a hard tumor; general condition good; free from cough, fever, and pain. The patient continued to improve until June 4th, when he was seized with a troublesome hacking cough, each paroxysm of which caused a jet of dark, sanious, and very offensive fluid to flow from wound of entrance; no pain and but little constitutional disturbance. Expectorants and nutritious diet. June 5th: Dark sanious matter continues to flow from wound of entrance in forcible jets, during each expiratory effort of coughing; during inspiration, air rushes into the wound with a hissing sound; cough continued troublesome, but without expectoration, except white mucus. Auscultation revealed both amphoric respiration and metallic tinkling. Patient had considerable fever. General treatment continued. In this way the patient continued, without much change of interest, until June 13th, when the dark sanious discbarge was substituted by healthy pus in moderate quantities. Shortly after this, an abscess formed around the wound of exit and discharged pus freely. June 30th: Patient doing well, with a good prospect of recovery. The case is reported by Surgeon D. C. O'Keefe* P. A. C. S. Case.—Private John Collins, Co. G, 26th Iowa Volunteers, was wounded at Arkansas Post, Arkansas. January llth, 1863, by a musket ball, which entered the left side between the clavicle and first rib, passed downward and backward, perforated the lung, and emerged to the right of the sixth dorsal vertebra. According to the statement of the patient, he expectorated a considerable quantity of blood and experienced a very severe pain in the left side. He was removed to the hospital and adhesive plaster placed over the wounds. The obliquity of the external wounds seemed to prevent the admission of external air. The surgeon evidently seemed to consider it a hopeless case, and paid but little attention to him, so that after a month he had become very much bent over, forward and laterally. Discharged from service on June 1st, 1863. Pension Examiner A. H. Ames reports, July 17th, 1863, that the wound has always been open at exit. " Great pain has existed along the course of the ball, and now a fistula extends from point of exit into the substance of the lung. His lungs are much diseased in consequence. Cough- ing, together with the pain, and great emaciation consequent upon the suppuration from the wound, will not let him live long." Dr. P. J. Farnsworth, of Lyons, Iowa, states, in a communication to The Medical and Surgical Reporter, Vol. XIII, No. 15: "His appearance, when he first came into our hands, was of extreme etnaciation. The left shoulder dropped down and the spine bent forward and sidewise. The wound in front was healed, but the one on the back was open, and when he coughed violently, air escaped. The cough was troublesome; the expectoration, bloody pus, in large quantities. The whole aspect was that of the last stages of tubercular disease. He had night sweats and swelling of the lower extremities, and a peculiar club- bing of the fingers. Cod-liver oil and stimulants were administered, with as generous a diet as he could bear. He lingered along for two or three months with slight improvement. There was every indication of tubercular disease and of a large cavity in the lung. A Soldiers' Home having been opened in Chicago, we obtained permission to send him there, he haviug no friends here. w e procured a carriage and carried him carefully to the depot, and saw him aboard a sleeping car, never expecting to see him again. This was in August, and we heard no more from him until December, when he returned in the uniform of an invalid veteran. His appearance was much improved, and he informed us that he did regular guard duty over the rebel prisoners at Camp Douglas. He was not quite well, but much of the cachectic look had passed away. The wound on the back had healed, and he was not much troubled with cough. The clubbed appearance of the fingers had disappeared, and he had become straight. His duties were light, and he was able to perform them. He is now here, having been lately discharged, and is in good health. There is a little dullness over the left lung, but nothing more. He informed us that he was in hospital but once after re-enlisting, about eleven months after he was wounded. The points of interest in the case are the appearance put on from an evidently severe wound through the lungs and the apparent entire recovery therefrom. The entire recovery did not take place in the eleven months, for when re-enlisted he must have been far from well, and only fit for the lightest duty ; but before the term of his enlistment expired, he was fit for field duty, and, to all appearance, is now in perfect health.'' 492 WOUNDS AND INJURIES OF THE CHEST. The six following are abstracts of fatal cases presenting some points of interest: Case.__Private G. P. L-----, Co. F, 4th New York Artillery, aged 28 years, was admitted into Douglas Hospital, Washington, April 5th, 1863, with a penetrating gunshot wound of the chest, received at South Side Railroad, Virginia, on April 2d. He stated that he spat blood upon the reception of injury. Pleurisy of the right side was well marked, with slight emphysema of the cellular tissue near the posterior wound, from which issued a thin sero- purulent fluid. The pulse and respiration were rapid; air entered and escaped freely from the posterior wound; the patient rapidly grew worse in spite of a generous diet and support- ing treatment, and died on April 9th, 1865. Fifteen hours subsequently the entry of the ball was noticed on the back, a little to the right of the spinous process of the ninth dorsal vertebra, whence it had passed inward and upward, fracturing the transverse process, chip- ping the eighth rib, fracturing the fifth, and escaping from the axilla of the same side. The rhdit pleural cavity contained thirty-four ounces of a dark, offensive, sero-purulent fluid. The parietal and visceral pleurae were covered with a greenish, soft, cacoplastic lymph, and the right lung, perforated by the bullet through the lower lobe, was compressed and collapsed. There was a slight serous effusion in the left pleural cavity: the remaining thoracic and abdominal viscera appeared healthy. Two specimens accompanying this history were contributed to the Army Medical Museum by Assistant Surgeon W. F. Norris, U. S. A. The first, No. 2411 of the Surgical Section, consists of the seventh, eighth, and ninth dorsal vertebras, with the fifth, seventh, and eighth ribs of the riglit side. The right transverse process of the eighth vertebra and the dorsal extremity of the corresponding rib are chipped by a bullet. The fifth rib is obliquely broken, and comminuted on its internal surface, with a transverse fracture externally. The second, a preparation of the lung, is shown in the adjoining cut. (See FiG. 234.) FIG. 234.—Preparation of the right ung, showing perforation bv a bullet. Spec. 2707, Sect. I, A. M. M. Cask.—Corporal Josiah Burton, Co. H, 15th Indiana Volunteers, aged 22 years, received a gunshot penetrating Avound of the right chest, at Mission Ridge, Tennessee, November 25th, 1863, the ball entering about four inches below the clavicle and passing directly through. He was taken to the hospital of the 2d division, Fourth Corps, where he remained until December 23d, when he was transferred to Cumberland Hospital, Nashville. When admitted, his health was fair and the wounds had nearly healed. Simple dressings were applied. On December 25th, he had a severe chill, followed by high fever. On the 26th, he complained of a severe pain in the right side, which increased on inspiration. There was dullness on percussion over the right side, and feeble respiratory murmur on auscultation. The pulse was full and somewhat accelerated; tongue coated with a dense white fur; bowels constipated; breathing labored and hurried. Purgatives and diuretics were given, and the patient was cupped to the extent of ten or twelve ounces. 27th: Condition somewhat improved; bowels moved- freely. 28th: Bronchial symptoms much worse; pain and tenderness in the hepatic region, less severe; breathing extremely laborious; expectorants, stimulants, and diaphoretics were administered. December 29th: Much worse; countenance anxious; breathing more hurried and labored; great prostration. Death occurred on December 30th, 1863. Necropsy: Right pleural sac contained three quarts of sero-purulent fluid in which flakes of lymph were floating. The pleura-costalis showed marked effects of inflammation. Purulent lymph adhered at every point to the walls of the chest. The lung was completely carnified and attached to the wall at *he points of entrance and exit of the missile, and the lower lobe to the diaphragm. The lung, upon section, closely resembled muscle, all vestiges of cellular tissue being entirely obliterated. The bronchus was open to the first ramification, where a mass of crude tubercles, of the size of a sparrow's egg, was found. Miliary tubercles were thickly scattered through the fleshy struc- ture The mucous membranes of the air-passages were highly inflamed, and the air-tubes filled with muco-purulent matter. The left lung was somewhat congested. The pericardium, thickened to the extent of half an inch, was indurated and contained a pint of sero-purulent fluid. The serous lining was roughened by lymph exudation, which was rapidly assuming a purulent character. The heart presented a singularly roughened, corrugated appearance; the walls being greatly thickened and indurated. The liver was highly congested. The case is reported by Surgeon C. McDermont, II. S. V. Case.—Private Morris Ward, Co. H, 63d New York Volunteers, aged 32 years, received two gunshot wounds at Antietam, Maryland, September 17th, 1862. One ball entered the back between the eighth and ninth ribs, left side, half-way between the angle and the junction with the costal cartilage, and lodged; the other entered two inches posterior of anterior superior spinous process of the ilium of left side and lodged in the gluteal muscles. He was at once conveyed to the field hospital of the Second Corps, where water dressings were applied. On September 30th, he was transferred to the hospital at Frederick, Maryland. Previous to admission, the patient did not complain of cough or pain in the chest. On October 5th, a ball could be distinctly felt beneath the nipple, but as the patient was quite weak from profuse suppuration from the wound in the gluteal region, the removal of the ball by excision was deferred. October 8th, burrowing of pus among the gluteal muscles and accumulation of gas. An incision was made an inch above the folds of the nates; but little evacuation of pus. Poultice ordered. On the Pith, another incision was made just below the crest of the ilium and a seton passed through the wound of entrance. The patient seemed much prostrated, but had no cough or expectoration. Tonics and stimulants administered. On the night of the 13th, he expectorated a small quantity of blood, and, on the next day, complained of pain in the chest where the ball had lodged. On examining the chest, a tumor was found to extend from the left nipple downward and inward for two inches, and of the same dimensions in breadth. On applying the ear to the tumor, a sound was heard resembling the passage of air, with a small quantity of liquid, through a slight opening. Tumor tympanitic on percussion; respiration but slightly embarrassed, but patient very restless. The tumor continued to increase, and the patient failed rapidly, notwithstanding the free administration of stimu- lants; death occurred on the morning of October 17th, 1862. Necropsy: Rigor mortis well marked. Body considerably emaciated. On laying open the wound on the posterior portion of the chest, the ninth rib was found fractured at that point. On COMPLICATED WOUNDS OF THE LUNG. 493 Fig. 235.—Segments of anterior portion or rihs, with condensed portion of upper lobe of left lung, with a round hall, which lay against the diaphragm. Spec 962, Sect. I, A. M. M. dissecting up the skin over the tumor, some extravasation of blood was found underneath. No opening where the ball could have entered the chest could be found, and it seemed probable that it had passed externally, glancing on the ninth rib, yet no external track was visible. The pericardium over the apex of the heart was adherent to the ribs. Recent pleuritic adhesions on both sides, and left lung adherent to ribs for a large space, where the ball was found underneath. Missile had ulcerated through the intercostal muscle into the lung and was found resting against the diaphragm at the bottom of a large abscess which contained air and pus. Pieces of clothing and bone were also discovered in the diaphragm. The pathological specimen, showing a wet preparation of a portion of the left lung adherent to sections of the third, fourth, fifth, and sixth ribs, is represented in the wood-cut (Fig. 235). and was contributed, with a history of the case, by Acting Assistant Surgeon Alfred North. [It must be understood that the ball entered posteriorly between the eighth and ninth ribs, on a level with the sixth rib anteriorly. The description of its course is not very clear. Kit did not fracture the rib, whence came the bits of bone found imbedded in the diaphragm ?] CASE.-Private Carl Behling, Co. E, 26th Wisconsin Volunteers, aged 22 years, received a gunshot wound through the upper lobe of the left lung, at Gettysburg, Pennsylvania, July 1st, 1863. He was at once conveyed to the hospital of the Eleventh Corps, where he remained until July 10th, when he was transferred to Jarvis Hospital, Baltimore. When admitted, he was suffering from a profuse, exhausting hemorrhage. It ceased, but recurred on the 23d, continuing for two hours. On August 6th, after eating a hearty dinner, he was about to walk from bis bed to the door, when a sudden and profuse hsemorrhage occurred. Death resulted in ten minutes. The case is reported by Assistant Surgeon D. C. Peters, U. S. A. Case.—Private Medad Beck, Co. G, llth Vermont Volunteers, aged 46 years, was wounded at Petersburg, Virginia, April 2d, 1865, by a conoidal ball, which entered the left side at fourth rib, about two inches from sternum, perforated the right lung, and emerged below the inferior angle of the scapula. He was treated in the field hospital of the Sixth Corps until April 12th, when he entered Harewood Hospital, Washington. On admission, the injured parts were in tolerably good condition. Tlie patient, however, suffered from dyspncea, extensive emphysema of surrounding cellular tissues, anxious expression of counte- nance, and symptoms of pneumo-thorax. Surgeon R. B. Bontecou, U. S. V., freely opened the chest by posterior incision, and removed a large amount of sanious pus. Supporting treatment. Patient died on April 17th, 1865, from exhaustion. Necropsy : Fourth rib fractured anteriorly, and eighth and ninth ribs posteriorly. Case.—Private C. Robinson, Co. F, 8th New York Heavy Artillery, aged 39 years, was wounded at Cold Harbor, June 3d, 1864. by a conoidal ball, which entered the left supra-clavicular space, and emerged one inch to the left of the middle dorsal vertebras. He was treated in the field until June llth, and was transferred to Lincoln Hospital, Washington. When admitted, his condition was one of very great prostration; suppu- ration profuse and sanious. Simple dressings were applied to the wound. Death took place on June 21st, 1864, from exhaustion. At the necropsy, the ball was found to have entered the left supra-clavicular space, passed downward through the thoracic cavity, and emerged in the middle of the dorsal region, one inch to the left of the eighth vertebra, having fractured the clavicle one and a half inches from its articulation with the acromion process, also the first, second, third, fourth, fifth, and sixth ribs, close to their attach- ment to the spine and grooved the posterior surface of the lung, left upper portion. On opening the body the veins were found turgid with exceedingly thin blood, which flowed out in large quantity. The right lung was attached to the wall by recent adhesions, and the left lung by older adhesions. The left cavity contained about two quarts of bloody serous fluid. The upper lobe of the right lung presented two large bullse, filled with thin blood. There was a wound three and a half inches long in the posterior portion of the upper lobe of the left lung. The base of the lower left lobe was carnified. The fractured clavicle and injured ribs were contributed to the Museum, with the foregoing memoranda, by Acting Assistant Surgeon H. M. Dean. The clavicle is No. 3460 in the Surgical Section. The ribs are represented in the accompanying wood-cut (Fig. 236). The next case, of a survival for seven years of an alleged lodgement of a shell fragment in the substance of the left lung, is followed by an abstract of a chest wound believed to have been caused by an explosive musket-ball; which is succeeded by a very remarkable case of recovery after the passage of a large projectile through the cavity of the right chest: CASE.-Private Patrick F. Bushell, Co. L, 5th United States Artillery, aged 30 years, was wounded at Winchester, Virginia, September 5th, 1864, by a fragment of shell, which entered over the fourth rib, three inches to the left of the median line, wounding tbe upper lobe of the left lung. He was treated in the field, and on the 29th sent to the hospital at Sandy Hook, Maryland. Simple dressings were applied to the wound. On January 2d, 1865, he was transferred to Fort Hamilton, New York Harbor, and discharged from service May 12th, 1865. Pension Examiner J. H. Oliver reports, December 10th, 1867 ; statement of pensioner: Shell wound of left breast, throwing him from his horse aud rendering him insensible for about four days. Profuse hemorrhage Fie. 230.—Segments of first six ribs of left side, with with pleuritic iulhesions to attached portion of lung. Spec. 2630, Sect. I, A.M. M. 194 WOUNDS AND INJURIES OF THE CHEST. occurred from the lung and wound. That from the lung has continued, modified, almost daily, up to present time; also cough expectoration, dull pain, and a sense of stricture through the left thorax. Breathing difficult. Palpitation of the heart, impaired appetite and physical debility. The cough has, in a measure, ceased, and, though feeble, he has partially regained his strength. On examination, an irregular cicatrix and a superficial depression were found near the anterior extremity of the left third rib, looking as if the bone had been driven in. He supposes a fragment of shell penetrated the cavity at that point and lodged within the substance of the lung, where it still remains. Auscultation and percussion indicate lesion in the lower part of the left lung. Tongue furred; skin clammy, with tendency to night sweats. Pension Examiner J. M. Adler reports, June 8th, 1868, the ball entered about two inches above the left nipple, producing compound comminuted fracture of the fourth rib. Portions of bone were probably forced into the substance of the lung; consequent inflammation and abscess of the lung. General debility and great emaciation. Hectic fever, night sweats, and purulent expectoration. Occasional haemorrhage from lung, sometimes of a very profuse character. The pensioner was last paid on March 4th, 1872. Case.—Private Philo T. White, Co. I, 7th Michigan Volunteers, aged 19 years, was wounded at Antietam, September 17th, 1862, by an explosive ball, which entered the arm above the elbow, and exploded in the belly of the pectoral muscle, making a cavity large enough to admit the fist. He was treated in the field by simple dressings, with anodynes, until the 27th, when he was transferred to Master Street Hospital, Philadelphia. On the 30th, opisthotonos occurred and was regarded as a symptom ot tetanus.. Opium was administered internally and externally, and carried to the point of narcotization. The pupil was contracted to the size of a pin-hole during the whole treatment. The patient made a complete recovery, and was discharged from service on December 19th, 1862. Surgeon Paul B. Goddard, U. S. V., reported the case. Examining Surgeon William B. Thomas, of Ionia County, Michigan, gave, May 14th, 1863, a different account: " Ball entered one inch external to the sternal articulation of the fourth rib on right side, fractured the rib, passed into the cavity of the thorax, and emerged one inch below the axilla of right side. The man has frequent haemoptysis and cough. Disability one-half and temporary." Case.—Major G. N. Lewis, 12th Connecticut Volunteers, was wounded May 27th, 1863, at Port Hudson, by an iron grape-shot, one and a half inches in diameter and a half pound in weight. This shot, being deflected from a horizontal course to one almost vertical, by the limb of a tree, struck the patient on the upper surface of the right clavicle, and fractured that bone; then taking a course downward, backward, and toward the median line ofthe body, plunged through the apex of the right lung, emerging from the chest about the third dorsal vertebra, and in contact with the column. Here, meeting the resistance of the skin, and its force nearly spent, it crossed the spine, and lodged under the skin on the left side near the fifth dorsal vertebra, whence it was removed, on the field, by Surgeon M. D. Benedict, 75th New York Volunteers. There was considerable primary hsemorrhage, and, of course, great prostration. When the patient had rallied he was sent on an hospital transport to New Orleans and placed in the St. James's Hospital, in charge of Assistant Surgeon J. Homans, U. S. A., on May 29th. Simple dressings and expectant measures were employed until the inflammatory symptoms had abated, and then tonic medicines and a supporting treatment were substituted. On July 19th, the patient was well enough to take the steamer for New York, and was furloughed. He remained a month in Brooklyn, taking iron, mineral acids, and cod-liver oil, and other restoratives, and morphia continuously, and then went to his mother's house in Middletown, Connecticut, and came under the care of Dr. J. W. Ellis, who has published* an instructive history of the progress and treatment of the case. This narrative is freely quoted in this abstract. In the early part of September, Dr. Ellis found the patient greatly emaciated, with an harassing cough and profuse muco-purulent expectorations, with great pain in the right chest, with diurnal chills, night- sweats, and diarrhoea. There were many of the rational signs of advanced phthisis. It was learned that an exfoli- ation had been eliminated on the voyage, and an examination ofthe track of the ball showed that it had become con- verted into a fistulous canal with indu- rated walls, communicating directly with some of the larger bronchi, and containing fragments of bone. A forced expiration, with the mouth and nostrils closed, caused air and jets of pus to be expelled from the orifices of entrance and exit; the lung having formed adhesions at both places. Pneumo- thorax had existed, but the lung early resumed its functions, and was scarcely at all collapsed in the early part of August. Dr. Ellis gave medicines that checked the diarrhoea, and he removed a small fragment of the clavicle from the anterior wound, and laid open the subcutaneous fistula that connected the point at which the shot was cut out between the lett fifth and sixth ribs, and that of its emergence from the thorax, near the third dorsal vertebra. Subseqnently the posterior opening of the true sinus was enlarged, and fragments of bone were felt, three and a half inches from the surface, imbedded in fine pulmonar) FIG. 2">7.—Cicatrix of entrance wound ot a half-pound grape-shot. (From a photograph.) FIG, ease. 238.—Cicatrix of exit wound in the same New York Medical Journal, VOL. XIV, p. 511. GUNSHOT WOUNDS OF BOTH LUNGS. 4cjr> tissue. These explorations produced extreme irritation, convulsive cough, and bloody expectoration. Several attempts at extraction were made at intervals of several days. The patient refused to take any anaesthetic, which embarrassed the surgeon's attempt to extract the larger fragment. Finally, seizing the bone with dressing-forceps, dividing the deep tissues with a narrow- bladed knife, and twisting the exfoliation into the axis of the sinus, it was extracted. A profuse discharge of pus foured from the opening, but there was very little haemorrhage. Some small bits of bone and shreds of foreign material were then removed. There were two subsequent attacks of haemoptysis, in the next fortnight; afterward the patient convalesced rapidly. "The wound remained open for nearly a year from its reception, and a small stick, three-eighths of an inch in diameter, could be readily thrust through the body without causing him much inconvenience,"—experiments of more than doubtful utility, interrupted by the closure of both orifices in June, 1864. In the middle of October,* promoted to a lieutenant-colonelcy, this brave officer rejoined the Nineteenth Corps, and participated in the campaign in the Shenandoah Valley. The long impacted piece of bone proved to be a fragment of rib. The accompanying wood-cuts (Figs. 237, 238) are reduced copies of those inserted in Dr. Ellis's paper, which were drawn from photographs. On August 12th, 1865, Lieutenant Colonel Lewis was honorably mustered out of service. Examining Surgeon P. W. Ellsworth, of Hartford, December 26th, 1865, gives the following report of the case: "A grape-shot (presented), weighing one-fourth of an ounce less than half a pound, entered about the right clavicle at the point of ligation of the subclavian artery as it passes the first rib. It fractured the clavicle, and, passing downward and backward, tore up the ribs and was extracted between the scapulae. The right lung was badly wounded, air passing through the opening for a year. At present the health is better than could be anticipated. Respiration is very faint, all over the back part of right lung, riglit arm quite weak ; cough at times, with a good deal of tenderness on right side of chest. At manual labor he could scarcely be rated as capable of one-third work. Many fragments of bone were removed formerly, leaving a very bad and depressed cicatrice between the scapulae. Disability two-thirds, and to a great degree permanent." This officer was pensioned, and, in March, 1872. his name was still borne on the rolls, and no change for the worse, in his health, had been reported. Gunshot Wounds of both Lungs.—Many cases were reported of recovery after penetration of both lungs by gunshot missiles. That life may be prolonged for many days under such circumstances, has been unequivocally demonstrated by dissections ; but the probabilities are remote of anything like a permanent restoration to even a partial degree of health after such an accident. The well-known fact that every one of the signs of lung injury that were formerly regarded as pathognomonic may exist singly, and that several of them may even co-exist without there being the slighest lesion of the lung tissue, should admonish the^ observer to extreme caution in committing himself to a diagnosis of penetration of both lungs by a ball, and lead him to demand the proof of physical as well as rational signs before arriving at an affirmative conclusion. The follow- ing cases are cited, but the writer is not satisfied that the evidence in any of them is incontestable. Again and again he has received from professional friends photographs representing cicatrices on the chests of patients in whom, had the missile passed in a direct line from one to the other wound, both lungs would necessarily have been transfixed. But the proof that the projectile had pursued this course was wanting or defective, and the surgeons who reported these cases have, without exception, receded from their earlier convictions, either yielding to the arguments suggested by reading and reflection, or to the more cogent evidence afforded by necropsies in the supposed cases of recovery. That two musket-balls should strike opposite portions of the two sides of the chest, and one or both missiles should inflict only a flesh wound, or that a ball should make the circuit of the thorax beneath the muscular planes, or should run around the costal pleura and emerge opposite its entrance,—these occurrences, though rare, indisputably take place and are not extremely infrequent, and they afford better solutions of the cases recorded in this group than the supposition that the functions of both lungs can be so seriously impaired as gun- shot penetration implies, without the supervention of fatal asphyxia at a comparatively early period: Case.—Private R. P. Peck, Co. E, 114th New York Volunteers, was wounded at Port Hudson, Louisiana, June 14th, 1863, and was admitted to hospital at Baton Rouge on July 6th. There was a gunshot wound of both lungs; a conoidal musket ball having entered between the third and fourth ribs, two inches to the left of the sternum, and escaped between the seventh * Report of the Adjutant General of Connecticut, for 1863, mentions the case of " Major Lewis, severe shot through body" (p. 142), and the report of the same officer, for 1865, states : " Lieutenant Colonel Lewis reported for duty October 15, 1864." |«. Hi WOUNDS AND INJURIES OF THE CTTF.ST. and eighth ribs, below the posterior border of the right axilla. This man was transferred to the Veteran Reserve Corps, and was subsequently admitted to hospital at Point Lookout, Maryland. On October 8th, 1864, he was examined by a Medical Board, of which Assistant Surgeon W. H. Gardner, U. S. A., was president, and recommended to be returned to duty. His general health and condition were then good; there was no evidence of lung disease, and no inconvenience had been occasioned by the wound, except, according to the patient's statement, some pain in damp weather. Cask.—Sergeant George E. Grover, Co. C, 3d Maine Volunteers, aged 40 years, having been wounded at Manassas, Virginia, on August 30th, 1862, was sent to Washington, and admitted to Mount Pleasant Hospital on September 1st. A conoidal ball had passed through the right arm, thence into the chest near the right nipple, through both lungs, badly injuring them, and fracturing the sternum, emerged outside of the left nipple. Bleeding from the lungs occurred on September 8th, 9th, and 10th. The wounds were stopped with plugs of lint and dressed simply ; brandy, iron, and quinine were administered, and the patient, recovering, was discharged from service on May 20th, 1863, and pensioned. A communication from Pension Examiner J. W. Toward, under date of September 30th, 1867, reports that the patient's sternum is quite tender and sore. He has raised blood from the lungs very often. The lungs-are very painful and irritable; there is severe cough, especially on laying down, and tlie patient is unable to perform any severe manual labor. His disability is rated total and probably permanent. Case.—Corporal XV. H. Burns, Co. C, 6th United States Cavalry, was wounded at the battle of Beverly Ford, Virginia, June 9th, 1^63, by a round ball, which entered immediately in front of the inner third of the left clavicle, passed through the apex of each lung and lodged beneath the right scapula. On the following day he reached the Lincoln Hospital at Washington, D. C, where he remained under treatment until December 25th, 1863, when he was discharged from service. The case is reported by Assistant Surgeon J. C. McKee, U. S. A. On July 15th, 1864, the man was examined by Dr. Cameron, pension examining surgeon, at La Crosse, Wisconsin, who reports his right shoulder and arm atrophied and the use of the right arm considerably impaired; also, that an effort had been made to extract the ball through an incision above the right scapula, and that a number of splinters of bone were removed, but that the missile could not be found. Case.—Private Albert Ullman, Co. I, 51st Ohio Volunteers, aged 22 years, was wounded at the battle of Jonesboro', Georgia, August 30th, 1864, by a musket ball, which entered the left shoulder and penetrated the thorax. He was treated at various hospitals and lastly at Camp Dennison, Ohio. On December 20th, 1864, the man was discharged from service, the wound having resulted in partial paralysis of the upper lobe of the left lung. On January 16th, 1865, he was examined by Enoch Sapp, pension examining surgeon, at Spring Mountain, Ohio, who reports him suffering from haemorrhage of the lungs on much exertion; also, that the missile entered at the angle of the left scapula, passed through the left lung, and is lodged in- the right lung. CASE.-Private George P. Brown, Co. C, 1st United States Sharp-shooters, was wounded by a musket ball through both lungs at the battle of Chancellorsville, Virginia, May 3d, 1863. On the retreat of the Army he was left behind with some other wounded men under charge of Surgeon G. P. Oliver, lilth Pennsylvania Volunteers, a# a log-house in the vicinity ofthe battle- field, where he remained until May 14th, when he was exchanged and removed to the field hospital ofthe Third Division, Third Army Corps. About two weeks afterward, the patient was allowed to leave for his home on furlough, and on October 3d, 1863, he was discharged from service at Boston, Massachusetts. Dr. Charles L. Fisk, pension examining surgeon, at Greenfield, Massachusetts, reports, under date of April 27th, 1867, as follows : Ball entered right side at eighth rib, posterior to the nipple, passed through the lungs, and escaped on the other side of the chest, exactly opposite the point of entrance. He also states that his right side swells ; that he cannot make much exertion, has cough, and can sleep only in a semi-sitting posture; that he also suffers from dyspnoea on exertion, and a great deal of pain in the right side and shoulder. He further reports that ribs were fractured on both sides and are badly united. Case.—" The patient was Harvey McGuire, at the time a private or non-commissioned officer (sergeant, perhaps) of the 44th Tennessee Regiment, a native Tennesseean, about 40 years of age, and of stout, wiry make, weighing, I suppose, one hundred and sixty pounds. It was in June of 1864, in front of Petersburg, Virginia, he was wounded, the missile being supposed to be from a Whitworth rifle. The bullet passed into one axilla and out at the other, fracturing a rib at the entrance and exit. From the orifice of exit, I removed, when he was brought in, several small fragments and spiculae of bone. When I first saw him, some two hours after receiving his wound, he was laboring under great dyspncea, and at every few inspirations coughing and spitting out mouthfuls of frothy blood. Auscultation revealed in the track of the wound, entirely across the chest, loud moist rales. To sum up the case, he recovered, and though for six or eight months was subject to slight haemoptysis on violent exercise, that I did not believe he would be returned to ranks any more, yet he remained with the command, I think attached to the wagon train, and was with us at the surrender at Appomattox Court-house. The year following the close of the war, he was living somewhere near Fayetteville, Tennessee, from which place he wrote me a letter, in which he said that he had fully recovered his health and was able to undergo active exercise with impunity." Dr. J. D. Jackson, of Danville, Kentucky, communicated the foregoing case in a private letter to the compiler. Case.—Sergeant W. J. Corder, Co. F, 4th Mississippi Regiment, was wounded at the battle of Kenesaw Mountain, June 27th, 1864. by a conoidal ball, which entered under the pectoral muscle of left side, passed through the breast, and emerged between the second and third ribs, about three inches to the right of the sternum. On June 30th, he was admitteil to the Fifteenth Army Corps Field Hospital, at Barton's Iron Works, Georgia. On his admission to hospital, the wound looked well and patient felt comfortable; cold-water dressings were applied, and the patient continued to feel comfortable until July 4th; in the evening, the wound having bled considerably while being dressed, he was attacked with a severe chill. On the morning of the 5th, he was much prostrated, he breathed with difficulty, and perspired profusely; his pulse was slow, but regular; stimulants ordered. In the evening he seemed better, but had another chill during the night. On July 6th, his respiration was very rapid and difficult, and his pulse fast and flickering; he felt but little pain, and that mostly in his bowels. He continued TREATMENT BY HERMETICALLY SEALING. 497 to sink, and died at 11 A. M. July 6th, 1861. The autopsy showed that the ball had cut the superior lobe of the left lung, divided the sternum through the manubrium, and cut very slightly the superior lobe of the right lung. In the left half of the thoracic cavity the lung was collapsed and the cavity filled with blood, mostly coagulated, while but a small clot was found in the right thoracic cavity. The other organs were normal. Acting Assistant Surgeon If. II. McKay reported the cas?. The last case proves unequivocally that a patient may survive a serious gunshot wound of both lungs for nine days at least. Of the many cases returned as gunshot perforations of both lungs, this is the only one in which an autopsy was made at so long an interval from the reception of the injury.* Hermetically Sealing.—It has been often remarked that the histories of all inventions and innovations have this in common, that it is customary first to deny their utility, and, if this is established, to contest their originality. Its advocates believe that the plan of hermetically closing penetrating gunshot wounds of the chest, proposed by Assistant Surgeon Benjamin Howard, U. S. Army, has shared this fate of successful discovery, and now deserves the merit accorded to useful advances in surgery. The subject has been the occasion of much discussion, and it is proposed, to enable the reader to judge impartially, to place before him all the evidence on the subject that has been obtained by this Office. It will not be a work of supererogation or an unnecessary occupation of space to show conclusively that what has been bruited abroad as the American Plan of treating gunshot penetrating wounds of the chest, was fairly tested during the war, and its indiscriminate application found to be pernicious. On June 25th, 1863, Assistant Surgeon Howard addressed a letter to Surgeon General Hammond, in which he " respectfully submits a new mode of treatment of Gunshot and penetrating wounds of Chest and Abdomen, requesting that necessary arrangements be made to enable him to test its .merits at the earliest opportunity." The letter is as follows : Sir: I have the honor to submit for your consideration the following mode of treatment ot gunshot and penetrating wounds of the chest and abdomen in which suppuration has not com- menced. All foreign bodies within reach having been removed, and bleeding of the wound having ceased, if it be from gunshot, pare the edges of the wound all round as in the operation for vesico- vaginal fistula; bring the opposite edges together, and retain them in accurate apposition by metallic sutures; carefully dry the wound and parts immediately surrounding; place thereon a few shreds of charpie arranged crosswise after the manner of warp and woof; pour on the charpie * " If both lungs be wounded at the same time," says Mr. Erichsen (Scienc* and Art of Surgery, Vol. I, p. 437), " 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 asphyxia. But in a somewhat extensive examination, I find very few allusions to this form of injury. It is true that Sir Everard HOME 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 after 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. But I believe Sir E. Home's post-mortem explorations enjoy little credit among his countrymen. Dkmmil (Militdr-Chirurgische Studien, Wttrzburg, 1864, p. 158) records 102 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. 246) 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 both lungs simultaneously is proportionately 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." But these dicta appear to be suggested by inference rather than observation. Dr. Frazer (op. cit., p. 52) mentions a case of a gunshot wound, opening both cavities of the chest and wounding one lung. The patient lived three days. Surgeon C. S. Woods, 66th New York Volunteers (Appendix to Part I, Med. and Surg. Hist, p. 88), says that after Fair Oaks "a few patients recovered where both lungs were traversed by the same ball. They were doing remarkably well when transferred to general hospital." It is marvellous that several such exceptional recoveries should occur after one action within the personal observation of a single surgeon, and implies a huge number of chest wounds under his charge. Dr. J. Mason Warren records a case (op. cit,, p. 564, case 339) of a " Pistol ball passing through Lungs." The missile "passed directly through the right side ofthe chest, and lodged under the integuments ofthe back." There was dyspncea, faintness, haemoptysis, and extreme mental depression. After reassuring language, and the administration of stimulants, Dr. Warren removed the bullet. The patient " eventually recovered after an attack of pleuritis and pneumonitis." This case should probably be classed with those at the beginning of this subsection, as a perforation through the intercostal spaces. At least there is not the slightest evidence of injury to the left lung, and the author must have used the plural inadvertently.—COMPILER. See also Hemman, J. A., Mrdicinish chirurgische Aufsdtze, Berlin, 1778; and Schlichtisg, J. I)., Traumatologia nov. antique, Amsterdam, 1751. 03 498 WOUNDS AND INJURIES OF THE CHF.ST. :i few drops of collodion so as to saturate it and form a sort of collodion cloth : let it dry ; then apply one or two additional coats of collodion with a camel-hair pencil, and repeat the process until satisfied that the wound is hermetically sealed. A dossil of lint may then be applied over it as a compress, secured by adhesive straps and roller bandage. The- natural condition of the parts is now approximately restored; the lung is suspended in a closed cavity ; the volume of air admitted while the wound was open soon becomes absorbed, and the lung is again at liberty to expand freely. The most distressing symptom, dyspncea, is relieved immediately. At the hospital of the 2d division, Fifth Corps, I applied this dressing to two cases of gunshot wounds of the chest, several days after they were received at the battle of Chancellorsville, both of them suffering greatly from dyspncea. In both, the symptoms were alleviated at once, aud the next day one said he felt quite well, and the other continued to feel better; the next day they were sent to general hospital and were lost sight of. Suppuration, which is apt to be so excessive and fietid in consequence of the admission of constantly renewed currents of atmospheric air, promises to be prevented or very much modified in extent and character. The coagulated blood in the pleural cavity, which becomes decomposed and foetid, producing a direct depression of the vital powers, is reduced to a simply mechanical inconvenience, and gradually becomes absorbed. The dressing is economical in point of time as it is quickly applied, and may seldom need renewing. In the case of a private of the 18th United States Infantry, in which I used this dressing, in 1861, for the first time, for bayonet wound of the abdomen, it remained intact until after the wound had entirely healed. It is simple and cleanly, and if successful will prevent the patient becoming obnoxious to himself and to all around him. If this mode of treatment were carried out, I believe the fatality of these wounds would be greatly diminished. I have been unable to demonstrate the value of this treatment, as every case but one (which was remarkably successful) has been sent away to some hospital where the dressing has invariably been removed and replaced by water or other dressing. I therefore respectfully request that, if it meet your approbation, such arrangements be made as will enable me on the first opportunity fairly to test the value of this plan of treatment. The medical director of this corps, and the medical directors of the two divisions, coincide with me as to the probable success of this treatment, and as far as they are able will generously assist me in carrying it out. At the next engagement, my duties will require me to be occasionally at both the division hospitals of the corps, where the medical director of corps kindly proposes that I treat a given number of these cases separately. I would respectfully request that I may be enabled to superintend the subsequent treatment of a certain number of cases and report to you the result." * * * The permission requested having been accorded * Assistant Surgeon Howard soon had opportunity to practice his method, especially after the great battle of Gettysburg, which was fought shortly afterward. Other surgeons adopted the practice recommended by Dr. Howard, and the treatment, as applied to gunshot penetrating wounds of the chest, was employed in a large number of cases. It has been sought to collect all the cases treated at Gettysburg, and after later engagements, and though this object may not have been fully attained, yet a sufficient number have been collected to afford a fair average of results. Dr. Howard and the other operators necessarily lost sight of many of their patients before the conclusion of the treatment, but in such instances the progress and termination of the cases have been ascertained from hospital records. Dr. Howard had the kindness to furnish the compiler of this work, in 1864, with a list of such patients as he had been unable to trace. The results of all of these have been determined. The successful cases will be first enumerated, and then those that ended fatally. It has been necessary to abbreviate the abstracts greatly, but when evidence of lesion of the lung tissue was recorded, that fact has never been omitted. Where the abstracts are *The endorsement, signed by Surgeon J. R. Smith, TJ. S. A., by order of the Surgeon General, was as follows: "Respectfully returned thro' Surgeon Letterman. The Surgeon General desires that, at the next battle of the Army of the Potomac, Assistant Surgeon Howard be placed in charge of a field hospital for the treatment of wounds of the chest and abdomen. If necessary to send those cases from the Army he may be sent with them. TREATMENT BY HERMETICALLY SEALING. 499 accredited to the operater or other reporter, it is not intended to imply that his language is employed, or that the result of the case, or other important facts, may not have been supplied from other sources. Case.—Private John Erlee, Co. A, 12th United States Infantry, received a gunshot wound of the right lung at Chancel- lorsville, Virginia, May 3d, 1863. The wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A , at the hospital of the 2d division, Fifth Corps. Erlee was returned to duty on July 12th, 1863. He is not a pensioner. The case is reported by the operator. Ca.se.—Private George Lohr, Co. K, 12th United States Infantry, was wounded at Gettysburg; the ball struck the right chest, below and to the right of the nipple, entered the cavity, and was extracted in the back. He was at once taken to the hospital of the Fifth Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On July 24th, he was transferred to Mulberry Street Hospital, Harrisburg, and, on September 6th, to the hospital at Fort Columbus, New York Harbor, whence he was returned to duty on November 5th, 1864. The Pension Examining Board at St. Louis, Missouri, reports, March 2d, 1870, that the pensioner suffers from adhesion of the pleura pulmonalis of right side, pain in right lung, dulness on percussion, cough, and general debility, which is greatly aggravated by cold and exposure. The case is reported by the operator. Case.—Private Frederick Hoffman, Co. (J, 14th United States Infantry, received a gunshot penetrating wound of the right chest at Gettysburg, July 3d, 1863. The ball entered on the left side ofthe lumbar vertebra? and emerged at the right side of the lower dorsal vertebrae He Avas taken to the hospital of the Fifth Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On July 20th, he was transferred to the hospital at York, Pennsylvania, whence he was transferred to Fort Trumbull, Connecticut, December 18th, 1863, for assignment to the Veteran Reserve Corps. He was discharged from service on February 19th, 1865. Pension Examiner E. R. Watson reports, February 6th, 1871, that " Hoffman cannot use much exertion; draws bis legs after him rather than lift them up; suffers a good deal of pain in the back, and is not able to carry anything heavy." The case is reported by the operator. Case.—Private Monroe P. Sanders, Co. F, 93d Pennsylvania Volunteers, aged 17 years, was wounded at the Wilderness, Virginia, May 5th, 1864. by a conoidal ball, which fractured the clavicle of the right side, passed through the right lung, and emerged immediately under the right scapula. He was taken to the hospital of the 2d division, Sixth Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, IT. S. A. On May 25th, he was transferred to Lincoln Hospital, Washington, and, on July 19th, to Mower Hospital, Philadelphia. When admitted, both wounds had healed; fracture united. Patient stooped a little, and could not take a full inspiration on the right side. He was transferred to the 118th company, 2d battalion, Veteran Reserve Corps, January 27th, 1865, and discharged from service on May 29th, 1865. Pension Examiner George P. Lineweaver reports, June 10th. 1869, that "the posterior wound is unhealed and constantly discharging. He has cough, with expectoration of mucus, and complains of difficulty of respiration. Disability total and permanent." Case.—Private William R. Stouffer, Co. E, 184th Pennsylvania Volunteers, aged 17 years, was wounded at Petersburg, Virginia, June 22d, 1864, by a conoidal ball, which entered the right pectoralis major muscle, and emerged at the lower angle of the scapula, perforating the cavity and lung. He was taken to the hospital of the 2d division, Second Corps, where the wound was hermetically sealed by Assistant Surgeon B. HowTard, U. S. A. On July 16th, he was sent to Sixteenth and Filbert Streets Hospital, Philadelphia, whence he was transferred to the Veteran Reserve Corps on January 25th, 1865, and assigned to duty at Satterlee Hospital. Surgeon Charles Page, U. S. A., reports, December 22d, 1868: " Stouffer has now enlisted for special service at the artillery school of Fort Monroe. His present condition is one of robust health, cheeks ruddy, and muscles firm and well developed. The respiratory murmur is perfect in the vicinity of the wound, at least I can detect no abnormal sounds, and there is perfect resonance on percussion. His chest measures 29£ inches, and expands to 32f inches." A communi- cation from Surgeon John E. Summers, U. S. A., dated Fort Monroe. Virginia, April 20th, 1872, states that no trace of this man can be found on the records of that post. Case.—Private Thomas Larkin, Co. F, 70th New York Volunteers, was wounded at Manassas Gap, July 23d, 1863, by a musket ball, which entered between the fourth and fifth ribs of the right side, passed upward and obliquely backward through the left lung, and emerged near the left shoulder. The wounds were closed by silver sutures, and hermetically sealed on the field by Assistant Surgeon B. Howard, U. S. A. The anterior wound, however, opened during the patient's conveyance to Washington. He was admitted into Mount Pleasant Hospital on July 30th, 1863, at which time there was pain in the left side; some cough, with expectoration of bloody sputa; a tolerably full pulse at 90 per minute; and a free and healthy discharge from the wound. The pain and cough yielded readily to the treatment adopted; the wound healed rapidly, and, at the end of three weeks, the patient was dismissed from further medical attention, and returned to dirty on August 21st, 1863. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. This soldier has not applied for a pension. Case.—Sergeant Frank C. Jones, Co. B, 64th New York Volunteers, aged 22 years, was wounded at Spottsylvania, Virginia, May 12th, 1864, by a conoidal ball, which entered the left axilla, passed down the back part of the chest, and emerged to the right of the spine, near the eleventh dorsal vertebra, striking its spinous process and iujuring the posterior portion of the left lung. He was at once taken to the field hospital of the 1st division, Second Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On May 25th, he was sent to Emory Hospital, Washington. Wrater dressings were applied. He was furloughed on June 1st, and remained at home for six months, during which time he was commissioned as lieutenant. He returned to duty, was commissioned as captain, and remained with his regiment until final muster-out, May 8th, 1865. Pension Examiner William Loughridge reports, December 9th, 1868, that "the injury was followed by haemorrhage and inflammation of the lungs. He still suffers from frequent attacks of inflammation of the left lung and from the injury to the spine, and is incapacitated from performing any kind of manual labor." The case is reported by the operator. 500 WOUNDS AND INJURIES OF THE CHEST. Cask.—Frivate Francis McCabe, Co. A, 17th United States Infantry, aged 23 years, was wounded at Spottsylvania, Virginia, by a conoidal ball, which entered about three inches below the middle ofthe left clavicle, passed through the chest, and emerged about the centre of the scapula. He was at once taken to the hospital of the 1st division, Fifth Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On May 14th, he was transferred to Columbian Hospital, Washington. Simple dressings were applied. He was sent to New York on August 3d, and discharged from service on August 25th, 1864. Pension Examiner Theodore H. Jewett reports that "the left arm is helpless and the left lung damaged. He will probably recover in time." The case is reported by the operator. Case.—Corporal Michael Cunningham, Co. F, 1st United States Sharp-shooters, aged 21 years, received a gunshot penetrating wound of the left side of the thorax at the Wilderness, Virginia, May 5th, 1864. He was conveyed to the hospital of the 3d division, Second Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. He was transferred, on May 25th, to the 1st division hospital, Alexandria; on June 5th, to Lovell Hospital, Portsmouth Grove, Rhode Island, and, on September 25th, to Baxter Hospital, Burlington, Vermont, whence he was returned to duty on October 26th, 1864. He is not a pensioner. The case is reported by the operator. Case.—Corporal Joseph Loll, Co. K, 63d Pennsylvania Volunteers, was wounded at Chancellorsville, Virginia, May 3d, 1863, by a musket ball, which perforated or penetrated the left lung. The wound was hermetically sealed on the field by Assistant Surgeon B. Howard, U. S. A., after which he was conveyed to the field hospital of the 1st division, Third Corps. On May 7th, he was transferred to St. Aloysius Hospital, Washington, and returned to duty on September 16th, 1863. He is not a pensioner. The case is reported by the operator. Case.—Corporal Peter Welker, Co. A., 1st United States Sharp-shooters, was Avounded at Manassas Gap, July 23d, 1863, by a conoidal musket ball, which entered above the right nipple, between the fourth and fifth ribs; passed through the lung and emerged at the inferior border of the scapula, fracturing at the same time the sixth rib. The wounds were hermetically sealed on the field by Assistant Surgeon B. HoAvard, U. S. A. The patient was sent to Washington, and admitted into Mount Pleasant Hospital, July 30th, suffering from pain in the right lung and some dyspncea, otherwise doing well. The dyspncea, attended with pain, increased almost to suffocation; pulse becoming greatly accelerated until the night of July 31st, when the posterior dressing burst open, and a profuse discharge of clotted blood and purulent matter took place; a similar collection, amounting to nearly a pint, gushed from the anterior Avound, upon the removal of its dressings, the following morning. Immediate relief was obtained and general improvement commenced; .the respiratory murmur, which had been absent in the loAver portion ofthe lung, returned and Avas perceptible everywhere, except in the immediate vicinity of the wound. The purulent discharge continued profuse, until about the first of October, but, by the 13th of this month, it had, in a great measure, ceased, and the patient was allowed a furlough. He returned on December 13th, 1863, greatly improved. The anterior opening had closed and the posterior nearly; from the latter, necrosed bone was subsequently removed. Opiates and stimulants were administered throughout the treatment, according to the requirements of the case. On February 29th, 1864, crepitant rales were heard only in the region of the Avound, and some pain felt about the shoulders. This man was discharged from service on March 29th, 1864, and was subsequently pensioned. Pension Examiner S. A. Fisk reports, July 20th, 1867, "the pensioner suffers from an inward soreness and spitting of blood; can only do light Avork, and has pains in the head." The case is reported by Assistant Surgeon C. A. McCall, U. S. A.* Case.—Private J. W. Jones, Co. E, 48th Georgia Regiment, was wounded at Manassas Gap, July 23d, 1863, by a conoidal •musket ball, Avhich entered half an inch above the left nipple, traversed the lung, and emerged near the spine of the left scapula. The wounds Avere closed on the field by Assistant Surgeon B. Howard, U. S. A., with Bilver sutures, and hermetically sealed. The patient Avas conveyed to Washington, and admitted, on July 30th, into Mount Pleasant Hospital, complaining of severe pain in the left side and shoulder; his breathing Avas short and painful; crepitant rales were distinguished over the left mammary region, and at the apex of the lung; pulse 100 per minute, and hard; countenance flushed; skin hot and dry; tongue white. On removing the dressings, there Avas a moderate discharge of tolerably healthy pus, attended by an almost instantaneous relief from dyspncea and pain. The pneumonia yielded to treatment in a few days; and in about three weeks the wounds had healed, and the patient Avas dismissed from further treatment. On September 23d, he was transferred to Lincoln Hospital, Washington, whence he was transferred to the Old Capitol Prison on October 14th, 1863. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case.—Corporal Henry G. Powles, Co. K, 2d Wisconsin Volunteers, was wounded at the Wilderness, Virginia, May 10th, 1864, by a musket hall, which entered betAveen the second and third ribs, passed through the right lung, and emerged below the right scapula. The Avound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On May 14th, he Avas sent to Campbell Hospital, Washington, Avhence he was transferred to the Veteran Reserve Corps, April 18th, 1865. He was discharged from service on June 19th, 1865. Pension Examiner P. R. Hoy reports, February 10th, 1866, " the pensioner suffers from adhesions and spitting of blood." He re-examined him on September llth, 1867, and stated that the consolidation of the lung and spitting of blood had steadily increased. The case is reported by the operator. In ten of the thirteen preceding abstracts, it is specified that an injury of the lung existed. In seven of the thirteen, recovery was partial, the patients being pensioned, with various degrees of disability. * The history of this case, up to the date of that publication, was inserted in the' surgical report in Circular No. 6, S. G. O., 1865, and introduced with the observation that: The histories of the cases, in which this plan (of hermetically sealing) was adopted, have been traced, in most instances, to their rapidly fatal conclusion. The following case is the only recorded exception." This statement was exact at that date; but, as is seen, many other nstances of farorable terminations have since been traced. I believe the evidence still fully sustains the "unqualified condemnation of the practice, then expressed.—CoxiriLLR. TREATMENT BY HERMETICALLY SEALING. 501 The plan succeeded, or patients treated by it survived, in the hands of many other surgeons, as the following abstracts show: Case.—Captain W. R. Peddle, Co. A, 157th Pennsylvania Volunteers, received a gunshot penetrating wound of the thorax and a flesh wound of the arm at Petersburg, A'irginia, July 7th, 1864. The wound was hermetically sealed at the hospital of the Fifth Corps, Avhere he remained until July 13th, when he was sent to DeCamp Hospital, New York Harbor. On September 15th, he Avas admitted to Officers' Hospital, Annapolis, Maryland, and discharged from service on September 27th, 1864. Not a pensioner. The case is reported by C. N. Chamberlain, U. S. V. Case.—Corporal Lucius G. Bradley, Co. B, 136th Ncav York A'olunteers, aged 29 years, was Avounded at Gettysburg, July 2d, 1863; the missile entered the right chest beneath the clavicle at its articulation Avith tlie sternum, and lodged between the-spine and scapula. The patient stated that the Avound bled very freely at first, and, in a few minutes, he discovered that he could not breathe Avithout, in the first place, closing the Avound 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 hermetically sealed Avith collodion, by Surgeon John J. Milhau. U. S. A., medical director of the Fifth Corps. Nourishing diet Avas administered and quiet enjoined. On July 24th, he was transferred to Chestnut Street Hospital, Harrisburg, Pennsylvania. AAlien admitted, he Avas very Aveak, and had entirely lost his voice. The Avound had never been interfered Avith after the first dressing Avas applied on the battle-field. On August 15th, the dressings became loose, and Avere removed, with the sutures; the Avound Avas found to be quite healed, lie was discharged from service on August 18th, 1H63. On one occasion during his stay at the Harrisburg Hospital, he expectorated a little bloody pus. Pension Examiner W. M. Herron reports, on February 16th, 1866, that the pensioner suffers from pain at the point Avhere the ball lodged. The case is reported by Acting Assistant Surgeon W. S. AAToods. Bradley Avas in tolerably good health on March 4th, 1872, Avhen he drew his half pension.* Case.—Private John P. Frink, Co. F, 17th Maine Volunteers, aged 19 years, was wounded at Deep Bottom, Virginia, August 18th. 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 same rib. The Avound Avas hermetically sealed at the hospital of the 3d division. Second Corps. On August 27th, he Avas transferred to Finley Hospital, AA'ashington, and discharged from service on June 8th, 1865. Pension Examiner Eugene F. Sanger reports, October 27th, 1868: "Necrosis followed, and spitting of blood. Dulness in region of wound and adhesion of lung to pleura. Pain, soreness, and dyspncea upon exposure and hard Avork." The case is reported by Surgeon O. Everts, 2Cth Indiana Volunteers. Case.—Lieutenant Adolphus F. Vogelbach, Co. B, 27th Pennsylvania Volunteers, received a gunshot penetrating wound of the chest at Mission Ridge, Tennessee, November 25th, 1863; the ball entered between 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 Avound was hermetically sealed with sutures and collodion. On December 22d, he was convalescent, and Avas transferred to Officers' Hospital, Lookout Mountain, Tennessee, Avhence he was furloughed on February 3d, 1864. Having returned to duty, he Avas promoted to the rank of Captain, April 27th, and mustered out Avith his company on June 10th, 1864. Pension Examiner James Cummisky reports, June 17th, 1864, that Vogelbach is much weakened and unable to do the lightest kind of work. Pension Examiner AVm. M. Cornell reports, October 26th, 1865: Wound more painful; raises more blood, and has greater difficulty ot respiration. The case is reported by Surgeon D. G. Brinton, U. S. V. Case.—Private Henry Herrick, Co. H, 5th Michigan Arolunteers, aged 20 years, Avas wounded at Petersburg, Virginia, June 16th, 1864, by a conoidal ball, Avhich entered anteriorly between the second and third ribs, injured the apex of the right lung, and passed out behind the scapula. He Avas taken to the hospital of the Second Corps, Avhere the wound Avas hermetically sealed. On the 24th, he Avas transferred to Mount Pleasant Hospital, Washington. On January 4th, 1865, he was sent to Harper Hospital, Detroit, Michigan, Avhence 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 permanent. The case is reported by Surgeon O. Everts, 20th Indiana Volunteers. Case—Private Horace B. Walters, Co. D, 84th Indiana Volunteers, aged 21 years, was wounded at KenesaAV, Georgia, June 27 th, 1864, by a conoidal ball, which penetrated the left side of the thorax. He was taken to the hospital ofthe 1st division. Fourth Corps, where the wound Avas hermetically sealed by Assistant Surgeon AVilliam H. Matchett, 40th Ohio Volun- teers. On July 3d, he Avas transferred to Hospital No. 2, Chattanooga; on July 23d, to Hospital No. 8, Nashville; on September 9th, to Jefferson Hospital, Indiana, and, on December 12th, to Cumberland Hospital, Nashville, Avhence he Avas returned to duty on December 20th, 1864. He is not a pensioner. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—Lieutenant Percival Knowles, Co. K, 6th Maine Volunteers, aged 23 years, Avas wounded at Rappahannock Station, Virginia, November 7th, 1863, by a conoidal ball, which entered three inches above the right nipple, passed backAvard and downward through the right lung, and lodged in the muscles of the back, at the loAver border of the scapula. On the 9th, he was admitted to Stanton Hospital, Washington. There Avas slight dyspnoea, with a full and irregular pulse; an absence of *In a letter from Ann Arbor, of July 20th, 1867, to Sugeon General Barnes, Dr. AVm. P. Breakey, late Assistant Surgeon 16th Michigan Volun- teers, transmits what purports to be " a tabular statement of eighteen cases of penetrating wounds of chest, operated on by B. Howard, Assistant Surgeon TJ. S. A., at Gettysburg, by hermetically closing them," and further remarks, alluding to the case of Bradley, that " it would be interesting to know whether the one case, shown by these tables to have recovered, united with first intention or became an open wound." Dr. Breakey subsequently published (Mich. University Med. Jour. Oct., 1871) a repetition of his statement, which is a curious example of the abuse of statistical enquiry. It is interesting to know that Dr. Howard was not the operator in the ease of Bradley,—that the wound did not reopen,—that the case was not a solitary success among those enumerated in his tabular statement,—both Lnmi and HOFFMAN' having recovered,—and then to consider what weight should be accorded to Dr. Breakey's argument.—L'OMriLEK. 502 WOUNDS AND INJURIES OF THE CHEST. the resjiiratory murmur beloAV the loAver end of the scapula, and complete dulness on percussion; he suffered no pain, and but slight constitutional disturbance. The track of the wound Avas excised doAvn to the ribs; the edges united by sutures deeply inserted, and the Avhole covered by isinglass plaster and collodion. On the 12th, there Avas some pain. The dyspncea and effusion had increased, and a slight friction sound Avas heard at the upper and lateral part of the chest. The dressings Avere removed on the 14th; there Avas no evidence of union by first intention; the wound Avas suppurating. The boAvels being confined, a light cathartic avus given. On December 4th, the ball Avas extracted, and Avater dressings Avere applied. By December 22d, both Avounds had healed, and effusion in the chest Avas nearly all absorbed. The patient Avas discharged from serATice on August 15th, 1864. Pension Examiner W. L. Nicholson reports, April 20th, 1870, that "solidification ofthe lung has taken place. Haemorrhage, which Avas not present at the date of his discharge to any marked extent, hoav occurs on an average every tAvo or three Aveeks, and, in my opinion, tubercles have formed. His strength has so diminished as to render labor impossible. Habits regular and moral.'' The case is reported by Assistant Surgeon G. A. Mursick, U. S. V. Case.—Sergeant Jonathan McAllister, Co. I, 126th Ohio A'olunteers, aged 31 years, was wounded at the AATilderness, A'irginia, May 12th, 1864, by a conoidal ball, which penetrated the left lung. He Avas taken to the hospital of the 3d division, Sixth Corps, Avhere the Avound Avas stitched and collodion applied. On May 24th, he Avas transferred to the 1st division hospital, Alexandria, whence he Avas discharged from service on February 20th, 1865. The use of the left arm was impaired. He is not a pensioner. Surgeon Robert Barr, 67th Pennsylvania Volunteers, reports the case. Case.—Captain George AV. Tomlinson, Co. I, 99th Pennsylvania Arolunteers, aged 40 years, was Avounded at Deep Bottom, A'irginia, August 15th, 1864, by a conoidal ball, Avhich entered about the fourth rib near the nipple, passed dowmvard through the lung, and lodged in the back near the seventh or eighth ribs. He was taken to the hospital of the 3d division, Second Corps, Avhere the wound Avas hermetically sealed and the ball extracted. On August 23d, he Avas transferred to Seminary Hospital, Georgc- toAvn, D. C; simple dressings were applied. He was furloughed on October 20th, and admitted to Officers' Hospital, Phila- delphia, December 12th. On February 13th, 1865, his debility Avas on the increase, owing to a profuse discharge from the Avound. There Avere no symptoms, except a diminished vesicular murmur along the course of the wound. Tonics, stimulants, and expectorants were administered. The discharge gradually diminished, and the patient improved. On March 1st, after some exposure, he had a severe attack of coughing, attended Avith copious muco-purulent expectoration. He Avas returned to duty on May 15th, 1865, at Avhich time his general health Avas fair; but the Avound Avas still discharging, and he suffered occasionally with violent attacks of coughing, from ulceration of the fauces and elongation of uvula. The upper portion of the lung Avas healthy; but there were indications of consolidation of tlie lower portion. Pension Examiner AAllson JeAvell reports, November 28th, 1865; " wound not healed; suppuration from diseased bone going on. Some cough and slight expectoration. Disability total and temporary." The case is reported by Surgeon O. Everts, 20th Indiana Volunteers. Case.—Private Thomas Conauton, Co. F, 56th NeAV York State Militia, aged 19 years, Avhile on duty at "Rebel Camp," Elmira, NeAV York, August 13th, 1864, Avas wounded by the accidental discharge of an Enfield rifle. A conoidal ball entered half an inch to the right of and beloAV the right nipple, passed through the lung, and emerged at the margin of the posterior border of the inferior angle of the right scapula. The same ball mortally Avounded a second man, and passed through the knap- sack of a third. Conauton felt faint from the loss of blood Avhich folloAved, but did not fall immediately. Cold-water dressings and bandage were applied. Half an hour later, Avhiskey Avas administered, upon sAvalloAving Avhich, he raised blood, and, at each effort to cough, the blood ran freely from his mouth until he Avas nearly exhausted. Three hours after the reception of the injury, he Avas admitted to the hospital at Elmira. There Avas considerable haemorrhage from both wounds and great dyspncea. On the removal of the dressings, the dyspnoea increased to almost immediate suffocation; but could readily be relieved by draAving the integument so as to close the external wounds. The anterior and posterior Avounds were at once converted into incised AA-ounds by Assistant Surgeon Charles A. Leale, U. S. V., and the edges brought together and retained in position by silk sutures and adhesive straps, and hermetically sealed AA'ith collodion. A bandage Avas then applied, producing moderate pressure over both wounds. An opiate having been administered, the patient was laid on his back. He passed a very comfort- able night; on the next morning there Avas considerable febrile movement, increased bronchial respiration, and a slight cough. Pulse 120. For four or five days, blood, of a bright arterial color, mingled Avith sputa, came aAvay in mouthfuls, amounting to at least eight ounces a day. The dressings came off in three days; the wounds had both closed by adhesion; not the slightest suppuration took place from the anterior Avound, and only a few drops from the integumentary surface of the posterior wound. Acute pneumonia supervened in the right side, which lasted between t\vo and three weeks. The patient convalesced Avithout an unfavorable symptom, and Avas returned to duty in less than five weeks from the reception ofthe wound. On March 19th, 1866, he was carefully examined. Externally, nothing could he seen except the cicatrices and marks of the sutures, while on auscul- tation aud percussion, a dulness Avas found at the middle lobe of the right lung, confined to a space of about four inches in circumference, Avhere pleuritic adhesion had taken place. Otherwise that lobe was perfectly healthy, as Avere the remaining lobes of both right and left lungs. He Avas in perfect health. The case is reported by the operator. Case.—Private Joseph Douricott, Co. C. 26th Georgia Regiment, aged 17 years, Avas Avounded at Winchester, A'irginia, September 19th, 1864. by a conoidal ball, which penetrated the left lung. He was at once conveyed to the depot field hospital, where the Avound was hermetically sealed. On January 4th, 1865, he Avas transferred to AA'est's Buildings Hospital, Baltimore, Avhence he Avas sent to Fort McHenry, Maryland, May 9th, 1865, for parole. Case.—Private Patrick Doming, Co. F, 15th United States Infantry, aged 28 years, was wounded in a street brawl at Mobile, November 1st, 1865. by a buckshot, which penetrated the left lung. He Avas admitted, on the next day. to the post hospital at Mobile. The Avound Avas sealed at first, after AA'hich simple dressings were applied. The patient was doing Avell on December :Jlst. 1865. He deserted on February 20th, 1866. There is no later account of him on the rolls ofthe Adjutant General's Office. Surgeon Samuel Kneeland, U. S. A'., reports the case. TREATMENT BY HERMETICALLY SEALING. 503 Two cases, in which this plan of treatment was successfully employed, are found in the Confederate records. At least Ave may infer that the case referred to in the first abstract was successful as the patient was strong enough to escape from hospital after six weeks of treatment: CASE.-Private W. D. Wheeler, Co. K, 2d Virginia Cavalry, received a penetrating gunshot wound of the chest at Winchester, A'irginia, September 19th, 1864. a conoidal ball passing through the apex of the right lung. He was conveyed to the field hospital, Avhere the Avound Avas hermetically sealed. He escaped on October 25th, 1864. Operator unknown. Case.—PriA-ate J. W. Branson, Co. C, 9th A'irginia Cavalry, aged 27 years, of robust constitution, Avas Avounded on July 29th, 1864, by a conoidal ball, which entered the right chest three inches beloAV the axilla, traversed the right lung, and lodged near the spinal column on a level with the wound of entrance. Haemorrhage from the lung followed the reception ofthe injury. The ball Avas removed by counter incision. He Avas admitted, on the next day, to Chimborazo Hospital, Richmond. It was decided, as the Avound had been so recently received, and his condition every way favorable, to treat the case by hermetically sealing the wound. The orifice of entrance AA-as carefully closed by means of thin layers of cotton, saturated Avith collodion. These Avere reneAved as often as found necessary to prevent the introduction of air into the chest. The case progressed favorably, att«nded by only slight circumscribed inflammation of the lung, some effusion in the pleural cavity, and a little fever, so slight, however, as to require but little treatment. The patient, at the time of his admission, and for several Aveeks afterward, com- plained of great soreness of both sides of the chest—more of the left than of the right. This soreness was attributed to a severe fall from his horse at the time he Avas Avounded. Under appropriate treatment and rest, the soreness gradually subsided, and the patient, Avhen fairly convalescent and Avalking about the Avard, av.is furloughed, and left in a carriage for his home in AVestmore- land County, A'irginia, Avith every reason to expect a speedy and perfect recovery. The case is reported by the operator, Surgeon P. F. BroAvne, P. A. C. S., in the Confederate States Medical and Surgical Journal for October, 1864. In this group of partial or entire recovery in fourteen cases, treated on the plan under consideration by other operators than Dr. Howard, it is stated in ten instances that the substance of the lung was wounded. Six of the fourteen patients are now (1872) pensioners, with serious disabilities,'—two deserted and two were paroled or furloughed, and their ultimate histories are unknown. Uniting this' with the preceding group, a total is presented of twenty-seven cases of gunshot penetrating wounds of the chest, including twenty instances attended by wound of the lung, in which, it is claimed, recovery took place under the method of treatment by hermetically sealing. The validity of these claims will be discussed at the close of this subsection. In contrast to the foregoing cases of more or less complete success of the treatment of gunshot wounds of the chest by "hermetically sealing," we have now to examine a series in which this method was unsuccessfully employed : Case.—Private Joseph Mallenbry, Co. B, 16th Michigan Volunteers, aged 30 years, received a gunshot penetrating wound of the chest and left arm at Gettysburg, July 2d, 1863. He Avas taken to the hospital of the Fifth Corps, Avhere the wound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Pyaemia set in on July 20th; stimulants, tonics, and nourishment were administered. Death resulted on July 24th, 1863. The autopsy showed infiltration of the right lung, and a conoidal ball was lodged in its middle lobe. There was no accumulation in the pleura. The case is reported by Surgeon A. M. Clark, U. S. V. Case.—Corporal Martin Noonan, Co. H, 64th New York Volunteers, received a gunshot wound of the lung at Spottsyl- vania, A'irginia, May 12th, 1864. He Avas taken to the hospital of the 1st division, Second Corps, where the wound was hermetically sealed by Assistant Surgeon B. HoAvard, U. S. A. Death resulted on May 18th, 1864. This case is reported by the operator. Case.—Lieutenant Edward S. Abbott, 17th United States Infantry, received a gunshot Avound of the lung at Gettysburg, July 3d, 1863. Assistant Surgeon B. HoAvard, U. S. A., hermetically sealed the Avound at the hospital of the Fifth Corps. Death occurred on the same day. The case is reported by the operator. Case.—Sergeant Aaron E. Banker, Co. E, 140th New York A'olunteers, received a gunshot wound ofthe lung at Gettys- burg, July 3d, 1863. He Avas taken to the hospital of the Fifth Corps, where the wound Avas hermetically sealed by Assistant Surgeon B. HoAvard, U. S. A. Death on July 12th, 1863. The case is reported by the operator. Case.—Corporal Daniel Norcross, 3d Massachusetts Battery, received a gunshot wound of the lung at the Wilderness, Virginia, May 8th, 1864. The Avound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death resulted on May llth, 1864. The case is reported by the operator. Case.—Private Henry A. Amidon, Co. K, 4th A'ermont A'olunteers, received a gunshot Avound ot the lung at the Wilder- ness, Virginia, May 5th, 1864. The Avound was hermetically sealed by Assistant Surgeon B. HoAvard, U. S. A. Death at the field hospital. The case is reported by the operator. 50; WOUNDS AND INJURIES OF THE CHEST. Case.—Private Charles MeGordas, Co. I, 1st Massachusetts Artillery, received a gunshot Avound ofthe lung at IVters burtr. A'irginia. June 18th, 1864. The wound Avas hermetically sealed at the hospital of the 3d division, Second Corps, by Assistant Surgeon B. HoAvard, U. S. A. The patient died on June 24th, 1864. The case is reported by the operator. Case.—Private AVilliam S. Jordan, Co. G, 20th Maine Volunteers, aged 18 years, received a gunshot Avound of the left lung at Gettysburg, July 2d, 1863. He AA-as taken to the hospital of the Fifth Corps, Avhere the Avound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Pyaemia developed on July 20th; stimulants and tonics Avere administered. Death resulted on July 24th, 1863. At the necropsy, the left side of the chest Avas found filled Avith pus, displacing the heart. The case is reported by Surgeon A. M. Clark, U. S. V. Case.—Private Edward McGoldrig, Co. G, 69th NeAV York Volunteers, received a gunshot wound of the right lung at Ny River, Virginia, May 12th, 1864. The Avound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A., at the hospital of the 1st division of the Second Corps. Death on the same day. The case is reported by the operator. Case.—Sergeant Alexander G. Ross, Co. E, 140th New York, was wounded on July 2d, 1863, at Gettysburg, by a musket ball, Avhich penetrated the lung. The wound Avas hermetically sealed by Assistant Surgeon B. HoAA-ard, U. S. A., after which he was sent to Seminary Hospital, Gettysburg. Death resulted on July 9th, 1863. The case is reported by the operator. Case.—Private John Mellott, Co. D, 7th AA'est ATirginia Arolunteers, aged 24 years, received a gunshot wound of the right lung at the AA'ilderness, A'irginia, May 5th, 1864. He was taken to the hospital of the 2d division, Second Corps, where the Avound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. The patient died on May 8th, 1864. The case is reported by the operator. Case.—Private Michael H. Moffatt, Co. F, 10th Massachusetts Volunteers, aged 22 years, received a gunshot wound of the lung at the Wilderness, Virginia, May 5th, 1864. He Avas taken to the hospital of the 2d division, Sixth Corps, where the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death on May 8th, 1864. The case is reported by the operator. Case.—Private Jeremiah Dorgan, Co. D, 7th Massachusetts Volunteers, received a gunshot wound of the lung at the Wilderness, A'irginia, May 5th, 1864. He Avas taken to the hospital of the 2d division, Sixth Corps, where the wound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death resulted on May 8th, 1864. The case is reported by the operator. Case.—Private Charles H. AA'ilson, Co. H, 4th Michigan Volunteers, received a gunshot wound ofthe left lung at Gettys- burg, Pennsylvania, July 3d, 1863. The Avound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death on July 5th, 1863. The case is reported by the operator. Case.—Sergeant Alva C. Wilcox, Co. D, 17th Connecticut Volunteers, received a gunshot wound of the lung at Gettys- burg, Pennsylvania, July 3d, 1863. The wound was hermetically sealed on the field by Assistant Surgeon B. Howard, U. S. A. Death resulted on July 7th, 1863. The case is reported by the operator. Case.—Private John Contoil, Co. G, 6th United States Infantry, aged 22 years, Avas wounded at Gettysburg, Penn- sylvania, July 3d, 1863, by a musket ball, Avhich penetrated the lung. The wound was hermetically sealed on the field by Assistant Surgeon B. HoAvard, U. S. A., after Avhich the patient was conveyed to the Seminary Hospital, Gettysburg, where he died on July 5th, 1863, from secondary hsemorrhage. The case is reported by the operator. Case.—Private Henry AVilliams, Co. D, 1st Connecticut Heavy Artillery, was admitted to the base hospital ofthe Eighteenth Corps, July 1st, 1864, with a gunshot penetrating Avound of the chest, received at Petersburg on the day previous. The ball entered beloAV the right clavicle, an inch and a half from the sternum, and passed out through the left scapula near the middle of the inferior edge. The Avound had been hermetically sealed at the field hospital by Assistant Surgeon B. Hoyvard, V. S. A. The patient remained under his care, his peculiar method of treatment being fully adopted. Death resulted on July 7th, 1864. Assistant Surgeon C. E. Munn, 27th Massachusetts Volunteers, and executive officer at the base hospital, states, in a communication to the Surgeon General of Massachusetts: " A post-mortem was made, ten hours after death, by Dr. AVendell, of New Hampshire, Drs. Munn and Emery, of Massachusetts, and Storrs, of Connecticut, also present. External examination: Chest well formed; wound in front, the appearance of being closed by metallic sutures a feAV hours before death; the wound of exit closed by adhesive straps and collodion. Tavo small wounds, made by tapping, on the right side, were dressed in the same manner. The attendants report the first, made on July 3d, Avas between the sixth and seventh ribs, tAvo inches back of the nipple; the other, made fourteen hours before death, between the fifth and sixth ribs. Percussion was resonant on the right side ; on the left, somewhat dull. Internal examination: The ball was found to have passed through the external and upper part of the sternum, entering the pleural cavity at the junction of the first rib, thence through the upper lobe of the left lung outward, backAvard, leaving the cavity three inches from the spine, betAveen the third and fourth ribs, and opening externally through the scapula. The lung on the right side Avas uninjured and healthy in appearance, except someAvhat more than usual post-mortem congestion in the posterior portion. Left lung congested throughout and firmly adherent to the walls of the chest. Through the upper lobe Avas the suppurative track of the ball. No fluid Avas found on the right side. Five ounces of pus Avere found on the left, close upon the diaphragm, having a connection with the upper part of the lung. There Avas a small quantity of serum in other parts of the side. The tAvo Avounds, from tapping, Avere traced through the Avails of the chest, into and through the diaphragm, into the liver. Remarks : First, hermetically closing the wounds did not, in this case, prevent the formation of pus. Second, paracentesis thoracis of the left side, the side containing the pus and serum, could not have reached the fluid Avithout endangering the lung and other organs. Third, the operation performed on the right or Avrong side, Avas an error in diagnosis, proA-ed by the failure to obtain fluid, and by the post-mortem presenting a healthy condition ofthe parts, and Avas a greater error, in puncturing so important an organ as the liver. The testimony of those Avatching the case was that the patient, up to that time doing AA-ell, soon began to fail." The case is reported also through Surgeon George Suckley, U. S. A'., medical director of the Eighteenth Corps. TREATMENT BY HERMETICALLY SEALING. 505 Case.—Private Miles Finch, Co. L, 2d Pennsylvania Cavalry, aged 36 years, was wounded at Todd's Tavern, A'irginia, Mav 8th, 1864. by a conoidal ball, Avhich perforated the right side of the thorax, lie was admitted, on the same day to the field hospital of the 2d division, Cavalry Corps, Avhere the wound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. On May 12th, he AA-as sent to Douglas Hospital, Washington. Stimulants Avere administered. Death resulted on May 23d, 1864, from asthenia. The case is reported by the operator. Case—Sergeant Thomas N. Hillard, Co. H, 70th New A'ork Volunteers, aged 22 years, was wounded at Manassas Gap, Virginia, July 23d, 1863, by a conoidal ball, Avhich entered the right side of the thorax, one inch beloAV the clavicle and three and a half inches to the left of the acromion process, fractured the second rib near its sternal extremity, passed directly through the lung, and emerged one inch to the right of the spinal column, opposite the spine of the scapula. The fifth rib was shattered at its superior surface, near its angle, but its continuity Avas not severed. He was taken to the hospital of the 2d division, Third Corps, where the Avound Avas hermetically sealed by Assistant Surgeon B. HoAvard, U. S. A. On July 30th, he was transferred to Lincoln Hospital, AA'ashington. AA'hen admitted, the wounds had partially opened, and Avere ragged from fhe tearing out of the sutures. The patient coughed incessantly, and spat up large quantities of frothy sputa, more or less mixed Avith blood. Respiration Avas 46 per minute, and labored Avith extreme orthopncea. The pulse Avas 96, and small. Every fit of coughing was accompanied by a profuse discharge of dark sanguinous fluid through either Avound. It was evident that the attempt to permanently close the orifice had proven a failure. Acting under instructions from the Medical Director of the department the treatment already inaugurated AA-as continued. An attempt Avas made to renew the coating of collodion, which Avas accomplished after some difficulty; but before the ether had had time to evaporate, a profuse discharge of the pleuritic fluids took place which rendered every effort at restoration impracticable. By August 5th, the discharge from the posterior wound had almost entirely ceased, while that from the anterior one continued to be large in quantity and of a purulent character. The discharge of this fluid was invariably accompanied Avith coughing, and always folloAved by an amelioration of all the rational symptoms. The hope was therefore entertained, that the accumulation of pus in the pleural cavity would be prevented, and that recovery would eventually take place; but as the necessity for repeated effort to throAV off the pus became more frequent, the strength of the patient became proportionately exhausted. On the evening of August 12th, he Avas seized with an unusually severe paroxysm of coughing, folloAved by a copious discharge of pus, which flooded his person and the bedding, and reduced him to a state of syncope from which he Avas imperfectly aroused under the administration of stimulus, but expired in a short time. The necropsy revealed extensive deposit of lymph over the entire right lung, and one-half pint of thick empyemic fluid in the cavity. The track ofthe wound Avas closed anteriorly. The.upper portion ofthe right lung was permeable to air. Only part ofthe first and the whole of the second and third lobes were impermeable and compressed. The left lung Avas Avell filled Avith air and weighed thirteen ounces; right lung eighteen ounces. The case is reported by Assistant Surgeon H. Allen, U. S. A. Case.—Sergeant Robert C. AVare, Co. E, 1st NeAV York Dragoons, was wounded at the AA'ilderness, May 6th, 1864, by a conoidal musket ball, Avhich fractured the fourth and fifth ribs of the right side, involving the lung. Assistant Surgeon B. Howard, U. S. A., hermetically sealed the wound upon the field. Being conveyed to Washington, the patient was admitted into the Douglas Hospital, on May llth, where he suffered from traumatic pleuro-pneumonia, from Avhich, in spite of careful treat- ment, he died on May 18th, 1864. The case is reported by the operator. Case.—Private Charles Kochendoffer, Co. E, 74th NeAV York Arolunteers, Avas Avounded at Manassas Gap, July 23d, 1863, by a conoidal musket ball, which entered one inch and a half above and external to the right nipple, and passed upAvard and backward through the lung, making its exit on the dorsal aspect of the right scapula, near the outer portion of its spine. The wounds were closed by silver sutures and hermetically sealed with collodion dressing by Assistant Surgeon B. HoAvard, U. S. A., on the field. Being conveyed to AVashington, the patient was admitted into the Mount Pleasant Hospital on July 30th, 1863, in the following condition: breathing, short and labored; pulse, 130 per minute and small; countenance anxious; cold, cadaverous tkin, and every appearance of confirmed collapse. On the removal of the dressings, a profuse discharge of sanious foetid pus occurred, AA'hich temporarily relieved the dyspncea; but in spite of stimulants the patient sank rapidly, and died on August 1st, 1863. The case is reported by Assistant Surgeon C. A. McCall, U. S. A. Case.—Private Robert Baker, Co. E, 140th New York Volunteers, Avas wounded at Gettysburg, July 3d, 1863, by a musket ball, which penetrated the lung. He was taken to the hospital of the Fifth Corps, where the wound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. The wound afterwards became open and suppurative. Death resulted on July 24th, 1*63. The case is reported by the operator. Case.—Private Charles Horton, Co. G, llth United States Infantry, received a gunshot wound of the lung at Gettys- burg, July 3d, 1863. The AA-ound was hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death resulted on July 12th, 1863. The case is reported by the operator. Case.—Private Isaac T. Sperry, Co. G, 73d Ohio Volunteers, received a gunshot penetrating wound of the thorax at Gettysburg, July 3d, 1863. The wound Avas hermetically sealed by Assistant Surgeon B. Howard, U. S. A. Death at the hospital of the Eleventh Corps, on July 5th, 1883. The case is reported by the operator. Case.—Private Levi Ells, Co. C. 12th United States Infantry, received a gunshot penetrating Avound of the chest at Gettysburg, July 1st, 1863. The Avound Avas hermetically sealed by Assistant Surgeon B. HoAvard, U. S. A. The patient died on July 4th, 1863. The case is reported by the operator. Case.—Private AV. D. Hammond, Co. F, 14th United States Infantry, received a gunshot penetrating Avound of the left side at Gettysburg, July 3d, 1863. The Avound was hermetically sealed by Assistant Surgeon B. HoAvard, U. 8. A. Death resulted on July loth, 1863. The case is reported by W. F. Breakey, Assistant Surgeon 16th Michigan Volunteers. 04 506 WOUNDS AND INJURIES OF THE CHEST. Case.—Private G. AA'. Stevens, Co. D, 16th Michigan A'olunteers, received a gunshot Avound of the riglit lung at Gettys- burg. Julv 3d, 1S63. The Avound Avas hermetically sealed by Assistant Surgeon B. HoAvard, IT. S. A., at the field hospital of the Fifth Corps. Death on July 10th, 1863. The case is reported by AV. F. Breakey, M. D., Assistant Surgeon 16th Michigan A'olunteers. Case.—Private Jacob Ganner, Co. G, 16th Michigan A'olunteers, received a gunshot penetrating Avound of the chest and left arm at Gettysburg, July 3d, 1863. The Avound Avas hermetically sealed, at the field hospital ofthe Fifth Corps, by Assistant Surgeon B. HoAvard, U. S. A. The patient died on July 10th, 1863. The case is reported by AV. F. Breakey, M. D., Assistant Surgeon 16th Michigan Arolunteers. Case.—Private Ambrose AATeiss, Co. H, 93d NeAV York Volunteers, aged 19 years, received a gunshot Avound of the chest at Deep Bottom, Virginia, August 14th, 1864, by a conoidal ball, Avhich perforated the right lung. He Avas conveyed to the field hospital of the 3d division, Second Corps, Avhere the Avound Avas hermetically sealed. On August 18th, he was transfeiTed to Campbell Hospital, A\Tashington. Death resulted an September 10th, 1864. The case is reported by Surgeon 0. Everts, 20th Indiana A'olunteers. Case.—Sergeant Peter Goldie, Co. A, llth Massachusetts Volunteers, received a gunshot penetrating Avound of the thorax at Petersburg, Virginia, September, 1864. The wound was hermetically sealed at the hospital of the 3d division, Second Corps. The patient died on September 13th, 1864. The case is reported by Surgeon O, Everts, 20th Indiana Volunteers. CASE.-Private Earl Halbard, Co. F, 5th Michigan Volunteers, received a gunshot penetrating wound of the thorax at Petersburg, A'irginia, September, 1S64. The wound Avas hermetically sealed at the hospital of the 3d division, Second Corps. The patient died on September 16th, 1864. The case is reported by Surgeon O. Everts, 20th Indiana Arolunteers. Case.—Private John AV. Smith, Co. F, 126th Ohio Volunteers, received a gunshot Avound of the left shoulder, penetrating the lung, by a conoidal ball, at Spottsylvania, Virginia, May 12th, 1864. He was taken to the hospital of the 3d division, Sixth Corps, Avhere the Avound was stitched and closed Avith collodion. On May 26th, he Avas transferred to the 3d division hospital, Alexandria. Death resulted on May 27th, 1864. The case is reported by Surgeon R. Barr 67th Pennsylvania Volunteers. Case.—Colonel Daniel Chaplin, 1st Maine Heavy Artillery, aged 50 years, received a gunshot penetrating Avound of the left side of the chest, at Deep Bottom, Virginia, August 17th, 1864. The Avound Avas hermetically sealed at the field hospital of the 3d division, Second Corps. On August 20th, he was admitted to Turner's Lane Hospital, Philadelphia, where he died on the same day. The case is reported by Surgeon O. Everts, 20th Indiana Volunteers. Case.—Private Isaac Evans, Co. I, 30th Indiana Arolunteers, received a gunshot penetrating Avound of the thorax, near Marietta, Georgia, June, 1864. The wound was hermetically sealed by Assistant Surgeon W. H. Matchett, 40th Ohio Volunteers. Death resulted on June 28th, 1864. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—Corporal Evan Francis, Co. H, 81st Indiana Volunteers, received a gunshot penetrating Avound of left side ot thorax, near Marietta, Georgia, June, 1864. The Avound Avas hermetically sealed by Surgeon S. H. Kersey, 36th Indiana A'olunteers, at the hospital of the 1st division of the Fourth Corps. The patient died on June 29th, 1864. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—Private Samuel AA'est, Co. K, 84th Indiana Volunteers, received a gunshot penetrating wound of thorax and Scapula, near Marietta, Georgia, June, 1864. The wound Avas hermetically sealed by Assistant Surgeon W. H. Matchett, 40th Ohio Volunteers. The patient died on June 26th, 1864. The case is reported by Surgeon J. D. Brumley, U. S. V. Case —Private Thomas Hayden, Co. K, 45th Ohio Volunteers, received a gunshot penetrating wound of the thorax, at Kenesaw Mountain, Georgia, June 26th, 1864. The Avound Avas hermetically sealed by Surgeon C. J. Walton, 21st Kentucky Volunteers. Death on June 27th, 1864. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—Private David Gallagher, Co. K, 14th New Jersey Arolunteers, received a gunshot Avound of the lung, at Locust Grove, ATirginia, November 27th, 1863, the ball in its exit extensively comminuting the fourth rib. He Avas conveyed to Brandy Station, where the fractured part of the rib Avas removed by a process of exsection; the edges of the Avound Avere trimmed and brought together very neatly Avith wire sutures and sealed with collodion. Death resulted on November 30th, 1863. Surgeon A- TreganoAvan, llth New Jersey, who reports the case, says: "The case would, in all probability, have terminated differently, but for the great imprudence of the patient. Ten hours after the operation, feeling so ' bully/ as he termed it, he indulged in immoderate exercise, resulting in almost sudden death." Case.—Private Patrick Daley, Co. E, 70th New York Volunteers, received a gunshot penetrating wound of the chest at Manassas Gap, A'irginia, July 23d, 1863. He was conveyed to the hospital of the 2d division, Third Corps, and HoAvard's treatment adopted. The case terminated fatally the same day; it is reported by Surgeon James Ash, 70th New York Volunteers, and by Surgeon C. H. Irwin, 72d New York A'olunteers. Case.—Private AV. Devausa, Co. B, 81st Indiana Arolunteers, received a gunshot penetrating Avound of the thorax near Marietta, Georgia, June, 1864. The Avound Avas hermetically sealed by Surgeon C. J. AValton, 21st Kentucky Volunteers. Died June 26th, 1864. The case is reported by Surgeon J. D. Brumley, U. S. V. Case.—Corporal Lewis Burgess, Co. G, 86th New York Arolunteers, received a severe gunshot penetrating wound of the thorax at Petersburg, A'irginia, June 23d, 1864. He Avas taken to the hospital of the 3d division, Second Corps, Avhere the Avound Avas closed Avith silver Avire and collodion. He died on June 29th, 1864. The case is reported by Surgeon O. Everts, 20th Indiana A'olunteers. TREATMENT BY HERMETICALLY SEALING. 507 Case.—PriA-ate JTr. P. Thompson, Co. I, 61st North Carolina Regiment, aged 52 years, was admitted to Chimborazo Hospital, Richmond, October 1st, 1864, with a gunshot penetrating wound'of the chest; the missile entered the right side between the third and fourth ribs, four inches from the sternum, passed through the lower portion of the upper lobe of the lung, and emerged through the loAver. angle of the scapula. The Avounds Avere hermetically sealed. AVhen admitted, he was suffering from great dyspnoea; bloody saliva oozed from the angles of the mouth; pulse slow and Aveak; skin cold and bowels costive. Occasionally, Avith much effort, the patient spat clots of blood. October 2d, pain in hypochondriac region, and some tympanitis. Death occurred on October 4th, 1864. The case is taken from Confederate case book. It is specified in all but fifteen of the foregoing forty-two fatal cases, that the lung was injured. The precise date of injury is ascertained in thirty-five instances, the seven other patients having been reported in return covering several days of righting. The interval between the reception of the injury and death was as follows: Died on the day of operation, 3; on the first day following, 1; on the second day, 3; on the third, 8 ; on the fourth 1; on the sixth, 4; on the seventh, 3; on the eighth, 1 ; on the ninth, 2; on the twelfth, 1; on the thirteenth, 1; on the fifteenth, 2; on the eighteenth, 1; on the twenty- first, 1; on the tAventy-second, 2; and on the twenty-seventh, 1; a total of 35. None of the seven other patients lived more than four days. The average of survival of the forty- two was, therefore, about a week. The complications were: fatal intermediary hsemor- rhage on the second day, fracture of the scapula, extended comminution of the ribs, lodgement of balls, hsemothorax, and empyema. All, or nearly all, of the foregoing group of sixty-nine cases were submitted to the treatment by occlusive dressing on the day of the reception of the injury, or the following day at the farthest, and it would appear that the dressings were not removed in any instance in the general hospitals, unless the reopening of the wound or the necessity of evacuating extravasated fluids made some modification in dressing imperative. Viewing the group numerically, surgeons rightly appreciating the gravity of gunshot penetrating wounds of the chest will not regard the mortality as large, especially when it is considered that, in the opinion of observers presumed to be competent, nearly two-thirds of the cases were attended by injury of the substance of the lung. Twenty-seven recoveries in sixty-nine cases given, if the figures may be relied on, is a mortality of 60.8 only. But we fear that the statistical statement is open to many criticisms. Undoubtedly there are on the Pension Rolls the names of thirteen patients who recovered from alleged penetrating gunshot wounds of the chest under the treatment by hermetically sealing, and have survived their injuries from seven to nine years. Only one, Bradley (p. 501), enjoys good health. He has carried a musket ball in his chest for nearly nine years without great inconvenience. Two of the twelve other pensioners have necrosis and empyema, and interminably open sinuses; five suffer from haemoptysis; two have partial paralysis; the others suffer from chronic cough, solidification of portions of the lung, dyspncea, and. other evidences of damage to the respiratory apparatus. Several have recently applied for increase of pension With all these disabilities they still live. » Of five cases, reported as rapid recoveries (from lung wounds in each instance), there are no late histories, I. F. lones and I. Douricott were paroled in three and eight months. Doming and Wheeler, deserters, disappear after four months and six weeks respectively Branson was furloughed in six weeks. During the brief period they remained under observation, these five cases presented very favorable illustra- tions of the plan of treatment under consideration. There remain of the twenty-seven reported recoveries, nine cases, two of which (Stauffer, p. 499, and Conauton, p., 502) appear to be satisfactory, while seven are open to objection. These seven are the cases of Erlee and Larkin (p. 499), Cunningham and Loll (p. 500), Peddle and Walters (p. 501), 508 - WOUNDS AND INJURIES OF THE CHEST. rtiul McAllister (p. 502). Peddle and McAllister were discharged for disability, and the other five were returned to duty in from ten weeks to six months from the date ot* the reception of their injuries. It is almost incredible that Dr. McCall should have sent Larkin to the ranks, knowing that he had been shot through the left lung one month before, no matter hoAV complete his convalescence might appear; yet such is the record. Captain Peddle was discharged, and may have had the unusual generosity to Avaive his claim for pension; but it is so extraordinary that the six enlisted men reported to have been shot through the chest should all have failed to make application for pension, that it is difficult to avoid the conviction that either the gravity of the injuries sustained by these men was, happily, greatly exaggerated originally, or else that the men imprudently returned to duty, were killed in action, or died in captivity. In the writer's judgment, only three of the series of twenty-seven cases, viz: Bradley, Stouffer, and Conauton are authenticated as complete and permanent recoveries. The five Avho deserted or Avere paroled or furloughed were probably equally satisfactory recoveries; and there are the twelve disabled pensioners. If twenty recoveries in sixty-nine cases were conceded, the mortality rate of 71.01 would still be too low, if it be assumed that these twenty were all examples of perforation or laceration of the lung. There is reason to believe that those signs, which, when several co-exist, afford a strong presumption of lesion of the lung, were Avanting in many of the cases, and that the diagnoses given were unwarranted. There is no doubt that, in some of the cases, threatened asphyxia from hsemothorax or empyema made it impracticable to persevere in the occlusive treatment, and that, the wounds were open dining con\ralesence. The fatality of gunshot Avounds really penetrating or perforating the lung is so great, that science Avould have been immeasurably indebted to Dr. Howard for an improvement upon ordinary methods of dealing with these serious injuries. It is obvious that such a pretension is far from haA7ing been established ; it is probable that the routine application of the plan has not been unattended by disastrous results ; and it is to be lamented that the numerous experiments have not even advanced our pathological knowledge. Occlusive dressings in such wounds are not new, nor sutures, nor debridement, nor thoracentesis ;* but these cavils Avould have been silenced had the combination of these means diminished the mortality of penetrating wounds of the chest. Unhappilyt this *Hexnen" observes (Principles of Military Surgery, 3d ed., 1829, p. 378) that: "This immediate closure of the wound has been recently adopted by M. Larrey with success. The practice is not noA'el. John de Vigo, in the tenth chapter of his third book, has given an account of it; and Par§ 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 tjie wound for 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 mentions emphysema. His 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 with great fidelity in his Traite Complet de Chirurgie, Vol. Ill, p. 20, Paris edition, 1732. But Belloste seems to haA-e done more practical good in this way than any other French surgeon. He argues strenuously and successfully against keeping the injuries of the chest open, in his Chirurgien d'Hopital, and he sets a very valuable example to writers of a more modern date; for, in a letter in explanation of Sancassani's Italian translation of his work, he acknowledges his obligations to honest old Magatus, who wrote nearly one hundred years before him. [D. J. Larrey treats of the subject in his Mimoires de Chirurgie Militairc et Campagnes, T. II, p. 154, in speaking of incised wounds of the chest observed in the campaign in Egypt. Pare (Oiuvres Completes, T. II, p. 94, Livre 8, Chap. XXXH) has, as Malgaigne remarks, borrowed from Vigo. (The edition in the Surgeon General's Library is the Munich edition of 1521, Practica in chirurgia copiosa, small folio.) The allusion to healing wounds of the chest by first intention is in the first part of the third book, fol. LXXIV. A/igo in his turn copied from Guy de Chauliac (La Grande Chirurgie, composes l'an de grace, 1363). See Joubert's restoration, published at Tournon in 1619, Chap. V, p. 290. The admonition which Dr. Howard has unheeded is furnished by Belloste in his eighth chapter. Cesari Magati, professor at Ferrara, published his work " De rara Medicatione Vulnerum, Folio, apud Venetiis, in 1616: " Unionem labiorum, mitem medicationem, clausum culnus commendat."—(Creutzenfeld.) Pare condemns the application of stitches in penetrating wounds of the chest, in the thirty-second chapter of his eighth book, and also in the Playes dhacquebutes, 1552, fol. 76. Felix Wurtz, in 1576, advanced the treatment of penetrating wounds of the chest by sewing them up as a general method. (Practica der Wundarzney, darinn allerley schiidliche Missbrduche der Wunddrzte abgeschafft werden. Aus den Handschriften des Autors, von neuen ubersehen und vermehret duich Rudolph AVurtzen, Basil, 1576) ; Professor T. Longmore remarks that " ' hermetically sealing ' is only a new term ;" but even this admission is erroneous ; for in 1827, Graefe, of Eerlin, in the case of a man of thirty-two, who had stabbed himself between the fifth and sixth ribs, near the sternum, the knife penetrating two inches, blood and air escaping freely from the wound, etc., etc., directed the following treatment: La plaie fut hermetiquement ferm6e, etc., etc. (See Clin, des Hop., T. II, No. 28, and Arch. Gen. de Med., T. XVI, p. 601 )—COMHLER.] TREATMENT BY HERMETICALLY SEALING. 509 consummation has not been attained. Additional and impressive illustrations have been furnished of the Avell-known facts of the great relief of dyspncea and the arrest of hemorrhage that sometimes, though far from invariably, follow the immediate closure of chest Avounds. Paring, suture, and reunion of the lips of deep wounds have failed, as of old to promote cicatrization of the torn track out of sight, and instances have been furnished of sewing up clothing within the thorax and of tapping through the liver that are serviceable for instruction rather than imitation. The foregoing series of cases of gunshot wounds of the chest treated by hermetically sealing probably includes all that recovered; because, if omitted on the official records, such examples would probably have found publicity through the medical press. But many fatal cases are unquestionably unmentioned. The fear of duplication has deterred the writer from citing those cases in Avhich the names of the patient or observer were wanting, or the result left undetermined, In the Appendix to Part I of this History (p. 200), will be found an interesting discussion, by Dr. J. S. Billings, of this mode of treatment, and of the opinions regarding it, entertained by the medical officers of the Army of the Potomac. Adopted by surgeons of the 3d division of the Second Corps, it was "regarded with disfavor by the majority of the medical officers of this Army." At Gettysburg, Dr. Billings, in charge of the hospital of the 2d division of the Fifth Corps, had under observation " six cases, in which the hermetically sealing process had been practiced by Dr. Howard. * * An assistant surgeon was left by Dr. HoAA^ard to take charge of the cases, and carry out his peculiar mode of treatment, and a written order was given by Dr. Letterman that these cases should not be interfered with. All of these men died within eighteen days. On two of them I had autopsies made, Avhich revealed empyema and pleuro-pneumonia. In one case a fragment of a woollen shirt lay in the cavity of the chest." Dr. Billings requested Assistant Surgeon C Smart, medical inspector of the Second Corps, to report on the results of this mode of treatment in the command to which he Avas attached. After expressing his chragrin that his investigation had resulted in little of real importance, owing to insurmountable obstacles presented by the imperfection of the records, and the absence on duty or on sick leave of many of the surgeons of the three hospitals of the Second Corps, Dr. Smart continues : "In the hospital of the 1st division, I have obtained positive information of the existence oi only three cases of chest wounds hermetically sealed; although I am fully satisfied that more than this number were so treated. Even in these cases 1 have been unable to obtain the names of the patients, or a statement of their condition before operation. That three cases, however, of pene- trating Avounds of the chest were sealed is certain; and it is equally so that this operation was followed by immediate and very marked improvement in the condition of the patients; and that they did well so long as they remained in the field hospital. What has become of them since then is unknown. The cases operated upon in this hospital were certainly not selected on account of presenting very favorable chances of recovery under ordinary treatment; the medical officers here being inclined to view the operation Avith an unfavorable eye; although they bring forward no facts to prove aught against it, on the contrary their experience pointing only to the relief supervening upon the completion of the sealing process, and hence patients that seemed to promise well Avere sedulously protected by the medical officers in charge of them from any operative interference. Dr. Howard was thus reduced to the necessity of selecting his cases for operation from those presenting such serious symptoms as to cause them to be set down as probably fatal, however treated. Yet in these cases sealing Avas followed by marked improvement in the condition of the patients, who did well during the short time they remained under observation. 510 WOUNDS AND INJURIES OF THE CHEST. uIn the hospital of the 2d division, the operation has been condemned without trial. v)ne case. I learn, was operated upon, according to Doctor Howard's method, by Surgeon Henry K. Martin, U. S. V. Belief Avas afforded, and two days afterward the patient was sent to City Point. No particulars are given. In the 3d division,* the operation has been practiced to some consider- able extent, not so much by Dr. Howard personally, as by the medical officers of the division, who first learned the practice after Gettysburg, and have since then adopted it, in some measure. Not having any record of the cases, they cannot speak of the ultimate issue of hermetically sealing. Yet, that cases treated thus are not necessarily fatal is evidenced by the case of an officer (name not given) who, but a few days ago, exhibited to Surgeon J. Jamison, 86th New York Volunteers, the cicatrices of the sealing performed by him at a previous period. Without reference to the issue in death or recovery, this operation is practiced in order to yield the relief from dyspiuea which is iiiATariably, in the experience of these surgeons, its immediate result. On the records, only two cases of penetrating wounds of the chest are mentioned as having been sealed. The reason given for this omission is that patients subjected to this mode of treatment are seldom brought to the operating table, and hence do not come under the observation of the recorders. Surgeon S. AV. Lyman, 57th Pennsylvania Volunteers, has lately sealed up two cases—the names he does not recall: . ''Case 1st.—Rail entering interval to the nipple on the left side, passed out in the neighborhood of the inferior angle of tlie scapula of the same side. The evidences of perforation of the lung Avere satisfactory. Blood Avas expectorated and air issued from both anterior and posterior apertures. As the dyspncea Avas very distressing, it was resolved to seal, which was effected in the usual manner : The edges Avere first pared and then held firmly together by means of two or three sutures; a pledget of lint Avas kept in position over the united lips of the wound by one or tAvo strips of isinglass plaster, and the Avhole coated over witli collodion. " Case 2d.—Ball entered on the outer side of the left shoulder, passed behind the head of the humerus, and, traversing the upper and back part of the axillary space, entered the chest. The aperture of exit Avas near the inferior angle of the scapula of the opposite side. The difficulty of breathing was extreme. The whole of the chest was emphysematous. Coagulated blood was coughed up and air issued from the Avound in the right side. This Avound having been sealed up by three sutures, air was discovered moving through the wound in the shoulder. The patient objected to having this one sealed, as he found, by pressing with his outspread hands upon his chest, he caused the air contained in the cellular tissue to issue from it, and so relieved, in some measure, his oppressed breathing. The opening, hoAvever, Avas closed up by two stitches after the air in the areolar tissue had been evacuated. In both cases the patients Avere relieved, and were doing well when sent shortly afterward to the rear. " In the latter case the propriety of closing up the wound in the shoulder might readily be questioned ; but I would be going beyond the scope of this report were I to attempt its discussion. Surgeon J. Jamison, 80th NeAV York Volunteers, has sealed up, during this campaign, at least eight cases. His last operation was on June 23d, on the person of a man, Lewis Burgess, belonging to his own regiment. He was called in haste to see this man on account of distressing difficulty of breathing. The operation afforded so much relief that after it the patient, who previously had been all anxiety, laughed and joked Avith his comrades.t A case, where nature adopted Dr. Howard's principle Avith modified practice, may be mentioned. Dr. W. S. Cooper, 125th New York Volunteers, relates that while the wagons ordered to carry wounded to the rear were being loaded up, a man belonging to his regiment, Avhom he had previously seen and recorded as being shot through the lung, complained to him that the officers loading up the wagons would not permit him to ride, saying that he Avas able to walk. The wound in the chest Avas sealed up by a hard cake of dried clots. The man, he has since learned, is convalescent. This was a decided case of injury to the lung, for the man coughed up small clots, and these, by the way, formed his passport into the wagon. Concerning mortality after this operation, I can say but little. No medical officer in this corps has seen a case of hermetically sealed chest wouud dead. Yet it is possible that some of the cases in the 3d division might have died without attracting attention; no particular care was evinced in watching the cases. In the 1st division, however, if a death had occurred, I am certain it would have been seized upon as proof sufficient to condemn the operation. From the registers ofthe I'd and 3d divisions, I haATe transcribed the names of one hundred and fifty cases of penetrating wounds not hermetically sealed; of this number, forty-nine died while in the Field Division Hospital. In * The chief medical officers of the three divisions were : 1st division, Surgeon D. N. Houston, 2d Delaware A'olunteers; 2d division, Surf."'"" •' F. Dyer, 19th Massachusetts A'olunteers; 3d division, Surgeon Orpheus Everts, 20th Indiana Volunteers.—El). t He died on June 29th. See page 506.—ED. TREATMENT BY HERMETICALLY SEALING. 511 this report fourteen cases* (not selected by reason of their presenting fair chances of a favorable issue) treated by sealing are recorded as having been sent to the rear doing well. It is possible that the palliation of the immediate symptoms may have something to do with this. However, more extended observation is required before any satisfactory conclusion can be arrived at upon this subject. In concluding, it may be needless to mention that the experience of those officers, in the corps, who have practiced the operation has as yet been too limited to enable them to form any idea based upon facts concerning the nature of those cases to which this operation is more particularly applicable."' * * * In the Army of the James, a strong prejudice Avas manifested against Dr. Howard's plan of treatment, especially by the surgeons at the base and field hospitals at Broadway Landing and Point of Rocks. Surgeon Hadley B. Fowler, 12th New Hampshire Volun- teers, in his monthly report of the base hospital for July, 1861, says : * * * "During the month ten cases of gunshot Avounds of the lung died here. Of ten cases treated by Dr. Howard, of AA'ashington, by the method of hermetically sealing the wounds in the chest and tapping to relieve effused fluid, nine died and one was sent to general hospital, the wound of exit freely discharging pus at the time he was put on the transport. The pathological results of two of his cases are reported; the other eight Avere examined by Dr. Howard, but results not made known to us." Of the cases here referred to, but two have been positively identified, the case of Williams, printed on page 504, and that of Private G. W. Ryerson, 9th Maine Volunteers.*]" The first was and the second was not an instance of hermetically sealing. Dr. Fowler's report gives the following additional names of patients with gunshot penetrating wounds of the chest who died in the hospital under his charge about the period referred to from gunshot wounds of the chest, viz : Private Lewis King, Co. I, 96th New York Volunteers, died July 2d, 1864. Private Albert Attwood, Co. K, 4th NeAV Hampshire Volunteers, died July 2d, 1864. Private Martin Kelley, Co. I, 186th Pennsylvania Volunteers, died July 3d, 1864. Private Albert A'ickery, Co. H, 8th Maine Volunteers, died July 4th, 1864. Private Louis Byron, Co. K, 169th New York Volunteers, died July 4th, 1864. Private Jesse Harvey, Co. G, 76th Pennsylvania Volunteers, died July 8th, 1864. Private James Peabody, Co. I, 9th Maine Volunteers, died July 8th, 1864. These names probably refer to the cases mentioned by Dr. Fowler as illustrations of the disadvantageous results of Dr. Howard's treatment. The more successful case, of empyema, sent to the hospital at Fort Monroe cannot be identified from the hospital records. Assistant Surgeon G. Derby, U. S. V., medical inspector of the Department of Virginia and North Carolina, made, on July 7th, 186-1, a report to Surgeon C. McCormick, U. S. A , the medical director of the department, relative to some of these cases. Copies of the report were furnished to the Acting Surgeon General and to Surgeon G. Suckley, medical director of the Eighteenth Corps, who had supervision of the field and base hospitals of the Army of the James. The report, divested of the endorsements and other official formulas, was as follows : "On the 4th instant, I inspected the base hospital of the Eighteenth Army Corps and found four cases of gunshot wound of the thorax, all of which were under the immediate charge of Assistant Surgeon Benjamin Howard, 17. S. A., Avho, although not connected with the hospital or * In the series of cases that I have reported by name, there are fourteen of the three division hospitals of the Second Corps, including nine fatal cases.—Ed. t An account of the autopsy in this case, in which the abdominal cavity was chiefly implicated, was published by Surgeon C. H. Carpenter, 148th New York Volunteers, in the Boston Med. and Surg. Jour., Vol. LXXI, p. 112. It will be noticed farther on among the wounds involving both chest and abdomen. 512 WOUNDS AND INJURIES OF THE CHEST. corps, had special authority from Washington, as 1 was informed, to direct the treatment of all similar cases which might be received. The essential points of his treatment consisted in hermet- ically closing the Avounds, and subsequently making, with the trocai1, new openings for the exit of accumulated fluid. On A'isiting the hospital again to-day, I learned that the cases I had seen three days previously had all died. I found three other similar cases Avhich had been subjected to the same treatment. Two of them were moribund. I also learned that in two instances, puncture of the walls of the thorax had been made by the trocar Avithout the evacuation of fluid. I found Dr. Howard, and said to him that, as medical inspector of the department, I felt at liberty to ask for his authority to do what he had done and was still doing. His reply Avas that Dr. Suckley, medical director of the Eighteenth Corps, had verbally authorized him to look after these cases. One official paper was shown me dated July 20th, 1863, and signed by Surgeon J. P. Smith. It author- ized Assistant Surgeon Howard, after the next battle, to take charge of cases of wounds of the thorax and abdomen. Dr. Howard, however, disclaimed any direct official authority for his present proceedings." This report was referred to Medical Director T. A. McParlin, of the Army of the Potomac, who fonvarded in reply the following report by Assistant Surgeon Howard: * "I have the honor to acknowledge the receipt of a communication by (!. Derby, Assistant Surgeon, U. S.Y., reporting certain alleged proceedings of mine in the base hospital of the Eighteenth Corps, with endorsements from the Surgeon General's Office and from yourself. With reference to the endorsement from the Surgeon General's Office, I beg most respectfully to state that I have never at any time or place ' assumed charge of patients Avho have gunshot wounds of the thorax,' nor have I represented that I possessed special authority from Washington or any other source to direct the treatment of them or any other class of cases. The report of G. Derby, Assistant Surgeon, U. S. V., is a gross misrepresentation, equally ungenerous and unjust, as will appear from the following statement of facts: On June 30th, 18G1, by invitation of my friend Surgeon Suckley, U. S. V., medical director Eighteenth Corps, I accompanied him on a visit to his field and base hospital. During the course of a conversation on the treatment of certain gunshot wounds of the chest by hermetically sealing, the doctor replied, 'You have a good thing there, doctor. Those cases are almost sure to die anyhow, and if there is anything which promises to he beneficial in their treatment, in any degree Avhatever, it ought to be tried. If I can do anything to help you in your investigations, I will be very glad to do it, &c.' I replied that if the Eighteenth Corps became engaged while the Army of the Potomac was quiet, if I had time, I would run down to take notes at least, even though I did not operate or treat any cases, &c, &c. During our visit, the doctor introduced me to the surgeons in charge of the field and base hospitals, respectively, and directed them to afford me every facility in their power to enable me to treat or take notes of cases as I might desire, so long as it did not conflict with the general arrangements. The same evening, the Eighteenth Corps became separately engaged, and on the day following, toward night, I found in the field hospital several chest Avounds. I operated on one case, Private Williams, 1st Connecticut Heavy Artillery, which promised very unfavorably; also commenced to operate on Private Kell}', G9th New York Volunteers, but as he appeared unable to endure the position I desisted. There were other cases, but, as it was growing dark, I left, requesting the surgeon in charge to send my patient on to the base hospital as soon as he could, together with the other chest wounds. They were not forwarded when I called the following day, as I had anticipated, but came several hours afterward. On account of the time Avhich had elapsed since the reception of the wounds, I gave up the idea of hermetically sealing any other case, though otherwise it might appear ever so favorable. On looking about the hospital, I found several chest cases, some of which were evidently mortal, which I found the ward surgeons were very anxious to get rid of. I saw Dr. FoAvler, surgeon in charge, and stated to him distinctly that I had one patient, Private Williams, and one only, for whom I Avas responsible,—gave my reasons for objecting to the same plan of treatment in any other of the cases; but, as I should be visiting the hospital frequently, requested that all the cases might be placed in the same ward with my patient, my desire not being so much to operate or carry out one special plan of treatment, as to obseiwe closely the largest possible number of cases. Eight cases were placed together with my patient in the same TREATMENT TVY IIERMETICALLV SRALINC. 513 ward under the immediate charge of Dr. Tennant. Before breakfast on the next morning, I had completed tho post mortcms of three of these cases; one was the case I had commenced to operate upon, as referred to, the others I had simply taken notes of. I visited the remainder daily until the 7111 instant, once with Dr. Suckley, who thought my patient was doing finely under the circum- stances. On each visit I took notes of the other cases, and ma.de suggestions as to their treatment, or modified it. I was unable to visit the hospital again until the 10th instant, when, calling on Dr. Suckley, I learned he had just left (Jeneral Butler's headquarters, Avhere he was informed, by Assistant Surgeon Derby, that 'all' my cases were dead, and that he should have the fact reported to the Surgeon, General, &c. 1 immediately went to the hospital and was informed on my first inquiry of the first surgeon I met, ' All your eases are dead.' I replied, 'I had but one, Avho, from the first, I apprehended would live but a short time,—that I was sorry the others had all died ; but had feared such might be the result.' I requested to see Dr. Tennant [Assistant Surgeon Charles J. Tennant, 21st Connecticut A'olunteers], the ward surgeon in charge, but found he had been ordered away on duty. I was referred to another surgeon Avho had succeeded him, and from him I learned that they were ' nearly all dead.'' I then visited the ward Avith him and the surgeon who had stated to me ten minutes before that they were all dead, when I found three living! two of them being more complicated than any others. I had taken special interest in them, and had modified their treatment more than that of all the others put together. In one, the liver was implicated. I had on one occasion removed about a pint aud a half of fluid from the right pleural cavity, strongly tinged with bile, and subsequently about a pint of the same nature. In the other there was extensive pulmonary hernia, which I had fixed so as to secure a permanent plug with adhesions around the orifice, and also exhausted the pleural cavity of air. This, I suppose, is the ease Assistant Surgeon Derby reports, in which the trochar was used without, as he had 'learned,' the removal of any fluid. Of the cases, nine in all, my patient lived till the eighth day; three of the others died on July 2d and 3d; two others, I suppose, died during my absence, and three were living on July 10th, 1SG1. Hermetically sealing was practiced in no case except that of my patient, Private AA'illiains, in whom both lungs were extensiA'ely involved—the ball having entered and passed through the left scapula, below its spine, passing out about two inches below the middle of the right clavicle. I met Assistant Surgeon Derby, U. S. V., at the base hospital on the 3d and 7th instant; on neither of these occasions were any explanations elicited from me, which I deemed unnecessary under the circumstances. My presence at the hospital and everything connected with the whole affair was simply an unofficial matter between Dr. Suckley and myself, to whom I should have simply referred Assistant Surgeon Derby, TJ. S. V., for information. It happened, however, that, on July 7th, I had in my pocket the communication he refers to from the Surgeon General's Office, so I showed it to him, at the same time stating that it had no relation whateATer to my present conduct, which was entirely without any written order or authority. I have on other occasions frequently consulted with and operated for brother medical officers in other commands than my own with the same mutual courtesy as is observed in private practice, which, so far as I know, is not forbidden by humane considerations, professional etiquette, nor by official order. I am personally responsible for my professional conduct and shall be happy to submit un- original notes of cases, or in any Avay contribute to its investigation. I think it must be evident, however, from a view of the facts herein stated, not as I have 'learned' them, but as I hwtv them, that my conduct in the case has been in perfect accordance with propriety and good discipline.7' The subject appears to have dropped here. Fighting was going on daily, and the attention of the higher medical authorities was occupied by very Aveighty affairs. The report was dated July 18th, 1864. Few cases in which the treatment in question was practiced are recorded subsequently. In March, 1865, however, Surgeon G. Derby, U.S.V., with a \Tiew to efface an impression that this Avas an approved method of treatment, printed a communication in the Boston Medical and Surgical lournal, containing the following emphatic language: "In July, 18G4, it came in my way to see six cases at one time treated in this manner at the field hospital of the Eighteenth Army Corps before Petersburg. All six promptly perished. The 65 511 AA'OUNDS AND INJURIES OF THE CHEST. verdict of army surgeons, who have tried this method, I think is unanimous. Can we not then be done with it—banish it from our books of military surgery, and let it rest with the multitude of exploded theories which have preceded it ? A Avriter in the London Lancet, some time ago, dearly showed that it was unphilosophical. Experience has proved it fatal."* Hernia of the Lung.—Writers on military surgery have regarded this as the rarest of the complications of wounds and injuries of the chest,f an opinion confirmed by the experience of late wars. Authors make two species of traumatic pneumocele, viz: wound of the chest with protrusion of the lung, and consecutive pneumocele or pneumatocele, or hernia of the lung properly so called, in which the protruding portion of the viscus is enveloped by a covering of integument and thickened pleura, or cicatricial or other adventitious tissues. Of the seven examples of hernia of the lung noted among the twenty thousand cases of chest wounds returned, five at least were of the primary variety. It is usually stated by systematic writers that these protrusions most frequently occur anteriorly and in the neighborhood of the nipple, doubtless because most of the recorded cases occurred after incised or punctured wounds, and hence at the part of the thorax most exposed to stabs. In the cases here adduced, all resulting from gunshot, the injury was inflicted low down in the chest; in five instances, at or below the ninth rib ; in two, below the nipple. Hence, several of the cases Avere accompanied by wounds of the belly, and escape of portions of the abdominal viscera as well as the lung. It is greatly to be regretted that the observations are so imperfect as to throw little light upon this obscure subject. The exact period at which the protrusions occurred and the behaviour of the tumor in inspiration and expiration pass unnoticed, and the want of details respecting the extent and direction of the wounds detract from the A^alue of the observations, Avhich, had they been minutely and carefully described, would have sufficed to decide several contested points. But the vicissitudes of the battle field are not favorable to accurate clinical records, and, meagre as they are, these histories must be accepted with gratitude because of their rarity. The first case relates to a man who was captured and taken to Richmond immediately after the reception of his injury: Case.—Private AA'. A. Perrin, Co. C, 106th NeAV York Volunteers, aged 29 years, received a gunshot Avound of the left thorax, by a conoidal ball, at the Wilderness, Virginia, May 6th, 1864. He Avas taken prisoner and remained in the enemy's hands until August 14th, Avhen he was paroled and conveyed, by the steamer New York, to Annapolis, Maryland, entering the First * Consult HOWARD, B., Treatment of Gunshot and Penetrating Wounds of the Chest and Abdomen by Hermetically Sealing, American Medical Times, Vol. VII, p. 156, October, 1863; Longmore, T., Remarks on the recently proposed American plan of treating Gunsliot Wounds of the Chest by "Hermetically Sealing," London Lancet, p. 5, Vol. I, 1864 ; Hoavard, B., A Review of some Remarks of Professor Longmore on the Treatment of Gunshot Wounds of the Chest by Hermetically Scaling, Am. Jour. Med. Sci., N. S., Vol. XLVIII, p. 545 ; Derby, G., Surgeon U. S. V., Gunshot Wounds of the Thorax; is the Treatment by Hermetically Sealing them justifiable, Boston Medical and Surgical Journal, Vol. LXXII, March, 1865; OTIS, G. A., Circular No. 6, AVar Department, Surgeon General's Office, Washington, 1865, 4to, p. 22; Brkakey, AV. F., tee Cases of Penetrating Wounds of the Chest, treated by Hermetically Closing, Michigan Univ. Med. Jour., October, 1871, p. 466; BROAVN, V. F., Gunshot Wound of Chest Treated by Hermetically Sealing, Confed. Stat Med. and Surg. Jour., Oct. 1864, p. 163; Chisholm, J. J., Conversion of Gunshot Wounds into Incised Wounds as a Means of Speedy Cure, Confed. Stat. Med. and Surg. Jour., p. 138, Sept. 1864; MICHEL, M., Healing of Gunshot Wounds by First Intention, ibid., July, 1864, p. 99; HECKER, A. R., Boylston Prize Essay on Gunshot Wounds, in Boston Med. and Surg. Jour., Vol. LXXTI, p. 97, 1865 ; HAMILTON, F. H., A Treatise on Military Surgery and Hygiene, New York, 1865, p. 281; Billings, J. S., Report on the Treatment of Diseases and Injuries in the Army of the Potomac during 1864, Appendix to Part I, Med. and Surg. History ofthe AA'ar of the Rebellion, p. 200; BRINTON, D. G., Report ofthe Operations of the Medical Staff of the Eleventh Corps at the Battle of Chattanooga, Ibid, p. 293. tMATTHEAV (op. cit., Vol. II, p. 326), the accurate historian of British Surgery in the Crimea, states that "no case of hernia of the lung is reported." M. LEGOUEST (op. cit., 2m■ • i. < In oriiohlli GUNSHOT WOUND OF THORAX AND ABDOMEN WITH HERNIA OF THE LUNG HERNIA OF THE LUNG. 515 Division Hospital. On December 23d, he was transferred to Camp Parole Hospital. Avhence he Avas discharged from service February 6th, 1S65. Pension Examiner B. S. Sherman reports, June 23d, 1S65, that the ball carried aAvay a portion of the eighth and ninth ribs, left side, forward of their angles, resulting in hernia nearly the size of a small teacup, Avhich it is difficult to keep in place Avith bandage and compress. Disability total and more or less permanent. He Avas still a pensioner in March, 1S72. This would appear to have been an example of consecutive pneumocele, the lung forcing the soft parts outAvard as their support was Avithdrawn by 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 No. 21, at Richmond, and of the transport steamer New 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: Case.—Captain Robert S------, Co. A, 29th NeAV York Volunteers, was wounded at Chancellorsville, on May 2d, 1863. A round musket ball, fired from a distance of about one hundred and fifty yards, 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 rib.. Without 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 Avound, the surgeons found a protrusion of the lung of the size of a small orange, Avhich they unavailingly attempted to reduce. The wound Avas enlarged, and still it Avas impracticable to replace the protruded lung. On May 3d, the field hospital, where Captain S. lay, Avas exposed to the enemy's fire. He Avalked half a mile further to the rear, 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 Avhich a ligature was thrown around its base and tightened. A day or two subsequently, the patient passed into the hospital of the 2d division of the Eleventh Corps, into the hands of Surgeon Robert Thomain, 29th New York Volunteers, Avho 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 Avas visited by Surgeon John H. Brinton, U. S. V., who found him walking about the Avard, smoking a cigar. There was an entire absence of general constitutional symptoms; no cough, no dyspnoea,-no abdominal pain; the bowels Avere regular and appetite good. The protruding portion of the lung Avas carnified; there Avas 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 Thomaine stated that the hernia had been gradually dimiuishing in volume. It was, at this date, half the size of an egg, and covered with florid granulations. On May 10th, a draAving of the parts Avas executed by Mr. Stauch, artist of the Army Medical Museum. (See Chromolithograph No. XI.) On June 2d, Captain S. was transferred to AVashington. There was an elastic, partly reducible tumor, over Avhich was an oval granulating surface an inch and a half by three-fourths of an inch. The 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. Avas again examined. The wound had entirely healed; the respiratory 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.) The captain Avas discharged from service on June 20th, 1863, and Avas subsequently pensioned. On May 19th, 1864, Pension Examiner E. Swift reports the patient to be entirely incapacitated from the wound, Avhich, at that date, was considerably tumefied. He rates his disability total and temporary. September 19th, 1865 : The tumor is reported to be undiminished 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 suffers someAvhat from gastric symptoms, his stomach being easily disturbed. The extra-thoracic tumor is resonant on percussion. The air, in entering, produces a crepitant crack- ling sound; the expiratory murmur is feeble. March 14th, 1867 : Two months ago, the tumor suddenly enlarged after straining efforts at lifting, being noAV 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 tumor 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; traction 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 Avails. A bandage, so arranged as to retain the tumor within its present limits and prevent further enlargement, was applied. A letter from the patient, dated January 23d, 1870, leads us to infer that this bandage has fulfilled its indication. On January 31st, 1870, the patient Avas reported to have, in addition to his other troubles, a hernia of the stomach, which viscus passed up 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. Wm. H. Romig, of AUeiitoAvn, Pennsylvania, the family physician of Captain Stolpe, Avrites : "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 be discovered with the internal organs. Never gives pain, but dyspncea is produced upon hastening his pace 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 as the right. AYeighs about one hundred and sixty pounds, and enjoys good health." 516 WOUNDS AND INJURIES OF THE CHEST. In the next case nothing can be learned relative to the isochronism in the variations of volume of the tumor with the two acts of respiration : Cask.—Private George AAr. Bowman, Co. K, 4th Ncav York Heavy Artillery, aged 17 years. Avas AA'ounded at Spottsyl- vania May 19th, l^.il, by a conoidal ball, Avhich entered four inches beloAV the left axilla, and emerged two inches to the left of the spinal column, on the same level. He Avas admitted to Armory Square Hospital, May 22d, lSiil. Hernia of a portion ofthe viscera occurred from pohit of entrance and was ligated by Acting Assistant Surgeon D. AA". C A'an Slyck. HeAvas furloughed July 1st, readmitted August 20th, again furloughed November 23d, and readmitted January 28th, 1865. On February 2d, 1*65, he Avas returned to duty, and mustered out September 26th, 1865. Pension Examiner AV. C. A\rade, Holly, Michigan, reports, November 12th, 1869 : ''Gunshot wound through ninth rib beloAV left scapula, ball emerging near spine, having penetrated the abdominal cavity. Pieces of bone have been removed, and part ofthe omentum sloughed away ; the muscles of the side are Aveakened. 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: Cask.—Private James Infant, Co. G, 5th NeAV Hampshire Arolunteers, aged 19 years, Avas wounded at Petersburg, April 2d, 1865, by a conoidal musket ball, Avhich entered just beloAvthe left nipple and emerged to the left ofthe sixth dorsal vertebra, penetrating the left lung. He Avas 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 hospital steamer to Washington, and admitted to Armory Square Hospital on April 16th. A portion of the lung, tAvo by five inches, protruded through the wound of entrance. Death occurred from asphyxia 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 hernia of the liA^er, 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. 349,1785), 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 Wolfe : Case.—Private B. S. Sheridan, Co. A, 9th Massachusetts Volunteers, was wounded at Malvern Hill, July 1st, 1862, by a musket ball, AA'hich entered the right side betAveen 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 Avound there Avas a constant dripping of bile. On July 4th, Sheridan Avalked from the ambulance station to James Uiver, a distance of a mile and a half, Avith the hope of getting on board of a gunboat. He was disappointed, and Avas taken prisoner and conveyed to Richmond. No dressings Avere applied to the hernia of the lung. It was uncovered, and the patient occasion- ally Avashed it. He suffered little pain or dyspncea, and there Avas an amazing absence of shock or prostration. On July 25th, the bile had ceased to dribble from the posterior wound, and the hernia of the lung had greatly receded. He Avas exchanged, and on July 29th admitted into the hospital at Chester, and placed under a tonic treatment. The mass of flesh was found to be muscular tissue, and was protruding to the length of two inches, and Avas about the thickness of the middle finger. He soon complained of severe pain 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 disappeared under treatment. After the protrusion had been sloughed away, the wound closed, leaving a tumor beneath the skin, in the position of Avhat Avas the base of the protrusion. This tumor Avas slightly variable in size, but could not be reduced. About the middle of September, a movable substance Avas discovered, Avhich appeared to be a portion of ball flattened on the eleventh rib, by the side of the tumor; it Avas determined to remove this substance, and at the same time ascertain the character of the tumor. On doing this, it Avas 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, passed through the oblique muscles, carrying Avith it a portion of their tissue, and Avas then deflected upward to the point of exit. The peritoneum Avas probably wounded near the point of exit, AA'hich 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 neAV position, which rendered it irreducible. The patient, at his own request, was returned to duty on October 31st, 1862. Pension Examiner J. AV. Foye reports, under date of April 6th, 1869, that the "ball entered the right chest on its posterior aspect at a point corresponding Avith the angles of the ribs and through the last intercostal space; passing forward it fractured the tAvelfth 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 ensiform cartilage. Through the opening thus made, a process of omentum has 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 noAV a hernia of the lung two inches in diameter at base at site of Avound of exit. The inferior half of the lower lobe of the right lung has undergone partial consolidation from interstitial deposit, submucous crepita- tion, dulness on percussion, and also physical signs in hernial tumor. His general health is much impaired, and he is at present incapable of any manual labor. His disability has increased." >l M.tnili | > 111 GUNSHOT WOUND OF THORAX AND ABDOMEN. HERNIA OF THE LUNG. 517 The sixth case is cited by Dr. B. Howard in his report already printed (p. 513), but in such A-ague terms that it is impossible to identify the patient, or to determine whether the tumor was ligated or excised or reduced without operation: Cask.—A soldier of the Eighteenth Corps received a gunshot Avound of the chest, before the entrenchments at Petersburg, late in June or early in July, 1864. He Avas conveyed to the base hospital at Broadway Landing, in charge of Surgeon II. B. Fowler, 12th NeAV Hampshire A'olunteers. He Avas placed in an hospital tent Avith a patient, Private Williams, Avho was under the charge of Assistant Surgeon B. HoAvard, U. S. A., Avho took notes of this and some of the other cases of chest wounds in the Avard. The only facts reported in regard to this are as follows: "There was extensive pulmonary hernia, which I had fixed so as to secure a permanent plug, with adhesions around the orifice, and also exhausted the pleural cavity of air. This, I 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 Avanting in essential details. It is published by Dr. F. H. Hamilton {op. cit., p. 295). It is interesting as one of the few examples of traumatic pneumocele 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, " Avas called to him the night after the second battle by one of the surgeons. He had been Avounded by a ball on the left side of the thorax, a little below the nipple. The ball had not been found. He Avas lying 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 Avas completely strangulated, being quite black, and insensible to the touch. AA'e 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. AVe 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 Avithout shelter two nights, and during each night he had been drenched Avith rain. In this respect he suffered, however, only in common with at least two thousand other Avounded and dying men. We cannot omit this additional tribute to the bravery of these noble fellows. During all this time, and Ave Avere with them every moment both night and day, there Avas never heard one cry of impatience or one murmur of complaint beyond that which Avas extorted by the agony of suffering. When the Avounded were sent down to the White House, this boy was sent with them, and Ave 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 neA^er 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 operation 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 Avas 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. Cloquet1 explains the mechanism of protrusions of the lung through a wound as follows : The expiratory muscles contracting simultaneously and suddenly 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. JSTelaton2 accepts this explanation, but Malgaigne3 proposes a different hypothesis, believing that in a sudden forcible i Cl.OQUET, Nouveau Journal de Medecine, 1819, T. VI, p. 328. 2NELATOX, Pathologic Chirurgicale, T. Ill, p. 441. 3 Malgaigne, Traiti d'anatomie chirurgicale, 1S59, T. II, p. 209. 518 AVOUNDS AND INJUEIES OF THE CHEST. 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 Avound in the parieties. Chelius1 and M. Morel-Lavallee2 accept neither of these explanations. The latter has written an exhaustive memoir on the subject, which may be studied with great profit. He has collected nearly all the recorded instances prior to the publication of his paper. They number but thirty,3 and only three of these, reported by Bicherand, Cloquet, and S. Cooper, resulted from gunshot wounds. If Guthrie's three cases, of which the particulars are wanting, occurred after gunshot,4 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.5 Fischer, in his recent admirable Avork on the surgical experiences of the Franco-German war, obsen^es that he could learn of no example of this accident among the Avounds 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 Avith auscultation and percussion should serve to establish the differential diagnosis; but mistakes have been committed, as in Ruysch's case. There is but a single instance of successful reduction of a traumatic pneumocele without previous ligation, the case of Angelo.6 A good recovery ensued, though the lung m 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 1 Chelius, A System of Surgery, American reprint of South's translation, Vol, I. p. 497. 2 Mokel-Laa'allee, Hernies dupoumon (Mem. de la Soc. de Chir., 1847, T. I, p. 75). 3 Rolaxdus, of Parma (Chirurgia, T. Ill, Cap. 25, Venet. 1449), was the first author to report a ease of traumatic pneumocele. The tumor was excised, the pedicle left in the wound, and the patient recovered. RosciUS next observed a case, in 1606, remarkable as following a sword-thrust between the fifth and sixth ribs, deeply wounding the lung ; excision ; recovery (Fabricius Hildanus, Opera, Obs. 22 p. 107). G. LOYSEAU (Observa- tions midicinales et chirurgicales, p. 25, Bordeaux, 1617) relates an example, the result of a pike-stab between the third and fourth ribs—reduction after excision. Rhodius, of Padua (Observationum medicinalium Centurise III, 8 vo., Padoue, 1657), cites a case caused by a large sword wound in the side, with recovery after excision. A canula was left in the orifice. AVhen this was discontinued the wound closed. Nicholas TULPIU8, of Amsterdam (Obscrvat. Medicm, T. Ill, p. 124, 3 ed. 1672), described 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 (Obs. 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 eusued and gangrene; but the patient ultimately recovered. Sabatier (Medicine Opcratoire, T. I, p. 206, 2d ed., 1810) mentions a case following a bayonet thrust. Consult also on this subject: BOYER, Traite des maladies chirurgicales, 5me 6d., T. V., p. 619; Hexxex, Principles of Military Surgery, 3d ed. p. 376; Gobil, Du mecanisme de la respiration; quelques mots sur les plaies de poitrine, les causes de Vemphysime et sur celles des pneumoclles, These de Paris, 1858, No. 10; JARJAVAY, De Vinfluence des efforts dans les maladies chirurgicales, Paris, 1847; Richet, A., Traite pratique d'anatomie medico-chirurgicale, Paris, 1857; VERGNE, Hemic du poumon, 1815, These de Paris, 106 ; GRATELOUP, Journal de Vandermonde, T. 53, p. 416; Thyllaye, Traite des bandages et appareils, 3""= ed., Paris, 1815; RicueraND, Nosographie et Therapeutique chirurgicales, T. Ill, p. 300; Richter, Chirurgisch Bibliotek, B. Ill, S. 138; MERCIER, Journal general de medecine, T. 34, p. 378; Boerhaave, in De H AE.v, Institutiones pathologies, T. I, Par. 712, p. 333; Plater Observationes, p. 96; Berthe, Journal de Sedillot, T. XVII, p. 61; Larrey, H., Bulletin de la societe de chirurgie, T. VI, p. 521; and Caspar's Wochenschrift for case of Scharf, 1845; No. 9; Baudens, Clinique des plaies d'armes a feu, Paris, 1836, p. 247; Velpeau, Comptes Rendus de VAcad. des Sci., 1844 ; HlgUIER, Mem. de la. Soc. de Chir., T. 1, p. 194. FiscnER. H., Kriegschirurgische Erfahrungen, Th. I, 8. 124, Erlangen, 1872 ; Larrey, D. J., Mem. de Chir. Mil, T. Ill, p. 91. *J 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 the 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 ofthe lung, on which Cruveiliiier (Anat. Path., Liv. XXI, p. 1), CLOQUET (Nouv. Jour, de Mid., T. A'l, p. 309), and H. H. SMITH (Principles and Practice of Surgery, 1863. Vol. I, p. 499) have treated, as these are foreign to the present subject. Professor Smith has observed 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 Minersville, Pennsylvania, in the Philadelphia Medical Examiner, February, 1855, p. 75. A segment of lung, six by two and a half inches, was removed. There was neither cough nor dyspncea. A rapid recovery ensued. The specimen is preserved. The protrusion is alleged to have expanded during inspiration. The same allegation is made in regard to the behavior of a protrusion of the lung in a case of wound ot the liver and diaphragm, which will be reported farther on. AVe 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. h' Angelo, Gazetta medica di M'luno, February, 1614. 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 parieties,1 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 ofthe conflicting views as to their treatment. Wounds of the Aorta and Cavcc.—Xo instance has been found upon the returns of a wound of the arch or thoracic portion of the aorta ;2 if any such cases occurred, the patients did not survive long enough to receive hospital treatment. This curious exemption from injury cannot depend exclusiArely upon the resiliency of the arterial coats, for the Army Medical Museum contains two specimens3 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,5 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,4 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 wras filled with coagulated blood, and there was copious extra\'asation 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. White5 mentions a case of bayonet stab causing a small puncture in the aorta a few lines without the pericardium. The profuse haimorrhage was promptly fatal. i Surgeon A. B. Crosby, U. S. Y., records (Appendix to Part I, p. 11) a serious case of intermediary haemorrhage (tenth day) from a gunshot wound involving the external mammary (thoracica longa). Acting Assistant Surgeon H. M. Dean gives a fatal case of secondary hsemorrhage from the left subscapular. The specimen, preserved as a wet preparation, is numbered 2835 ofthe Surgical Section. The artery sloughed twenty-flve days after the passage of a musket hall through the axilla. Private F. M. D-----, Co. D, 35th North Carolina Regiment, aged 27 years. Wounded at Petersburg, June 16th, 1864. Bleeding arrested by pressure acd Monsel's salt, July 10th; fatal recurrent hemorrhage on July 12th, 1864. Examples of ligations of the long thoracic and of branches of the circumflex arteries are given in Section III of this Chapter. 2 It is well known that the annals of surgery contain a few such examples. GUATTANI (Auctorum Latinorum de Aneurismatibvs Collectio, Koma, 1745) records the case of a man who survived for eight years an incised wound of the arch. Pelletax describes (Clinique Chirurgicale, Paris, 1810, T. Ill, p. 241) the case of a man who liA-ed two months after a puncture of the aorta near its origin by a foil. Heil (Henke's Zeitschrift, 1837, B. II, S. 459) details a case in which a patient lived twelve months after receiving a stab in the ascending aorta. GREEN, T. M., of Macon, Georgia, publishes (Southern Med. and Surg. Journal 1855) an account he had from Dr. J. B. AA'iley, " a competent and reliable observer," of an autopsy of a man stabbed, a month previously, by a narrow blade, near the origin of the aorta in front. In the Journal de Medecine, T. XL\TI. p. 435, is a similar history, of a man who survived six days. LEROUGE has inserted in Saviard's Observations Chirurgicales, which he edited, a similar case, the patient living eleven days. Cases of rupture of the aorta from external violence have been recorded by MORGAGNI (De Sedibus et Causis, etc., Patavii, 1765, Ep. LIII), Laurexcix (Arch. Gen. de Med., T. VI. p. 301), St. Leger (Montpelier Theses, MS., quoted by Berard), and a specimen of this lesion is preserved in the Museum of St. Bartholomew's Hospital.—Ed. 3 Specs. 910 and 4085, Sect. I, A. M. M. 4 Surgical Memoir on the Wounds ofthe Blood Vessels, New York, 1870, Case XLIX. £• Circular No. 3, S. G. O., 1871, A Report on Surgical Cases, etc., pp. 35 and 99. r>20 WOUNDS AND INJURIES OF THE CITEST. The folloAving is one of the feAV examples of gunshot wound of the descending cava: Cask.—The body of Private John AT. Frey, Co. D, 1st Maryland Potomac Home Brigade, was brought to the hospital at Frederick, Maryland, May 21st, 1664, for burial. He was said to have been shot by a cavalryman in the town in self- defence, Frey having assaulted him, demanded his money, and shot at him twice, whereupon the caA'alryman fired upon him. A great stream of blood is said to have gushed from his mouth as he fell forAArard dead. Necropsy: The ball, supposed to have been from a pistol, entered three-quarters of an inch to the right of the middle line in front, at the edge of the sternum, betAveen the first and second ribs, between the pleural sacs, in the mediastinal space, pierced the vena cava descendens, one inch aboA'e the base of the heart, passed thence through the right side of the right bronchus, severing three rings immediately opposite the point of bifurcation of the trachea, and thus opening a direct communication from the vena cava into the trachea (giving ready exit to a large stream of blood), thence backward and a little downward, perforating the right pleural cavity, and emerged between the seATenth and eighth ribs, grazing the lower border of the seventh, one-quarter of an inch from the spinal column. The lung was not Avounded. The loss of blood Avas the cause of death, which was nearly instantaneous. There was a little clotted blood in the areolar tissue beneath the sternum. Acting Assistant Surgeon John H. Bartholf reports the case. Acting Assistant Surgeon J. B. White1 has reported, since the war, a remarkable instance of this lesion. A musket ball passed through the stock of the musket of the deceased, entered the second right intercostal space, divided the superior cava, traversed the chest diagonally beneath the aorta, emerged through the third left intercostal space, shat- tered the left humerus, and was found in a battered state, thirteen feet from where the wounded man fell. There was scarcely any haemorrhage externally. The left pleural cavity contained a large amount of serum, with jelly-like clots. The hsemorrhage seemed due exclusively to the division of the descending cava. The patient survived long enough to be carried from his post to the hospital close at hand. Fig. 239.—Heart, great vessels, and portion of lung perforated bv a musket ball. Spec. 5567, Suet. I, A. M.M. In the same report (p. 146) Assistant Surgeon S. M. Horton, U. S. A., relates the case of a soldier of the Eighteenth Infantry, with an arrow wound of the descending vena cava. The 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. Although 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 ball 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, 134th New York A'olunteers, aged 20 years, was Avounded at the battle ot Gettysburg, Pennsylvania, July 1st, 1863, by a rifle ball, which entered above the right clavicle, passed under the sternum, and emerged between the fourth and fifth ribs. He Avas treated at the Eleventh Corps Hospital, at Gettysburg. On July 2'M, hsemorrhage took place from the arteria innominata, for Avhich compression was applied. Death followed on July 25th, 1863. The case is reported by Surgeon James A. Armstrong, 75th Pennsylvania Volunteers. CASE.-Private AVilliam A. J------, Co. E, 7th West Virginia Volunteers, aged 26 years, Avas Avounded in the engage- ment on the AVeldon 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 Avound was plugged with lint, and the wounded man avus conveyed to City Point, and thence, on an hospital steamer, to AA'ashington, Avhere he Avas received at Emory Hospital. On October 30th, he was kept quiet, with a simple dressing to the Avound. On the 31st, he was placed under the influence of chloroform, and an exploration was made for the ball, which led to a profuse hsemorrhage. Plugging the Avound Avas the only > Circular No. 3, S. G. O.. 1*71, -1 Report on Surgical Cases, etc., p. 34. AVOUNDS OF THE GREAT BLOOD-VESSELS. 521 alternative. AfterAvards a compress and bandages were applied. On November 1st, tlie patient suffered greatly from dyspnoea caused by hremothorax. The blood effused in the mediastinum appeared to compress the trachea. He died on November 2d, 1-H'>1, five days after the reception of the AA'ound. Tlie autopsy was made by Surgeon N. R. Moseley, IT. S. V, in charge of the hospital. The ball Avas 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 Avas contributed to the Army Medical Museum by Surgeon Moseley, and is No. 3410 of the Surgical series. The clinical notes Avere furnished by the Avard Surgeon, Dr. C. B. McQuesten. 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 be 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.-Private John J. T------, Co. A, 122d NeAV York Volunteers, Avas admitted to the field hospital of the Sixth Gorps, September 20th, 1864, with a gunshot wound of the right side of the neck, received the day previous at Winchester, A'inrinia. When admitted he was very Aveak from haemorrhage from wound and haemoptysis. The Avound was plugged and water dressings applied; anodynes and nutritious diet administered. The haemorrhage and haemoptysis continued; the right side ofthe 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, depressing the sternal portion into the apex of the right lung; the dorsal fragment projected upward Avith a sharp pointed extremity, Avhich perforated the subclavian artery in the second part of its course. The ball then emerged above the spine of the scapula. The mediastinum and the right pleural cavity were filled with blood. The right intercostal spaces bulged outward. The heart was forced over to the left. The riglit lung was collapsed. There were traces of periosteal inflammation on the ante- rior surfaces of both portions of the 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 move- ment of the shoulder, rather than by gradual attrition. The rib is drawn half size in FiG. 240. The specimens were presented by Acting Assistant Surgeon AV. Leon Hammond. 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 are 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 tAvo cases recorded in the next Section : Case.—Private Levi Reglea, Co. D, 16th Pennsylvania Cavalry, aged 25 years, by occupation a farmer, Avas admitted from field hospital, City Point, Virginia, on August 16th, 1864, with a gunshot fracture of the clavicle, first rib, and scapula. The ball entered the right chest one inch from the sternum, and immediately over the clavicle, passing through and splintering it badly, slightly fracturing the first rib, thence through the right scapula, and lodged beneath the infra-spinatus muscles, one inch beloAV the middle of its spine, where it could be distinctly felt. AA'hen admitted, his general health Avas excellent—although anaemic from the loss of the blood Avhich occurred immediately after the injury—and the Avound apparently doing well; both the *Dictionaire des Sciences Medicates, T. II, p. 317. "La chirurgie est impuissante contre les lesions des artdres placees dans lenterieur du crane, de la poitrino et du bas-Arentre. Ces lesions sont esscntiellement mortelles, a cause de rhemorragie effrayante qui s'ensuit, et qui ne tarde pas, 6. epuiser les forces du malade; car les blessures des arteres, loin de s'obliterer d'elles-memcs, tendent tonjours 6. s'agrandir par 1'cffort lateral du sang, et par le dechirement des fibres de la tunique musculeuse." 66 Fig. 240.—Oblique gunshot fracture of right first rib. Spec. 3376, Seet. I, A. M. M. FiG. 241.—Perforation of right subclavian by the sharp point of a fractured first rib. Spec. 3377, Sect. I, A. M. M. 522 WOUNDS AND INJURIES OF THE CHEST. power of motion and sense of touch were Avanting in the arm of the wounded side, thus indicating that there Avas serious injury to tlie brachial plexus. Avhich was further confirmed by frequent complaint of sharp, shooting pains extending doAvn the arm and forearm to the finger ends. It Avas also noticed that the pulse Avas entirely wanting at the Avrist, nor could there be anv pulsation of tlie bracliial artery, indicating that there Avas some serious injury or obstruction to the subclavian artery. Ordered water dressings, tonics, and a good nutritious diet. On September 1st, several spiculae of bone were removed from the wound, Avhich continued to do well up to half-past seven o'clock P. M on September 7th, at Avhich time there was a profuse hcemorrha»-e from the subclavian artery, by Avhich the patient lost fifteen or tAventy ounces of blood in a feAV seconds. Upon arriving at the bedside, the haemorrhage Avas found perfectly controlled by the nurse, to Avhom I had given explicit instructions 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 Avell during the night; in making the changes there Avas no blood lost; stimu- lants were freely administered. At fifteen minutes before twelve in the morning, a consultation was again held, Avhen it Avas decided to ligate the subclavian artery in the second third. Acting Assistant Surgeon Walter F. Atlee, U. S. A., consulting physician, operating. An incision Avas made, but, OAving to the condition of the parts, the artery could not be found. During the operation all compression Avas removed, but there was not the least haemorrhage. After the operation the patient's body Avas cold; the skin moist, Avith 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 hsemorrhage, to make compression. Observations by Acting Assistant Surgeon M. J. Grier, Avho administered an ansesthetic consisting of four fluid ounces of sulphuric ether and two of chloroform: "Pulse, at commence- ment of setherization, 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 Avhich returned to its former condition. Sometimes, when the administration Avas prolonged, it reached the frequency of 160—aHvays falling below 115 in a few seconds after the admission of the atmosphere. He Avas very susceptible to its influence, and was A'ery easily controlled by the occasional application of the sponge. ToAvard the close of the operation, it Avas 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 Avas considerable reaction; the pulse 98, general expression better, and the body much Avarmer. 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 haemorrhage recurred, the patient loosing about the same amount as at first—in a few seconds—before proper compression could be made. The second haemorrhage left him exceedingly 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 Avhich time he began to sink rapidly, Avithout any further loss of blood, and died at eight o'clock. Autopsy elicited the following facts: The clavicle Avas perforated 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 spiculse of bone were driATen into it, plugging it up entirely for nearly two inches; the injured part Avas 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 Avould have been fruitless. The condition of the artery and surrounding parts accounted for the failure to find tlie artery, as well as the absence of pulsation. It was also found that the brachial plexus Avas injured, Avhich accounted for the loss of poAver 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 Avith which the perforation was tamponned would be instantly fatal, and that the Avound approached the innominata so closely that the possibility of placing a ligature on that trunk alone admitted of discussion: Case.—An unknoAvn soldier Avas wounded at Antietam, September 17th, 1862, by a conoidal musket ball, at short range. The missile entered at the junction ofthe inner third with outer two-thirds of the right collar-bone, made a clean perforation in the anterior Avail of the bone, and largely splintered the posterior portion, and emerged above the right scapula. The Avounded man was carried to the field hospital at Keedysville. On admission, he Avas 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 Avas found that a spicula of the clavicle had transfixed the left subclavian. The artery Avas not preserved. The clavicle, represented in FiG. 242, Avas presented to the Museum by Assistant Surgeon S. I- ig. 242. —Longitudinal gunshot fracture ot the right clavicle. Posterior r view. Reduced one-half. Spec. 137, Sect. I, A. M. M. A. StorrOAV, 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 embolism of the axillary. WOUNDS OF THE BLOOD-VESSELS. 523 Wounds of the Internal Mammary Artery.—Ballingall1 tells us that haemorrhage 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,2 whose opinions on every subject connected Avith the surgery of the arteries are justly received with the most respectful attention, is very facetious at the expense of the "theoretical surgeons" Avho 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 follow 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 haemorrhage yet without haemop- 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 Dallas, Georgia, June 3d, 1861, the ball entering over 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. AA'hen admitted he Avas 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 SAveats set in, folloAved, on the 10th, by severe and profuse haemorrhage from the external wound. The patient Avas much reduced by profuse suppuration and pleuro-pneumonia Avhen 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 Avas plugged with lint soaked with solution of persulphate of iron. The haemorrhage was controlled, but the patient sank and died in tAvelve hours. Necropsy : Lungs greatly engorged. The sternum was fractured transversely at junction of middle with upper third. The synchondro- sternal articulations of first and second ribs Avere 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 inominata, right subclavian and carotid, and also the left, Avere all in situ, without perfora- tion; but the internal mammary was found in the mutilated muscular tissue with its mouth gaping; the haemorrhage evidently occurred from the last mentioned vessel. The specimen of fracture of the clavicle and sternum Avas preserved and is represented in the cut, FiG. 243, as sent ^ . ., ,r mi .jji .. n.-, i ■ i _ • i u vi FiG. 243.—Neciosed fragment of the sternum and portion to the Aluseum. The middle portion of the clavicle was excised, probably 0f left clavicle after gunshot fracture. Reduced to one-third- post 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 ofthe fragment ofthe sternum, which had been crushed into the anterior mediastinum. The specimen of the wounded artery Avas, unfortunately, not saved. The osseous preparation was presented by Acting Assistant Surgeon R. 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 mammary artery. He was treated in the field hospital until the 18th, Avhen he Avas conveyed to the hospital at York, Pennsylvania, Avhere he entered on August 23d. There Avas sloughing of the internal mammary artery AA'hich gave rise to intermediary haemorrhage to the amount of thirty ounces. Cold applications and compresses were applied. The case terminated fatally on August 24th, 1863. Surgeon H. Palmer, U. 8. V., reports the case. The following case probably relates to a lesion of the internal mammary, as that is the only branch of the subclavian in the immediate vicinity of the wound described: CASE.-Private Colby Shrader, Co. I, 17th Kentucky Volunteers, was wounded at the battle of Shiloh, April 7th, 1862, by a musket ball, which passed through the right arm into the thorax, lodging on the pleura. He Avas treated at the general hospital at Mound City, Illinois. On April 17th, haemorrhage set in from a branch of the subclavian artery. Professor S. D. Gross tried to ligate the bleeding vessel, but failed. The patient died on the following day. The post-n,ortem examination revealed a cul de sac within the pleura filled with blood. The case is reported by Surgeon E. C. Franklin, U. S. V., and Surgeon H. Wardner, U. S. V. l BALLINGALL, Outlines of Military Surgery, 5th ed., London, 1855, p. 3G0. s GlJTHKIE. Commentaries, dec, already cited, p, 517. 524 WOUNDS AND INJURIES OF THE CHEST. The next case was communicated by Surgeon AV. Clendenin, U. S. V., to Dr. John A. Lidell, and is published by the latter in his valuable memoir on wounds of the blood- vessels:1 Case.— "-------------, Co. A, 45th Elinois Volunteers, was Avounded at the battle of Mission Ridge. The hall struck the edge of the sternum obliquely near its junction Avith the cartilage of the fourth rib, and emerged from the side of the thorax between the third and fourth ribs, a little more than three inches external to the orifice of entrance (on the left side). The wound extended through the parietes of the chest without injuring the lung or pericardium. For iavo or three minutes the haemorrhage was somewhat profuse, but it ceased spontaneously; the degree of shock Avas severe. After the haemorrhage had ceased, the man Avas transferred, in an ambulance, to hospital at Chattanooga. For ten days the case progressed favorably (the Avound looked Avell, but it Avas thought that the patient Avas scorbutic), with every prospect of recovery; but Avhile the patient was in the act of drinking Avater, coughing Avas excited, and haemorrhage supervened. Efforts were made by the attending surgeons to arrest the bleeding, by means of styptics, compression, etc., but Avithout success. No attempt Avas made to place a ligature upon the vessel. The patient died from exhaustion on the night of the twelfth day after he was wounded. There Avere no positive evidences of internal haemorrhage. Post-mortem examination made tAvelve hours after death. A small piece of bone had been gouged out of the edge of the sternum; no fracture of sternum or ribs; pleura costalis cut through to the extent of nearly one inch; internal mammary artery severed; plura pulmonalis and lung uninjured. The pleural cavity contained a clot of blood weighing eighteen ounces. Is it not highly probable that ligature of the internal mammary artery Avould have saved the life of the patient, as a ligature of that vessel was practicable, and the attending circumstances favorable?"* Dr. Lidell, Avho has studied the subject of traumatic haemorrhage with great care, and whose observations on Avhat he aptly designates as "battle-field hemorrhage" I have frequent occasion to cite, makes the following comments on this case : "I believe that the question raised aboAre by Dr. Clendenin, should be answered affirmatively. And Avhy, let me ask, was the A^essel not searched for and tied when the secondary haemorrhage occurred, in this case 1 The reply to this inquiry is contained in the report of the case, and is clothed in these words: " Efforts were made by the attending surgeons to arrest the bleeding by means of styptics, compression, etc., but without success." The truth of the matter is that inefficient means Avere employed for the purpose of arresting the hsemorrhage in this case, and the means that might have proAred effectual in controlling it Avere utterly neglected. The only effect which appears to have been produced by the use of styptics and pressure, was to cause the blood to flow internally instead of externally, and thus to accumulate in the pleural cavity. At the same time the secondary haemorrhage must have been profuse, for it made its appearance on the tenth day, the patient died on the night of the twelfth, and, on making an autopsy, a coagulum weighing eighteen ounces Avas found in the pleural cavity. It Avould have been well for this patient if such agents for the relief of secondary haemorrhage, arterial in character, as styptics and pressure had never been heard of, for then the attending surgeons would haAe been compelled to search for and tie the bleeding Aressel, and thus his life would, in all probability, have been saved. It seems to ine passing strange, that the relation in which the employment of styptics and compression stands to the employment of the ligature for the arrest of secondary haemorrhage, arterial in character, especially if it be profuse, should eATer be overlooked by the surgeon. The reader must pardon me for stating in this place Avhat I believe that relation to be, namely, the former should never be employed for the arrest of profuse secondary arterial haemorrhage, unless the ligature has failed to control the bleeding, or, from some inherent reason, cannot be applied with safety to the patient. Styptics and pressure should be used for the arrest of that form of haemorrhage, not from choice, but as remedies of expediency and of last resort. A single remark should be made with regard to the primary haemorrhage which occurred in the foregoing case. Although it was rather profuse, for two or three minutes,* it ceases spontaneously, because the vessel from which it came (the internal mammary artery) had been completely divided by the projectile, and thus Avas in a condition to permit occlusion of the bleeding orifice to spontaneously occur." i Lidell, J. A., On the Wounds qf Blood-vessels, Traumatic Hsemorrhage, Traumatic Aneurism, Traumatic Gangrene. Surg. Mem. of the AVar of the Rebellion, Xew York, 1870. ; There is probably an error in the military description in this ease. The 45th Illinois regiment, attached to the Seventeenth Corps, was at A'icks- burg at the date referred to, and no corresponding case appears on its hospital record. Lieutenant Jacob Elliott, Co. A, 42d Illinois A'olunteers, was admitted on November 25th, 1863, at Chattanooga, with a gunshot wound of the chest, and died on December 8tli, 1863, with symptoms similar to those described. The cases are probably identical. Surgeon Clendenin was Acting Medical Inspector of the Department of the Cumberland at the time, and appears to have taken notes iudustriously for his own use. The hospital records are very imperfect.—tlD. AVOUNDS OF THE BLOOD-VESSELS. 525 M. Tourdes has written an excellent monograph1 on this subject. He shows from tlie cases he has collected that the lesion occurs Avith equal frequency on either side, that the prognosis is always extremely grave, that more than half of the cases are accompanied by section of the costal cartilages, and that this section always occurs Avhen the vessel is wounded below the fourth rib, the last observation applying particularly to incised wounds. There may be external haemorrhage and internally into the anterior mediastinum, into the pleural cavity and into the pericardium. The diagnosis may be very difficult, for the signs of intrathoracic extravasation are often equivocal. Nelaton2 observes that if the haemorrhage is suspended at the time of examination, anatomical considerations may afford presumptive evidence, and that every deep wound near the margin of the sternum from the first to the seventh rib should be viewed Avith suspicion. External arterial haemorrhage decides the point; but this sign is often absent. The diagnosis may be complicated by bleeding from wounded lung, and the internal haemorrhage then affords no decisive sign, the position of the wound alone suggesting the presumption that the internal mammary artery is interested. The vessel is often of sufficient calibre to furnish blood very freely, and death may result either from the profusion of the bleeding or from asphyxia from haemothorax. Larrey advised to close the wound and leave the care of the bleeding to nature; but there are serious objections to this plan, which Larrey employed indiscrimi- nately for all chest wounds with internal bleeding.3 For example, if the blood passes into the pericardium, the heart's movement is impeded, and soon arrested; if it enters the pleural cavity or mediastinum, there is room for haemorrhage which must be mortal, and if the patient escapes these primary accidents he is exposed to those of putrid decomposition of the extravasated blood. Hence, Ave should prefer, with Velpeau, Marjolin, Gross, and Lidell, to tie the vessel, though this is an operation of extreme and sometimes almost insurmountable difficulty, a point which will be considered in the next Section. Wounds of the Intercostal Arteries.—Gibson4 remarks that " haemorrhage from this source is neither so profuse nor so dangerous as has been commonly imagined," a sentence containing two erroneous propositions; for, as will be presently shown, a lacerated intercostal may pour four pounds of blood into the pleural cavity, and eleven out of fifteen cases reported during the war, or 73.4 per cent., had a fatal result. Didactic authors generally make light of this accident,5 alluding justly to its extreme rarity, usually quoting Boyer's hackneyed witticism of the contrivances for arresting the bleeding being more numerous than the authenticated examples of the lesion, and often concluding by the suggestion of some ingenious method by the author. Baudens,6 however, admits that wounds involving the intercostal arteries are interesting, and, agreeing with him that, though rare, they are important, I shall here enumerate the cases that Avere reported l TOUKDES, Des blessures de Varthre mammaire interne sous la point de vue medico-legal, Paris, 1849, p. 41. 3 Nelaton, Siemens de Path. Chir., T. Ill, p. 450. 3 " II est bienpreferable," he says, " d'abandonner I'hemorrhagie produitepar I'intercostale ou par la mammaire interne, aux seuls efforts de la nature; on ferme laplaie le sang s'accumule dans le thorax, et le poumon n'etant plus comprime par I'air, se dilate de nouveau et annule le vide de la cavite." Clinique Chirurgicale, T. IV, p. 101. 4 Gibson, AV., Institutes and Practice of Surgery, 7th ed., Philadelphia, 1845, Vol. I, p. 112. SBOYER, Traite des mal. chir., 5me ed., T. V, p. 610; DUTUYTREN, Lecons orales, etc., T. VI, p. 355; VlDAL, Traite de Path. Ext, 5™ ed., T. IV, p. 96; Nelaton, Siemens de Path, chir., T. Ill, p. 452; Erichsen, Science and Art of Surgery, Vol. I, p. 438, observes that "the intercostal arteries usually seem to escape; or at least, if wounded, they do not bleed in a troublesome manner;" Legoukst (Chirurgie d'Armee, 2me ed. p. 347), regards most of the cases of wounds'of the intercostal arteries cited by authors as fort contestable ; but admits that the twenty-eight cases collected by Martin (Des Lesions des artlres intercostales, Paris, 1855) leave little room for criticism. t> Baudens, Clinique des plaies d'armes a feu, p. 213. 526 WOUNDS AND INJURIES OF THE CHEST. during the Avar" that were treated by 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 hsemorrhage that have occasioned so many sneers. Case.—Private Oscar A. Barnes, Co. F, 20th New York Cavalry, was wounded, on March 5th, 1864, while sitting in his tent in camp at Nortlnvest 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, passed 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 after the accident the ball Avas extracted, together with several small pieces of bone, through an incision made through the integuments. Haemoptysis and profuse haemorrhage from the intercostal artery having set in, the wound was plugged with lint and cold-Avater dressings Avere applied. The patient was placed on the wounded side and perfect rest was enjoined. Opiates Avere freely administered. Expectorants Avere giveu to assist in relieving the lungs. As soon as suppuration appeared, the dressings were changed, and warm cataplasms Avere applied. The patient continued to expectorate bloody sputa for five days after the reception of the injury, after Avhich he steadily improved. By the end of the month he had so far recovered as to be able to Avalk about. On July 31st, in the following year, he Avas mustered out of service. In April, 1867, the man Avas examined by Dr. George M. Cook, pension examining surgeon at Syracuse, New York, Avho reports him suffering from expectoration and frequent formation of abscess ofthe lung; also from lameness, resulting from a gunshot fracture ofthe metatarsal bone of the left foot, the disability being rated one-fourth for the latter Avound 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. AVilson, 118th NeAV York Volunteers. Case.—Private George. Goodwin, Co. H, 100th NeAv"York Volunteers, aged 19 years, received a gunshot wound ofthe riglit lung during the attack on Fort Darling, May 16th, 1864. He Avas treated for a few days at the field hospital ofthe Tenth Army Corps, and subsequently at the Broad and Cherry Streets Hospital, Philadelphia. On June 23d, a haemorrhage occurred from the intercostal artery. From six to ten ounces of blood were lost, when the haemorrhage was checked by the application of persulphate of iron, aided by a compress. There Avas no recurrence afterward. On the following day, the patient had an attack of rubeola. He soon convalesced and improved steadily, and was soon able to leave for his home on furlough. On August 26th, 1864, he was returned to his command entirely recovered. He is not a pensioner. Surgeon John Neill, U. S. V., reports the case. In the two folloAving fatal cases of haemorrhage 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 ofthe 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 bronchial arteries. He was conveyed by rail to the Third Division Hospital, at Alexandria, where he died from the effects of hsemorrhage, on August 17th, 1862. CASE.-Private Charles Hale, Co. F, 22d Massachusetts Volunteers, Avas Avounded 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. Tavo days after the reception of the injury, the wounded man reached the Finley Hospital, where the bleeding Avas imperfectly controlled by compresses and styptics. The patient died on the following day from the effects of hsemorrhage. Surgeon B. B. Breed, U. S. V., reports the case. In the next three cases the arterial lesions were verified.at the autopsies. Two were complicated by hemothorax : CASE.-Private 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 upward, 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 Patrick Gilroy. CASE.-Private Josiah 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, he was admitted to Asylum Hospital, Knoxville, where he died on December 1st, 1863. 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 inflammation of upper and middle lobe of right lung; lower lobe collapsed; cavity between pleura pulmonalis and pleura costalis filled with blood from a secondary haemorrhage, whieh had been both internal and external. The case is reported by Surgeon C. W. McMilleu, 1st Tennessee Mounted Infantry, by Avhom the autopsy Avas made. In the tenth edition of his favorite Vade Mccum (p. 484), Dr. Druitt, after adverting to Mr. Lawson's statement that " the intercostal artery was not once secured in the Crimean campaign," cites Circular No. 6, K. G. O., 1*65, as authority for the assertion : "the same was the case in the American wars." On page 71 of that report two cases of ligation of the intercostal are referred to. WOUNDS OF THE BLOOD-VESSELS. 527 Case.—Lieutenant John S. Robinson, Adjutant 7th Illinois Volunteers, Avas wounded at the battle of Allatoona Pass, Georgia, October 5th, ISli-l, by a conoidal musket ball, Avhich entered near the inferior angle of the left scapula and emerged anteriorly, fracturing the sixth rib, penetrating the left lung, and tearing an intercostal artery. Copious bleeding from the anterior opening, together Avitli expectoration of blood, folloAved the injury. The haemorrhage was checked by the application of persul- phate of iron. After this, tincture of veratrum viride Avas administered for about tAvo weeks. The patient remained at the field hospital ofthe 4th division, Fifteenth Corps, for over four Aveeks, being greatly debilitated and in bad health at first, but mending sufficiently to bear transportation to a general hospital on November 3d. On the following day, he reached Hospital No. 1 at Chattanooga, Tennessee, Avhere he died on January 4th, 1865. Surgeon T. R. Zearing, 57th Illinois Volunteers, reports the Avound, and Smpgeon J. H. Phillips, U. S. V., the termination of the case. In the seven foregoing instances, haemorrhage was primary in four, intermediary in one, and secondary in one, and resulted from wounds by 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 Avere associated in four cases at least by perforation of the lung. Nearly all of the wounds were in the space bounded by 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 hemothorax, empyema, etc , in the observation at the close of the Chapter.* Specimen 1640, of the Army Medical Museum, is an example of the rare lesion of a rupture of the left subclavian vein.-f Case.—ATalentine K------, commissary detachment, was caught between the buffers of tAVO raihvay cars, July 20th. The humerus, clavicle, and scapula Avere fractured, the neighboring soft parts Avere pulpified, though the skin was unbroken. The left arm became sphacelous, and the patient died July 23d, 1863. Tlie subclavian artery Avas obliterated, Avhere it leaves the first rib. The subclavian vein wras torn and had supplied the blood Avhich distended the soft parts. Assistant Surgeon W. Thomson, U. S. A., presented the specimen and memorandum. Specimen 2721, shows a bayonet wound of the right subclavian, near the innom- inata, opening two-thirds of the cylinder of the artery. It is from a soldier killed at Fort Wagner. Aneurism.—False diffused and consecutive aneurisms were among the secondary conditions rarely observed after gunshot wounds of the thorax.J The following is an example, and a few others will be cited in the next Section. Case.—Private J. H. Carpenter, Co. C, 4th Virginia Cavalry, aged 28 years, was wounded on May 12th, 1864, by a minie" 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, Richmond, Virginia. The patient spat blood at the reception of the Avound and for several days afterwards; and on May 20th, haemorrhage occurred from a branch of * Consult Harder, Diss.de hxmorrhagia arterise intercostalis sistenda, Berolini, 1823; Assalini, Manuale di Chirurgia, Milano, 1812, p. 57; RAVATON, Pratique moderne de la chirurgie, Paris, 1785, Vol. II, p. 130; CHELIUS, Uber die Verletzung der Art. intercostalis in Heidelberger klinischc Annalen, B. I, T. IV ; Gakt, Science and Practice of Surgery, p. 884 ; VEU'EAU, Nouv. £le. de Med. Op., T. II, p. 265; IlAUIUSON, Surgical Anatomy of the Arteries, 4th ed., Dublin, 1839; FRASER, P. A., Treatise on Penetrating Wounds of the Chest, London, 1859, p. Ill; Sanson, Des himorrhagies 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 page 522 be regarded as such. The case reported by Mr. Blenkins (Fraser, op. cit., p. 13), where a ball passed between the right subclavian artery and A-ein, 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 torn blood-vessels. {Traumatic affections of the great blood-vessels of the chest are usually passed over cursorily by systematic authors, and our information concerning these is scattered through theses, monographs, journals, and collections of cases. LEGOUEST (op. cit., p. 333) quotes a unique instance of recovery from a punctured wound of the aorta, observed by Dr. Neil of Bamberg, in 1812 (Henke's Zeitschrift fur Arzn., Heft II, 1837, 1839, and Arch. gin. de mid., 2me serie, 1838, T. II, p. 109). the cicatrix being verified a year subsequently at the autopsy after death from pneumonia. Demme (op. cit., p. 37) saw a young Austrian at the hospital of St. Francis, at Milan, perish from secondary htemorrhage four weeks after the reception of a gunshot injury of the pectoral portion of the descending aorta. Blandin (Anatomic topographique, 2d ed., 1831, p. 287) observed at the Beaujon hospital a young man who survived a short time a pistol wound of the azygos A'ein, near its termina' curve. BRESCHET (Repertoire gineral d'anatomie et de physiologic pathologiqiie et de clinique, T. IV, p. 196) records an autopsy of a youth of twenty-five years, who received in a duel a punctured wound of the azygos vein in the curve it describes before emptying into the cava near the right side of the body of the fifth dorsal vertebra; the patient survived three days. Ti.MiEUS, of Colberg (Responsis medicis et diaeteticis, 1668, C. XVI, quoted by Bonetus, Sepulchretum, Vol. Ill, p. 359 ) records the case of a nobleman, stabbed through the right axilla, between the third and fourth ribs, the blade wounding the pulmonary artery. Frothy blood flowed externally and there were frequent syncopes; but the wounded man lived three days. Specimen 3388, ofthe Surgical Section of the Army Medical Museum, affords a rare instance of compression of the left upper pulmonary vein by a conoidal ball imbedded in the adjacent bony substance. The patient died on the twelfth day from secondary haemorrhage. See Hennen (I. c. 3d ed. p. 97) for a case of rupture of the azygos. 528 WOUNDS AND INJURIES OF THE CHEST. the axillary artery, but Avas controlled by a solution of persulphate of iron. He improved until June 6th, Avhen considerable fever supervened, Avith great pain in the right side and cough; no expectoration; ten grains of calomel and tAvo grains of opium Avere administered at once; the next day he Avas much improved, Avith no pain and less fever; anodynes were given nightly, and he continued to improve until the 18th when the wound had healed. It AA'as then discovered that traumatic aneurism of tlie axillary artery had formed; the pulsating tremor was distinctly felt and easily recognized. The patient remained in hospital until a satisfactory diagnosis could be made. He Avas furloughed on June 27th, 1864. The case is reported by Dr. Dickie, P. A. C. S., in a case-book of the Chimborazo Hospital. Wounds of the Pericardium and Heart.—Some of the cases reported are inter- esting in a medico-legal point of view, others as illustrating the difficulties of diagnosis in this class of injuries, and others again as objects of curiosity or extreme instances of what nature can bear. Wounds of the Pericardium.—A number of examples of gunshot wounds of the pericardium were recorded, in which the patients survived several weeks, and the symptoms were noted with more or less exactitude, and the nature of the lesions were verified by post-mortem examination. Cases of recovery are also noted, in which, if the evidence of this injury is not irrefragable, the reporters appear to have formed the diagnosis with tolerable precision. Some observations of secondary pericardial disease excited by gunshot injury have already been cited (pp. 488, 492) and others will be adduced. The cases tend to confirm the conclusion of Fischer,1—derived from an analysis of fifty-one cases, with twenty-two recoveries,—that wounds of this membrane, unless gravely complicated, are less dangerous than has been generally supposed: Case.—Private Henry C. Vaughn, Co. K, 3d Iowa Cavalry, aged 28 years, was wounded, during General Pleasonton's campaign in Missouri, October 23d, 1864, by a conoidal ball, which entered the ninth rib, just under the left nipple, and emerged about eight or nine inches posterior to the point of entrance, wounding the pericardium in its course. The rib was very much splintered at the point of entrance. He was taken to the post; hospital at Independence, Missouri, where simple dressings were applied. On October 25th, he Avas transferred to the hospital at Kansas City, Missouri. Extensive pleuritis and the decom- posed fluids made the case a very severe one, but the patient bore his extreme sufferings with great fortitude. Death resulted on November 5th, 1864. The case is reported by George H. Hood, Acting Assistant Surgeon. Case.—Private James Ackerman, Co. I, 81st Pennsylvania Volunteers, aged 18 years, was wTounded at Gaines's Mills, Virginia, June 27th, 1862, and admitted to Hygeia Hospital, Old Point Comfort, June 30th, with gunshot comminuted fracture of both bones of the forearm near the elbow-joint; the ball, a minie, having passed through, and then entering the chest, between the fifth and sixth ribs, at the junction ofthe cartilage with rib. Tlie ball could not be found, although search Avas made Avith a female catheter. The track of the Avound was very obliquely through the intercostal muscles toward the apex of the heart. There was dulness of the anterior part of the left chest, and he suffered some pain and dyspnoea. There was no cough nor expectoration. The patient seemed well and comfortable during the day, but at night was always delirious, frequently screaming out that " the rebels Avere after him." The arm was placed in an angular tin splint, and dressed with cold water until the inflammation subsided and suppuration became free. He died July 12th, 1862, At the necropsy, the ball Avas found to have passed along the diaphragm from the place of entrance and entered the pericardium at its apex, and was found lying loosely in that sac, together with considerable serum and flakes of lymph. The surface of the heart was also covered Avith lymph, but its coverings Avere not wounded. The track of the wound had healed, as well as the wound in the pericardium; in fact, it was difficult to detect the spot which marked its entrance. The lungs and liver were healthy. The arm did not exhibit any evidences of repair. The case is reported by Surgeon R. B. Bontecou, U. S. V. Case.—Private Ambrose Burgess, Co. E, 16th Maine Volunteers, was wounded at Fredericksburg, Virginia, December . 13th, 1862, by a conoidal musket ball, which fractured the fourth rib and penetrated the lung; the missile entered the left side about the angle of the seventh rib, taking an upward direction, and emerging at the nipple, between the third and fourth ribs. He Avas received into the First Corps hospital, and, on December 23d, admitted to HareAvood Hospital, Washington- When received he was exceedingly weak; the wound was dressed, and brandy and milk punch freely administered; he continued, hoAvever, to sink, and died December 26th, 1862. Necropsy showed that the ball in its course had opened the pericardium and penetrated the loAver lobe of the lung. The case is reported by Surgeon Thomas Antisell, U. S. V. In the next case it is to be regretted that the opportunity of making an autopsy was neglected: Cask.—Private John A. Clark, Co. I, 3d Maine Volunteers, Avas admitted to Judiciary Square Hospital, Washington, July 10th, 1863, Avith a gunshot wound of left lung, received at Chancellorsville, A'irginia, May 2d, 1863. He Avas discharged the service on February 12th, 1864. There was confirmed tuberculosis; predisposition existing before enlistment; the exciting cause, probably, being the wound; also slightly impaired use of arm. The case is reported by Assistant Surgeon Alexander 1 Fischeu, G., Die Wunelcn des Herzens und des Herzbeutels, in Archiv fur Klinische Chirurgie, B. IX. p. 571. WOUNDS OF THE PERICARDIUM. 529 Ingram, U. S. A. Pension Examiner James B. Bell, Augusta, Maine, reports March 22d, 1864 : "Ball entered one inch above the left nipple slightly to the inside, passed directly through the chest at right angles Avith the Avails; probably Avounded the pericardium, and passed within half an inch of the heart. The disability iioav results from haemoptysis, debility and pain, and may be permanent.'' December IStli. 18,66, he reports: ''Died from haemorrhage of the lungs from the seat of the Avound on June 6th, 1866." In the first of the three succeeding cases of recovery, the diagnosis of wound of the pericardium is more positively made than in the other two: Case.—Private Anthony H. Rabell, Co. I, 83d Pennsylvania A'olunteers, aged 27 years, was Avounded at Spottsylvania, A'irginia, Alay 8th, 1864, by a conoidal ball, Avhich entered left chest four inches beloAV axilla, fractured fourth and fifth ribs, passed through the pericardium, and Avas removed from middle portion of sternum. He was taken to Fifth Corps hospital, and, on May 14th, admitted to HareAvood Hospital, AVashington. Supporting treatment, with rest and quiet, Avas adopted. He Avas furloughed on July 12th, and returned to hospital September 18th; was again furloughed October 30th, and readmitted November 25th, 1864. February 4th, 1865, the wound had entirely healed; he complained of a difficulty in lying down, and required his shoulders to be raised in order to obtain rest; this Avas probably caused by adhesions that had taken place. He was discharged the service June 6th, 1865. The ease is reported by Surgeon R. B. Bontecou, U. S. V. Pension Examiner George S. Gale, Ncav A'ork City, reports, January 1st, 1869, that the ball entered three inches beloAV and back of left nipple, passed up and forward to sternum, injuring the bone, and causing pleuritis and consequent adhesions; there Avas shortness of breathing on severe exercise; the muscular adhesions along the track of the ball, particularly, cripple the action of left arm by rendering the pectoral muscles nearly poAverless. Cask.—Captain AA'illiam McConihe, Co. F, 2d Ncav York Volunteers, Avas Avounded at Chancellorsville, Virginia, May 2d, 1863, by a conoidal ball, Avhich entered the left chest between the fifth and sixth ribs near the sternum, and lodged. He Avas conveyed to the field hospital of the 1st division, Second Corps, where simple dressings Avere applied to the Avound. He was subsequently treated in private quarters in AA'ashington ; Avas furloughed on the llth, and discharged from service May 26th, 1863. Pension Examiner AAr. \AT. Potter reports, August 7th, 1866 : "The pulse is irregular, frequent, and feeble. The peculiar action of the heart and the condition of the circulation lead to the belief that the structure of the pericardium, or the heart itself, was injured by the ball. Disability total and permanent." Case.—Private Calvin F. Jones, Co. H, 36th Illinois Arolunteers, was admitted to Hospital No. 1, Murfreesboro', Tennessee, January 8th, 1833. with a gunshot penetrating Avound of the chest, received at Murfreesboro', December 31st, 1862. He Avas returned to duty February 19th, 1863, and discharged from service April 9th, 1863. Surgeon F. AAT. Lytle, 36th Illinois Volun- teers. Avho reports the case, states, on the certificate of disability, that Jones was Avounded through the left side of the chest, involving the tissue of the left lung, and probably ofthe heart or its coverings, giving rise to palpitation whenever he takes any exercise. Case,—Private AVilliam L------, Co. B, 6th Ohio Cavalry, aged 18 years, was wounded in a skirmish on the Rapidan River, Virginia, September 8th, 1863; one ball entered the left side of the thorax on a level with the fourth rib, posterior to the junction of the cartilage Avith the bone, and emerged eight and one-half inches posterior to the wound of entrance, and three ribs loAver down, fracturing tBe seventh rib anterior to its angle. The second ball entered on a level wTith the tenth rib, passed from behind forward, and fractured the ninth rib about one inch posterior to the junction of the cartilage Avith the bone. He Avas conveyed to AA'ashington, and admitted, on the 12th, to Lincoln Hospital. On admission, he was very pale and ansemic and suffered greatly from his wounds; no emphysema of surrounding integument. Respiration 40 per minute, short and labored. Cough harassing, though no sputa was brought up. No difference in measurement existed betAveen the two sides of the chest; pulse, 108; sleeps poorly; orthopncea prominent. September 17th : It Avas observed that, in addition to the empyema AA'hich Avas present on the left side, a violent pleurisy had attacked the right. The combined sources of depression rapidly exhausted the remaining vital power of the patient. On the 20th, several spicula? of bone were removed from the wound of exit. The coughing would occasionally cause large quantities of purulent matter to be discharged from the wound. The person and surroundings of the patient became offensive in the extreme, rendering him a pitiable object. On the 25th, pericarditis was detected. At this time, he presented the folloAving symptoms : orthopncea; sits up in bed AA'ith head-frame behind him; respira- tion 45 per minute and laborious; face expressive of great exhaustion, pallid; nostrils dilated strongly at every inspiration; wild expression of eyes, pupils contracted. Pulse variable, generally rapid, compressible, and soft. No fever or delirium. Death resulted on October 6th, 1863. Necropsy: Right lung displaced; almost the entire space of anterior part of the thorax occupied by distended pericardium ; left lobe of liver united to omentum by a recent exudation of lymph ; thirty ounces of fluid in right pleural cavity, twenty ounces of pus in left. Right lung covered from apex to base with a layer of yellowish lymph, and in many places erected into trabeculse uniting lung to pleura costalis ; lobes agglutinated together and to the diaphragm ; posterior portion of lung engorged with blood ; left lung semi-solidified and filled Avith minute abscesses. Upper part of pleura covered Avith layer of lymph, loAver part thickened and discolored by pus. Abscess in first lobe completely circumscribing second lobe; the pericardium contains thirty ounces of a clear colored mahogany serum and, together Avith the heart, was covered with a thick layer of yellowish lymph. The liver was somewhat softened. Acini someAvhat indistinct. Spec. No. 1722, Sect?. I, A. M. M., shows a wet preparation of the sixth, seventh, and eighth ribs. The specimen shoAvs firm pleuritic adhesiom. Specimen No. 2243 of the same section sIioavs a Avet preparation of the heart and pericardium. Both of the serous surfaces are shaggy with profuse 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 Avere contributed, with a history of the case, by Assistant Surgeon H. Allen, U. S. A. 67 530 WOUNDS AND INJURIES OF THE CHEST. Wounds of the Heart.—It is Avell known that wounds of the heart are no longer considered, as in ancient times,* absolutely and invariably mortal ; but Ave are still ignorant of the degree of injury the organ may sustain without destruction of life, and can only conjecture the causes of delay in the termination of some rare cases presenting lesions that are generally instantly fatal. The diagnosis is very obscure. Hemorrhage, syncope, pain, dyspnoea, precordial 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 cardiac region without establish- ing 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 Avithdrawal of the extravasation by paracentesis.^ A perusal of the conflicting views of Avriters 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 observed, 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 Avounds 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 jaAV, 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 24tb, 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 Avas made in the lower part of the neck to give exit to the pus, and through this opening the finger could be passed doAvn into the: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 Avalk 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. * HrrPOCRATES: Aphorism XVIII, Sect. 6 ; 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 (De locis affect., Lib. V, cap. 2): " Protinus hominem mori necesse est," and " Igitur, si ad rentrem cordis vulnus aliquando pendraverit, protinus magno cum sanguinis fluore moriuntur, id que precipue, si sinistrie partis venter fucrit vulneratus." t Several authors have made collections of cases of wounds of the heart. The latest and most complete perhaps is by Dr. GEORG FISCHER, of Hannover, who, in an article in von Langenbeck's Archiv fur Klinische Chirurgie, B. IX, H. 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 gunshot wounds; seventy-six, Avith ten recoveries, were contusions and traumatic ruptures. M. Jamain (Plaies du coeur, These de concours pour Vagregation, Paris, 1857, 8vo. p. 100) has analyzed one hundred and twenty-one cases. Dr. Purple (New York Journal of Medicine, 1855, N. S. A'ol. XIV, No. Ill, p. 411), with his Statistical Observations of Wounds of the Heart, has compiled a table of forty-two authenticated cases of wounds of the heart that were not immediately fatal, twelve being injuries from gunshot. Ollivier (d'Augers) records (Diet, de Med., 1834, T. ArIII) fifty-four cases of wounds of the heart, and Sanson (Plaies du coeur, These, 1627, p. 16) enumerates the more important cases cited by his predecessors. DtTUYTREN ^Leipns orales, 2me €d.) refers to fourteen cases, four of which came under his own observation. FOURMER .gives several examples in his Cas Rares (Diet, de Sci. Med., T. IA'). Chastanet (Journal de Medecine Militaire, Paris, 17e^, T. II, p. 377) has collected many cases frcm Bonetus, Morgagni, and others, and recorded five highly iiituresting observations of his own. I have grouped together (Otis, A Report 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 1S70, eighteen being gunshot, two incised, and one a punctured wouncMrom an arrow. WOUNDS OF THE HEART. 531 The next case refers to a patient Avho 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 Avound of the left side in an affray Avith the provost guard at Frederick, Maryland, February llth, 1862, at about 11 P. m. The person discharging the pistol Avas standing Avithin a feAV feet of Thompson, Avho had his left side turned toward him. The bullet entered just over the fourth rib, on a line Avith the anterior fold of the axilla. The patient immediately became much prostrated and speedily unconscious, Avith much jactitation and labored respiration, but no haemoptysis or emphysema Avas observed. He was first seen about 11.30 P. ai. On auscultation and percussion the action of the heart was Aveak and tumultuous, and the left side of the chest exhibited marked dulness, indicating effusion of blood into the pleural cavity. He died at 12.15 A. M. The necropsy, twelve hours afterward, revealed a fracture of the fourth rib, a Avound of the lower and anterior portion of the upper lobe of the left lung, which track Avas found continuous Avith one passing through the left ventricle of the heart about its centre, aud emerging at the right 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 Avas 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 ofthe Avound in the pulmonary tissue, was a mass of coagulum, Avhich explained the absence of haemoptysis and emphysema. The bullet Avas the ordinary conical one used in revolving pistols. A Avet preparation of the heart is Spec. No. 8H7. Sect. I, A. M. M., and Avas contributed, Avith a history of the case, by Assistant Surgeon R. F. AVeir, U. S. A. Circular No. 6, 1865, states erroneously that the patient " survived tAvelve 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 AA'right, Co. C, 4th Regiment, Veteran Reserve Corps, aged 28 years, Avas Avounded at Quincy, Illinois, September 8th, 1864; he Avas assaulted by an intoxicated citizen, Avho 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 Avas cold and almost pulseless, though conscious. He complained of a general sense of indescribable suffering and unquenchable thirst; very little hsemorrhage had taken place. The situation of the balls could not be ascertained. Anodynes, diffusible stimulants, friction, and artificial heat Avere 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 Avas 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, entered the right lung about its middle, passed through it and into the left auricle of the heart, thence through the auriculo-venticular 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 Avere small, which made the track difficult to trace through the different tissues, bo much so that with the utmost care and perseverence no ball Avas found. A pint or a pint and a half of blood Avas 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 Avound of the left breast and shoulder at Spottsylvania, Virginia, May 12th, 1864. He Avas conveyed to the field hospital, where simple dressings Avere applied to the Avound. On May 25th, he Avas 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, Avhence he was discharged from service July 14th, 1865. He died at MattuAvan, A'an Buren County, Michigan, November 22d, 1866. A post mortem examination was made by Drs. David Brown and Nathan AI. Smith. The ball entered- the body between the fourth and fifth ribs on the left side, passed upward and backAvard and emerged between the clavicle and scapula of the same side, Avounding in its passage the anterior surface of the auricle of the heart, producing the appearance of a cicatrix 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 Avere 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 [maculcc albidai) of Rokitanski have been mistaken for cicatrices. 532 AVOUNDS AND INJURIES OF THE CHEST. 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. Diemerbroeck describes (Anat. Corp. hum., Lib. VI, c. I) a man receiving a sword thrust in the chest, and falling dead instantly : Quasi fulniine ictus concidit moxque c.ctinctus 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, Avoorara, or prussic acid, or by a wound of the medulla oblongata. Mr. Poland correctly observes (loc. cit, p. 60S) 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 folloAving 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 Avounds:* Case.—Private Edward Barrett, Co. F, 32d New York Volunteers, was shot by a sentinel at Camp Newton, A'irginia, January 30th, 1862. Medical Inspector Frank H. Hamilton, U. S. A., in a report of the case in the American Medical Times, Xo\. A'lII, p. 193, says : "Assisted by Surgeons Little, BroAvn, 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 eighth rib and carrying some small fragments into the track of the wound. The wound of entrance,Avas rather smaller than an ordinary musket ball, oval, its edges slightly inverted and surrounded with a reddened areola, caused by the integument being slightly abaded or deprived of its cuticle by 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, cylindrical channel, which channel Avas 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 lobe 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 Avound of exit was larger by one-half than the Avound of entrance, someAvhat oval also, the edges not everted, but looking discolored, as if they were blackened by powder. This discoloration AA'as found to be due to a slight extravasation of blood into the tissues under the skin. The heart Avas 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 ofthe heart were not in any instances more than three lines in diameter, and appeared like slits, as if made by a pointed instrument. After this man was shot, he uttered one exclamation and fell apparently dead." Cash:.—" Lieutenant Dennis H. J------, Co. I, 55th Massachusetts Volunteers, was accidentally shot through the heart by a felloAV-officer at YelloAV Bluff, Florida, March 23d, 1864, while they were attempting to escape from an apprehended attack by the rebels. In the hand of the latter officer Avas a Smith and AVesson revolver cocked, which Avas discharged as they both slipped and fell together at the edge of the Avater into which they Avere trying to drag their boat. Jones instantly fell back into the Avater, 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 report 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 supposed rebels proving to be a party 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 Avas manifested, except a sort of groan Avhen the body Avas raised, about five minutes after the accident, which may well be supposed to have been the result of the sudden displacement ofthe large quantity of fluid in the cavities rather than of any conscious voluntary action. The accident occurred at five o'clock p. jr. Necropsy : Rigor mortis slight. Surface of body very pale and rather cool. The single external wound Avas very small and situated two inches below and a little inAvard from the left nipple. There had been no external haemorrhage, but on opening 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 betAveen the fifth and sixth ribs, the ball had passed almost directly backAvard, inclining obliquely toward the middle line, perforating the pericardium and the heart near its apex, so as to leave iavo openings in the pericardium and left ventricle, and had buried itself, base foremost, in the body of the eleventh dorsal vertebra, but Avithout 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 descriptions of sudden deaths from wounds of the heart, consult Helavig (Observationes mcdico-physiese, 4to, Augsburg, I860, Obs. 68); Pltiou (Mimoircs sur les platespenetrantes de lapoitrine, in M6m. de l'Acad. roy. de Med., Paris, 1833, T. II, p, 426)—an armorer falls dead without uttering a word, the heart traversed lengthwise by two pistol balls ; Tijleus (Casus med. prax., Leipzig, 1677, Lib. AT, Obs. 38), subitoque concidens, illico mortuus est; Ollix ikr (I.e., p. 249), three eases of stabs of left ventricle; heart contracted and empty. It is probable that the rapidity of dwath is due not to the profuse bleeding, as SEXAC (Traite de la structure du coeur, Paris, 1749, T. II, p.'371) supposed, but to the (ibstai-l''to the circulation caused by distension of the pericardium as Moit'.AO.M (I. c, cp. 07) explains. WOUNDS OF THE HEART. 533 diameter at its inner extremity, but greatly increased in calibre from within outward so as to be of a conical shape, Avith edges somewhat torn. The columns carnea) on the septum Avere barely grazed in one spot, Avhence it may be inferred that the ventricle was dilated when struck by the ball. The contrast between the two wounds suggests the idea that the inversion ofthe ball may have been caused by the contraction ofthe posterior Avail of the ventricle at the moment of perforation. Both the ventricles were empty.'' Spec. 2639, Sect, I, A. AI. M., is a Avet preparation of the loAver part of the heart; the missile is attached. It was contributed, with a history of tlie 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 en\'elope 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, Avas Avounded at Antietam, Maryland, September 17th, 1862; the ball entered the left chest, passed through the seventh rib, and lodged in the lung; he also received a Avound through the calf of the left leg. He was treated in the field until October 3d, Avhen he was transferred to Frederick, Maryland; in the hospitals of which place he remained until January 27th, 1863, Avhen he Avas returned to duty. He Avas discharged from service at post hospital, Detroit, Alichigan, June 1st, 1863. Pension Examiner H. O. Hitchcock reports, under date of February 12th, 1864, that the ball still remaius in the chest, causing great functional disturbance of the heart, pain, and prostration. Disability total. Cask.—Lieutenant J. H. Allen, Co. G, 15th Arirginia Infantry, received a gunshot wound ofthe left lung, implicating the pericardium, at Antietam, Alaryland, September 17th, 1862. He Avas subsequently retired from service on account of endocarditis, resulting in structural change or organic disease of the heart, Avhich rendered him perfectly unfit for field service. The case comes from a medical certificate for retirement, signed by the members of a Confederate Examining Board. Case.—Private Alexander Smith, Co. I, 100th New A'ork Volunteers, aged 37 years, is reported 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 ball 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 Avith blood. He has distinctly marked hypertrophy of the heart. The throbbing of his heart can be seen across the room. Pulse 92 and irregular. He is emaciated and Aveak, and has laborious breathing, accompanied Avith pain and a distressing sense of suffocation when he exercises. The cough and expectoration undoubtedly 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 organic 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 Avound." His attending physician has attended him for sixteen years and says he was a healthy man. His reasons for disputing the examiner's 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, Alrginia, July 30th, 1864. Being at once conveyed to the field hospital, simple dressings were applied to the wound. On August 2d, he Avas transferred to the hospital at Fort Alonroe; on the 7th, to De Camp Hospital, NeAV York Harbor, and on September 13th, to Satterlee Hospital, Philadelphia, Avhence he Avas returned to duty October 19th, 1864. On October 24th, he entered Augur Hospital, A'irginia, 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 loAver 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. Case.—Private John W. Hopper, Co. B, 79th Indiana Volunteers, was admitted to Hospital No. 1, Louisville, Kentucky, February 28th, 1863, with a gunshot penetrating Avound ofthe chest, receiA-ed at Murfreesboro', Tennessee, December 31st, 1862. He Avas discharged from service March 29th, 1863. Pension Examiner AVilson Lockhart reports, May 15th, 1863: "The ball entered the posterior portion of the left lung and lodged someAvhere in the region of the heart, affecting 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 heart 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 survival of wounds of the heart are mainly instances of stabs by swords or daggers. Pare was one of the first (in 1552, Lib. VIII, c. 32) to refute the preA'alent 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 enough to admit the finger, pursued his opponent, thrusting at liim several times, for two hundred paces, and then fell dead. Among the more interesting cases of wounds by the sword or knife are those recorded by PERCY (Sanson, Obs. 19), where the patient lived nine hours after the right auricle was freely laid open;—by Billy (Zodiacus medico-gallicus, Genevae. Aprilis, 1C80, obs. X), whose patient lived five days after a sword wound of the right auricle. Dr. Billings has recently acquired a copy of this very ■are work, the first medical journal ever published, for the Surgeon General's Library. Billy's case is cited in the Sepulchretum of Bonetus, T. Ill, p. 376, and by Ollivierf?. c, p. 252); by LEaouCE (in his edition of Saviard's Recueil d'obscrvnlions de Chirurgie, 1792, obs. 113), of a soldier who resumed bis avocations on the ninth day after receiving a stab in the right auricle, and died suddenly on the eleventh day at a cabaret. Ollivier regards wounds of the right ventricle as not only the most common but the least promptly fatal. Tor incised or punctured wounds of this cavity, see tho cases 534 WOUNDS AND INJURIES OF THE CHEST. observed in the Army in the five years succeeding the war, eighteen were from gunshot, and two from stabs by knives. One of the latter furnished the Museum with a remark- able 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 were empty, the sac of the pericardium and the mediastinum were filled with blood.1 Fig. 244.—Heart, with an in- cised wound of the right auricle. Spec. 4870, Sect. I, A. M. M. FIG. 245.—Sternum, showing an oblique incision through gla- diolus. Spec 4809, Sect. I, A. M. M. The collection of the Army Medical Museum includes seven' specimens of gunshot Avounds of the heart,—five from pistol balls2 and tAvo from conoidal musket balls,3—a specimen of incised and one of punctured wound,4 and two specimens of cardiac disease resulting secondarily from gunshot injury.5 The duration of life after wound of the heart is not proportionate to the extent of the wound.6 of PANAKOLI (Iatralogismorum seu medicinalium observationes pentacostx quinque, Roma, 1652, Pent. X, obs. 45), life prolonged for four days; and a similar case is reported by JOBERT (Arch. gen. de Med., 1839, p. 209); those of BARTHOLIN (Hist. anat. ct med. rar. Cent. I, Hist. 77); Garmann (Ephcm. nat. cur., obs. 114, p. 228); BOYER (in Fourcroy's Medecine icclairie par les sci. phys., T. II, p. 92), are examples of incised wounds of the right ventricle, in which the patients survived five days. Durande reports (Memoire sur I'abus de Vensevelissement des morts, Strasbourg, 1789) a case in which a patient survived a sword thrust of the right ventricle fifteen days, and N. Muller, according to Tulpius (06s. med., Lib. c. 113), saw a similar case. Moraxd (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 grave symptoms until the fourth day ; the patient died on the ninth. Diemerbroeck's (Anat. Corp. Hum., L. VI) patient 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, Remarques sur les plaies du coeur, Anc. Jour. de M§d., T. XLVIII, p. 244); those of Rot (Bonetus, I. c, T. Ill, p. 357) and Fantoni (Giornale di letterale d'ltalia, T. XXI, p. 148), not until the twenty-third day. Of sword wounds of the left ventricle, not immediately fatal, Courtial (Nouv. obs. anat. sur les os, 1705, p. 138) cites a case in which the patient walked five hundred paces and liA'ed five hours; FE1SI (II Filiatro Sebezio, 1834, p. 37), one of death on the tenth day; FANTONI (I. c, p. 145), one of a soldier who lived seventeen days. 1 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 Medical Museum, Sect. I, Spec. 837, pistol-ball perforation of left ventricle and right auricle,—survived one hour and a quarter; see details in text. No. 2639, a similar specimen, antero-posterior perforation of left ventricle near septum,—instant death; cited in text, also in Boston Med. and Surg. Jour., Vol. LXXI, p. 292. No. 5688, laceration of right ventricle by a ball from a Navy revolver,—death instantaneous. No. 592!(, oblique perforation of anterior wall of left ventricle by a small Derringer ball; cavity not opened (see Circular No. 3, S. G. O., 1871, p. 33) ; suicide,— lived twenty-seven minutes. No. 5949, pistol-shot through right ventricle,—survirved fifteen minutes. "Army Medical 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 Medical Museum, Sect. I, Spec. 4870 ; cited in text. No. 5958, stab near apex in right ventricle by a jack-knife,—ran thirty yards and survived twelve minutes. s Army Medical Museum, Sect. I, Spec. 504; musket ball imbedded between innominata artery and descending cava, provoking pericarditis (Cat. Surg. Sect. A. M. M., p. 453). This is the case referred to in connection Avith wounds ofthe innominata on p. 520. Further than that it was presented by Surgeon D. AV. Bliss, IT. S. V., and that it was renurved 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). uThis was illustrated in Dr. Carvallo's patient (Spec. 5929, mentioned in font-note 2), also by the well-known case of Tour d'Auvergne, first gren- adier of France, who died'immediately from a superficial lance wound of tlie 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 A'entricle, causing instant death. (SUE, Apercu general de la med. leg. In Recucil piriod. de la Soc. de Med. de Paris, T. VIII, 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 the Avound on the duration of life, or the relative frequency of wounds ofthe several cavities, or lodgement of foreign bodies in the heart, or of rupture of that organ. WOUNDS OF THE MEDIASTINUM. 535 Gunshot Wounds of the Mediastinum.—It is certain that even large foreign bodies may penetrate or pass through the mediastinal 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 gunshot fractures of the sternum. The following is an additional case: Case.—Sergeant James G. Powers, Co. C, 57th Massachusetts Volunteers, was Avounded at Petersburg, Virginia, July 30th, 1804, by a conoidal ball, Avhich fractured the fifth and sixth ribs, and carried aAvay a portion of the sternum. He also received a fracture of the middle third of the humerus. He Avas carried to the field hospital of the 1st division, Ninth Corps, where Surgeon AA'. X. AVhite, 57th Alassachusetts A'olunteers, administered chloroform and ether and amputated the left arm at the junction of the middle and upper thirds by circular operation. He died August 16th, 1864. This case is supposed to be the one alluded to by Assistant Surgeon George AI. Met iill, V. 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 OA-er it The broken pieces of bone have been remoA-ed; 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." 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 ofthe skin and sloughing ofthe 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.—No 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 (op. 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 campaign, Matthew and M. Chenu, do not specify any 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. * " Tellement rares," says M. LEGOUEST (op. cit., 2me 6d. p. 336), qu'on n'en possede pas d'exemple authentique : il est juste de reconnaitre qu'elles peuvent passer inapercues, au milieu du desordre des parties voisines qui doit nScessairement les accompagner." Henxen" (op. cit., 3d ed. p. 404) remarks: "Of lesions of the Thoracic Duct, I shall not insult my readers by treating; the uncomplicated injury is barely possible; but art can do nothing_ toward its cure." I cannot conceiA-e 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. Professor S. D. GROSS (op. cit., Vol. II, p. 459) tells us that Blumenbach refers to an instance. I cannot find the reference in J. FuiEDRICH Blumenbach's Medicinische Bibliothek, Gottingen, 1783, in which the author confines himself to anatomical details observed by Sabatier, Hewson, and Pecquet. BOSETUS, however (Sepulchretum, A'ol. III. p. 360), cites from Bartholinus seA'eral examples of wounds of the chyliferous duct, characterized by the escape of a copious white liquid, copiosus albicans humor. Chelius (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 be injury of the most highly important parts, the mortal result is usually not to be prevented." Demme mentions (Studien, 1864, p. 114) that in the Italian AA'ar of 1859 he could learn of no instance of wound of the lymphatic duct. Buescuet, in his article Dichire- ments, in the Dictionary in 60 volumes, T. VIII, p. 140, has collected from Morgagni (op. cit., epis. XVI, § 7), Soemmering (De morb. vasorum absorben- tium corp. hum. p. 52), AA'illis (Pharm. ration.), L,os6ius, Monro, Lieutand, and others, many instances of spontaneous laceration of the thoracic duct, but regards the case recorded by Guiffart as alone well authenticated. All the authors refer to the extravasation of a lactescent liquid in the cavities of the chest and abdomen as the principal sign of this lesion, and generally pronounce it speedily mortal, great emaciation supervening, if death is delayed. 536 WOUNDS AND INJURIES OF THE CHIvST. Wounds of the thoracic portion must be very rare, as only a solitary instance appears on the reports of the war : Case.—Private John Henry Jones, Co. E, 15th New Jersey Volunteers, Avas wounded at Spottsylvania, May 10th, 1864, by a conoidal ball, Avhich entered the right arm posteriorly, passed forward and upward, comminuting and carrying aAvay 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 vertebrae, and lodged against the oesophagus. He was admitted to Lincoln Hospital, at AA'ashington, on May 16th, and died May 20th, 1864. Post mortem examination revealed the course of the hall as described. The apex of the right lung Avas covered with lymph; there was ccchymosed 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 Avas congested, but no clot found in the canal; the kidneys and liver were congested and the gall bladder Avas 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 (I. 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,1 and that they are indicated by pain in the diaphragm, by gastralgia, and generally by vomiting. These symptoms commonly subside in ten days or a fortnight, but are reechoed by more persistent 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 hsematosis, digestion and respira- tion would be observed ; but the complicated nature of these injuries appears to forbid any precise analysis. Dr. S. AV. Mitchell, in his recent instructive monograph,2 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. Wounds of the Diaphragm.—The r'ecords contain references to one hundred and twenty cases of wounds of the diaphragm that came under treatment. Some of them have been described3 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 believed, rarely heal, and leave always a liability to hernial protrusion.4 i Baudkxs, Cliniqn*~des plaies d'armes a feu, Peris, 1836, p. 249. 2MITCHELL, S. AV., Injuries of the Nerves and their Consequences, Philadelphia, 1872, p. 212. 3 See ante, cases of Perrin, p. 514, STOLPE, p. 515, Boavman, p. 516, Sheridax, p. 516. These four arc examples of diaphragmatic hernia. For bayonet wound of the diaphragm, see case of Rae, p. 468. For examples of recovery after gunshot wounds of the diaphragm, see cases of Hoi'E, p. 480, C'OLLIXS, p. 471. See also case of Ackeumax, p. 528. 4Consult, on this subject, GUTHRIE (Commentaries, I. c, p. 499), Baudens (I. c, p. 301), FRIDERICI, De dinphr. ex vulnere Ixso, Diss. Jenae, 1671; Schexk, De diaphragmatis nat. et morbis, Diss. Jenae, 1671; Nelatox, Elem. de path, chirurgicale, T. Ill, p. 483; Legouest (I. c, p. 363); Ettmullku, Diss, de vulneribus diaphragmatis, Lipsiae, 1730; PERCY, Diet, de Sci. Med., T. IX, p. 214; CLOQUET, Did. de Med., T. X, p. 25!); Deveegie, Medicine legale, 3"" ed., 185,', T. II, p. 35; Desault, Jour, de Chir., T. Ill, p. 9; Mhktexs, Vulnus pectoris complic. cum vulnere diaphragmatis, Strassburg, 1758 ; Caa'aliku, Observations sur quelques lesions du diaphragm, These de Paris, No. 362. OPERATIONS. 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 cases1 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 hsemorrhage, 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 Avhich 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 ;2 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 1 The operators, dates of operation, and duration of survival were : Mott, in 1818, 26 days ; Graefe, in 1822, 67 days; Norman, in 1824, 60 hours; Arendt, in 1830, 8 days; Bland, in 1832, 8 days; Hall, in 1833, 3 days ; Dupu'ytren's, Parisian colleague, in 1834, — days ; Lizars, in 1637, 21 days ; Hutin, in 1842, 12 hours; Cooper, in 1859, 9 days : Cooper, in 1860, 34 days; Pirogoff, about the same time [Grundzuge der Allgemcinen Kriegschirurgie, Leipzig, 1864, p. 459], 24 hours ; Gore, in 186-, 17 days ; Smyth, in 1864, recovery. In four cases the artery was exposed but not ligated because ofthe diseased condition of its coats, namely: by Porter, in 1831 (Dublin Jour., 1832, Arol.); by Key, in 1832, death on the 23d day (Crisp, On Diseases of the Blood-vessels, p. 206) ; by A. Post, and by Hoffman. The brachio-cephalic artery is said to haA'e been tied twice by Bujalsky (Tabtilx anatomico. chirurgicseligandatum ateriarum majorum exponentes, St. I'otersburg, 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, Operationcs lithotomite. exponentes, is in the Office library. 21 presume no one will question, at this date, that Hutin should have attempted to place double ligatures at the seat of puncture in tho axillary, and, failing in this, to have amputated the arm. 68 538 WOUNDS AND INJURIES OF THE CHEST. life, and that the solitary success achieved by Smyth was attained by the removal of the sources of recurrent haemorrhage. The operation suggested would not be more formidable, so far as the apprehension of shock is concerned, than the ablation of the arm Avith the scapula, or Avith the cla\Ticle, operations that.have been successfully accomplished for tumors of those bones. In a lean patient, if the bleeding could be stanched long enough to pass a ligature about the brachio cephalic, the remaining steps of the operation Avould 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 haemorrhage in one instance, tAvice 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.—Corporal G. M. Caughman, Co. K, 13th South Carolina Eegiment, aged 25 years, was wounded July 3d, 18G3, the ball passing through the upper part of the chest, Avounding the lung and the subclavian artery where it passes between the clavicle and the first rib. The subclavian Avas ligated on the inner side of the clavicle.. The operation was successful; the patient Avas furloughed, with the wounds entirely healed, but Avith 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.1 Case 2.—Corporal Davis J. Palmer, Co. C, 8th Iowa Volunteers, aged 20 years, received a gunshot-wound of left axilla at Shiloh, Tennessee, April 7th, 1862, the ball entering two inches below the clavicle, traversing pectoralis major muscle and lodging near scapula, after wounding the axillary artery; haemorrhage occurred on April 8th. He was admitted to Floating Hospital Empress, on April 14th, and on the same day a tumor three inches in diameter, pulsating Avith 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 ofthe trapezius Avas made, the border of the scalenus anticus was found, and the left subclavian Avas ligated, with the greater portion of its sheath, chloroform having been administered. The condition of patient at time of operation was anaemic. Bottles of hot Avater Avere applied to relieve the excessive numbness of the left arm, and nourishing diet was given. He was transferred to general hospital at Keokuk, Iowa, April 20th, 1862. He Avas, on June 16th, 1863, mustered in as captain, Co. A, 25th.Iowa A'olunteers, and mustered out as lieutenant-colonel on June 6th, 1865. The ligature came away on May 20th, thirty-six days after the operation, and he Avas furloughed on May 29th, 1862. He was discharged the service on September 6th, 1862. The case is reported by the operator, Surgeon Thomas F. Azpell, U. S. V. Examining Surgeon AVilliam McClelland, AVashington, IoAva, reports, May 21st, 1867: " Ball entered near collar bone, and was afterwards cut out at the lower edge of the shoulder blade. The muscles of the shoulder and arm are greatly absorbed, and, in consequence, the arm is very weak. He is one-half incapacitated from performing manual labor. Disability one-half and temporary. Still a pensioner in 1872. Case 3.—Private John T. Endy, Co. F, 5th North Carolina Eegiment, aged 23 years, was wounded July 2d, 1863; the ball entered one and a half inches beloAV the left scapula, ranged forward, and lodged. There Avas great tumefaction and effusion about the shoulder, while the AA'ound under the deltoid region was filled with clots of blood. . Hsemorrhage superA'ened on the morning of the 16th, but Avas controlled by pressure and styptics; it occurred again the evening of the same day and was controlled in like manner. On the morning of the 17th, very profuse haemorrhage took place, which could only be controlled by pressure over the subclavian artery. An exploration of the wound failed to discover the bleeding vessel, and it was determined to ligate the subclavian in its third division. The operation was performed without any untoward accident, but, while the haemorrhage was lessened, the flow of blood could not be entirely arrested in the wound, even Avith the assistance* of styptics ; it was, therefore, decided to ligate also the supra-scapular artery, \vhich had been exposed in the operation; this being done the haemorrhage immediately ceased. The patient Avas put to bed Avith the arm warmly wadded, and at night there Avas sufficient temperature in the parts beloAV the seat of ligature. The ligature from the supra-scapular came aAvay on the tenth day and that from the subclavian on the thirteenth day. The patient got well Avithout any bad symptom, and Avas furloughed August :51st, 1863. The ball was not discovered. Surgeon H. L. Thomas, P. A. C. S., reports the case.2 ' Thomas, II. L., Confederate States Medical and Surgical Journal, A'ol. I, p. 185. -Ibid., p. 18o. It wquld be of interest to have the names of the operators. LIGATIONS OF THE SUBCLAVIAN. 539 Cask 4.—Private Charles AViggins, Co. G, 9th New York Heavy Artillery, aged 21 years, Avas Avounded at Petersburg, March 25th, 1805, by a minie ball, Aviiich entered one and a half inches below the clavicle, and emerged near the upper third of the axillary border of the scapula. He was admitted to Finley Hospital, at AVashington, Alarch 29th. Intermediary haftnorrha e from the axillary occurred; and, on May 7th. the outer third of the right subclavian artery Avas ligated. He progressed favor- ably, and Avas discharged from service on August 3d, 1865. The case is reported by Surgeon G. L. Pancoast, U.S. V. Pension Examining Surgeon Ai. D. Benedict reports, August 2d, lSlK): "musket ball through right shoulder and axilla, resulting in partial paralysis of corresponding arm and hand ; limb is entirely disabled at present; will probably improve. Disability total. Duration tAvo years." In 1872. this pensioner's name Avas still borne on the rolls. Cask 5.—Sergeant James Hickey, Co. M, 1st NeAV York Veteran CaA'alry, aged 28 years Avas Avounded at Piedmont, A'irginia, June 5th, 1801. Ball entered an inch below the centre of the right clavicle and passed directly through. On September 17th, he Avas admitted to Camp Parole Hospital, Annapolis, Maryland. There Avas aneurism of the axillary, subclavicular portion; bruit distinct; rough feeling to the touch. On September 19th, ligation of subclavian artery in its third portion Avas performed: chloroform and ether Avei e administered; the condition of the patient was very good. On October 5th, the Avound had nearly healed; the ligature had not come away; the arm and hand Avere cooler than natural; the aneurism was as distinct as before the operation; no pulse could be detected in the brachial, radial, or ulnar. He was transferred to Rulison Hospital, February 19th, 1805, whence he Avas discharged from service on Alay 30th, 1865. The case is reported by the operator, Surgeon F. H. Gross. U. S. X. Pension Examiner T. B. Beed, of Philadhlphia, May 21st, 1867, reports: "No use or poAver of right ami. Circulation very feeble, and atrophied muscular condition. Man is disabled from all labor by the aneurism alone. General health impaired. Is liable to rupture and death by any exertion." In 1872, this pensioner's name was still on the rolls. Ligations of tho subclavian in its third portion, for wounds of the axillary or the extreme distal portion of the subclavian, or for injuries of the vessels resulting in ulceration or gangrene and intermediary or secondary hsemorrhage, such ligations, as applications of the methods of Hunter or Anel (for the vessel was often tied \Tery near the bleeding point) to wounded arteries, were quite often and very unsuccessfully employed. In the five following cases, the right subclavian Avas secured : Case 6.—PriATate Harrison McMiehael, Co. A, 57th Indiana Volunteers, aged 19 years, received a gunshot wound of the right side of the chest, at Franklin, Tennessee, November 30th, 1854, the ball passing beneath the clavicle and injuring the coats of the axillary artery. He was admitted to hospital at Nashville December 1st, 1801. The artery soon sloughed off at the junction of the axillary Avith the subclavian, causing haemorrhage and threatening immediate death. On December llth, chloroform Avas administered and the subclavian artery was ligated. He was treated with stimulants, but died from secondary haemorrhage December 16th, 1864. The case is reported by the operator, Surgeon S. E. Fuller, U. S. V. Case 7.—Private Thomas J. Conterman, Co. G, 48th New York Volunteers, aged 21 years, Avas wounded at Fort Darling, Virginia, May 9th, 1864, by a mini6 ball, which entered the right axilla, two and one-half inches above lower border of pectoralis major, and emerged two inches above posterior fold of axilla. He was admitted to St. Joseph's Hospital, New York City, on May 23d, and on Alay 31st, the right subclavian artery Avas ligated at outer third. At the time of operation the parts Avere SAVollen, sloughy, and painful, but sound at seat of ligation, patient feeble from loss of blood; pulse, 130; skin hot. Haemorrhage recurred three times; the patient did not improve in any respect. On June 2d, chloroform was administered and a branch of axillary plexus of veins Avas ligated by division of pectoralis major. He died June 2d, 1864, three hours after the second operation and fifty hours after ligation of subclavian artery, from exhaus- tion. On autopsy, the subscapular artery Avas found to have sloughed three-fourths of an inch from origin; the axillary vein and an adjacent vein also. A wet prepa- ration of the right subclavian artery is represented in the Avood-cut (FiG. 246). It was contributed, with a history of the case, by the operator, Acting Assistant Surgeon George F. Shrady. Fig. 246.—A posterior view of the innominata, right common carotid, and subclavian, with a ligature on its outer portion, ofthe axillary and some of its branches. There are anomalies in the origin of the vertebral and thyroid axis and the axillary divides into brachial aud ulDar. The subscapular has sloughed. Spec. 4331, Sect. I, A. M. M. Case 8.—Private Edwin Pfluger, Co. H, 2d Pennsylvania Heavy Artillery, aged 28 years, was wounded before Petersburg, June 27th, 1864, by a conoidal ball, which entered the right shoulder posteriorly and perforated the scapula just below the spine. He was admitted to the hospital at Fort Monroe on July 4th. On July 14th, intermediary haemorrhage, to the amount of three pints, occurred. Assistant Surgeon Edward Curtis, U. S. A., ligated the axillary artery in its continuity, not far beloAV the clavicle ; haemorrhage recurred on the 24th ; and, on the 25th, Dr. Curtis ligated the subclavian artery in the third part of its course. Haemorrhage recurred on the 27th, from the distal end of the axillary artery, but it Avas arrested by plugging the wound. The case terminated fatally on August 10th, 1861. • 540 WOUNDS AND INJURIES OF THE CHEST. Fig. 247.—A posterior view ofthe distal end ofthe anonyma, the origin of the common carotid, and the right subclavian divided by a ligature in its third portion. The subclavian had been divided longitudinally behind to display the small fibrinous clot. Spec. 2812, Sect. I, A. M. M. Cask 9.—Private J. W. King, Co. C, 29th North Carolina Eegiment, Avas Avounded at Chickamauga, Georgia, September 19th, 1~(1:>, the ball passing through the right shoulder joint, fracturing and detaching the head of the humerus. The missile entered near the coracoid process and passed out over the spine ofthe scapula. The accident Avas folloAved by a high degree of SAvelling and inflammation, extending from the seat of injury down the forearm ; suppuration copious and offensive, with high irritative fever. On October 10th, there Avas haemorrhage from the anterior Avound, which Avas arrested by pressure; on the llth, the hamorrhage recurred copiously from both wounds, and the subclaA'ian Avas ligated in its external third. There Avas no further haemorrhage, but gangrene attacked the wound of operation on the 20th, and the patient died the next day. The case is reported by Dr. II. L. Thomas. Case 10.—Sergeant Henry B------, Co. D, 12th NeAV Hampshire Volunteers, aged 21 years, was admitted to Emory Hospital, AA'ashington, June llth, 1804, AA'ith a gunshot wound of the right shoulder, received at Cold Harbor on the 3d. A minie ball entered below the clavicle and passed out at the anterior aspect of the arm, about three inches beloAV the shoulder joint. He also received a flesh Avound of the upper third of the right thigh. The patient had a haemorrhagic diathesis, Avhich his father stated was hereditary in the family—for example, a simple cut of the finger would cause^ haemorrhage to such an amount as to endanger life. Under these circumstances, and upon consultation, it Avas decided after his first attack of haemorrhage to ligate the subclavian. The operation Avas successfully performed on June 17th, by Surgeon N. R. Moseley, U. S. X. Strong hopes Avere entertained of the patient's recovery; but, unfortunately, in addition to his peculiar diathesis, he had a severe cough, Aviiich it seemed almost impossible to relieve or arrest temporarily. On the morning of the 29th, while in conversation, the artery gave way, and death was almost instantaneous from haemorrhage. The adjacent Avood-cut represents the specimen, Avhich was prepared and presented, with the notes of the case, by Surgeon N. K. Moseley, the operator. I consists of a portion of the innominata and of the subclavian and carotid, and is figured in the Avood-cut (Fig. 247). There were slight fibrinous exudations on either side of the point at which the ligature cut through. The commencement of the vertebral and superior intercostal are shown, and the thyroid axis and transversus colli. In the three following cases the left subclavian was tied: Case 11.—Private Dexter AV. I------, Co. B, 6th Connecticut Volunteers, aged 35 years, was admitted to hospital at New Haven, Connecticut, June 13th, 1864, with a gunshot wound extending under spine of left scapula, forward and inward tOAvard cavity of the chest, received at Bermuda Hundred, Virginia, May 20th, 1864. There was gangrene in the Avound the size of an orange, extending deeply into the tissues; secondary haemorrhage occurred from branches of the axillary artery. On June 18th, the subclavian artery Avas ligated, in the outer third. On June 20th, there were chills, followed by aH the symptoms of pyaemia. He was treated by the administration of morphia and whiskey, and bromine Avas applied to gangrenous parts. He died on June 24th, 1864. The wood-cut (FiG. 248) represents a wet preparation of a section of the left subclavian. The clot is well shoAvn. Contributed, Avith a history of the case, by Acting Assistant Surgeon T. B. ToAvnsend. Case 12.—Private J. H. Henderson, Co. F, 57th Pennsylvania Volunteers, Avas Avounded at Fair Oaks, Virginia, May 31st, 1862, by musket ball, Avhich entered the left arm in front ofthe insertion of the deltoid and passed out at the posterior border of the axilla. He was admitted to Judiciary Square Hospital, AVashington, on June 4th. The humerus was uninjured; arm much ecchymosed. June 19th, there was copious haemorrhage from the anterior Avound. Or. June 23d, the left subclavian artery was ligated, in the outer third. At the time of operation there Avas great prostration from the hsemorrhage. No unfavorable symptoms till June 26th; then great mental excitement, patient asserting he was dying; was partially quieted by anodynes; no chills. He died from pyaemia June 27th, 1862. The case is reported by Acting Assistant Surgeon Francis H. Brown. Case 13.—Private John Hites, Co. C, 7th Iowa Volunteers, aged 19 years, received a gunshot Avound of the left axilla at Corinth, Mississippi, October 3d, 1862. He was admitted to the City Hospital, St. Louis, on October 15th, where, on October 22d, intermediary haemorrhage occurred and the subclavian artery was ligated, in the third portion of its course. Haemorrhage recurred on October 29th, and the patient died October 31st, 1862. The case is reported by the operator, Surgeon John T. Hodgen, U. S. V. In the two following cases the artery was secured, according to the now little employed method below the clavicle, at the extreme distal portion of its course: Case 14.—Private Benjamin Brannan, Co. B, 61st Noav York Volunteers, aged 22 years, received, at Spottsylvania, May 8th, 1864, a gunshot wound of the right shoulder and arm. He was admitted into the Campbell Hospital, Washington, on May 13th. Secondary haemorrhage to the amount of forty ounces occurred on May 29th,'and Surgeon A. V. Sheldon, U. S. V., ligated the subclavian artery in its continuity beneath the clavicle. The patient did well until June 15th, Avhen the ligature came aAvay and slight hsemorrhage occurred, which avus arrested by compression, but recurred, and he died on the 19th. The case is reported by the operator. Fig. 248.—Coagulum in left subclavian six days after ligation. Spec. 4089, Sect. I, A. M. M. LIGATIONS OF THE SUBCLAVIAN. 541 Cask 15.—Color Sergeant Smith E. Dow, 4th NeAV A'ork Volunteers, aged 2rt years, Avas AVounded at Petersburg, Virginia, October 27th, 1864, by a ball, Avhich entered near inferior clavicular margin, passing inward, downward, and backward, divided into two parts, and emerged near superior angle of right scapula. lie Avas admitted to the Fairfax Seminary Hospital, Virginia, November 2d, 1804 ; there Avas extensive sloughing and suppurating, and on November 5th the right subclavian artery was ligated below clavicle. He Avas feverish and weak from hiss of blood. Patient did Avell for ten days after the operation, when he was alloAA'ed to sit up. Ligatures removed; profuse haemorrhage, four ounces; compression made. Eleventh day, haemorrhage of four ounces; decided to ligate. Parts indurated; on pulsation artery could not be seen at its normal position; compression continued. He died November 18th, 1864, from recurring haemorrhage, the artery having divided at point of ligation. Necropsy: Parts of the wouhd indurated; almost impossible to trace the course of arteries and veins; bony deposit below clavicle, implicating arteries and veins; subclavian artery divided at point of ligation; ends contracted two inches; upper end drawn iuAvard from its normal position two inches. The case is reported by the operator, Assistant Surgeon Harrison Allen, U. S. A. Traumatic Aneurism.—The following case of gunshot wound of the axilla was complicated by traumatic «Vi ii'used aneurism, on account of which ligation of the subclavian was performed at a period of two hundred and sixty days from the date of reception of the injury. The distinguished operator vainly endeavored to carry out the correct rule of practice by ligating the axillary: Case 16.—Corporal Thomas Ward, Co. C, 2d Pennsylvania Reserve Corps, received a AA'oundof the left axilla by a mini6 ball, at Alechanicsville, A'irginia, June 25th, 1862. He Avas admitted to hospital at AVashington, July 4th, 1862, and transferred to Philadelphia, September 2d. He AA'as admitted to Christian Street Hospital on September 3d; on admission, both orifices of Avound Avere healed. February 1st. 1863. SAvelling commenced in axilla. March 1st, there Avas some fluctuation in tumor; no bruit or thrill; an exploring needle revealed only extravasated blood; integuments discolored. March 14th, profuse arterial bleeding. On Alarch 15th, the left subclavian artery Avas ligated, in its outer third, and] an unsuccessful attempt Avas made to ligate the axillary, and a large quantity of extravasated blood Avas turned out of the axilla. At the time of operation there was excessive pain in the arm, ascribed to lesion of the brachial plexus; hypodermic injections of morphia had no effect, and cold-Avater dressings gave more relief than anything else; there was extreme prostration from haemorrhage. Reaction never fairly set in, and he died on March 17th, 1363. The operation Avas performed by Dr. S. D. Gross, Professor of Surgery in Jefferson Aledical College. The case is reported by Acting Assistant Surgeon John J. Reese. In the following cases of circumscribed aneurism, resulting from gunshot injury, the subclavian Avas tied unsuccessfully on the thirty-eighth and the seventieth days from the reception of the original wound : Case 17.—Corporal AVilliam Broderick, Co. C, 199th Pennsylvania A'olunteers, aged 39 years, Avas admitted into Hampton Hospital, Fort Monroe, on April 5th, 1865, with a gunshot wound of the left shoulder, received April 2d, 1865. Ball entered just below clavicle, outer side, passing through the thorax and emerging at the inferior portion of the scapula. Secondary haemorrhage occurred several times ; the aneurism Avas three inches in diameter. On May 30th, the left subclavian artery was ligated in the external third. The aneurism decreased very rapidly after the operation, and on July 8th, only a slight fulness was observed in the place of the aneurism; the Avound united, except an inch at the external end of the incision. On the ninth day profuse haemorrhage occurred, filling the original sac and the tissues in front ofthe shoulder. He died from exhaustion June llth, 1865. Post mortem shoAved ligature yet on the artery, and a clot in the vessel on either side of ligation, not very firm nor adherent to inside of artery; one inch of axillary artery gone; no fibrinous deposit in the aneurismal sac; blood clot soft. The case is reported by Assistant Surgeon E. McClellan, U. S. A. " Case 18.—Private J. B. Click, Co. G, 5th Virginia Cavalry, was wounded, November 8th, 1863, at Brandy Station, by a minie ball, which entered the anterior fold of the right axilla about its middle, ranged through the axillary space, and Avas removed by counter incision between the spinal column and the vertebral border of the scapula. When admitted into the hospital, November 9th, the day after the reception of the Avound, there was no indication of any more serious injury than is usual in flesh Avounds. All of his symptoms Avere favorable, and he rested easy till the fifth day, when he complained of very severe pain, extending from the shoulder to the tips of the fingers. This was accompanied by sleeplessness, a costive state of the bowels, and great weakness. He continued suffering more' or less in this Avay till December 3d. A small, hard, and circumscribed tumor Avas then detected for the first time under the tendon ofthe pectoralis major. This tumor increased rapidly in volume. On the 6th December, fluctuation and also pulsation became evident, and, on auscultation, a double sound similar lo the bellows murmur of the heart. No thrill Avas perceptible either in the tumor or the radial artery. The symptoms were still too obscure to determine accurately its character, and opinion Avas very much divided. Some maintained strenuously that it Avas an abscess, from the very feeble pulsation and entire absence of all thrill, and also from the fact that pressure upon the subclavian over the first rib failed to diminish the size of a tumor. Others were disposed to regard it as an arterio-venous aneurism; and others again asserted that it was an extravasation of blood, produced by ulceration of the coats of a vein. On the 9th December, all pulsation in the tumor and in the brachial and radial arteries ceased suddenly. The bellows murmur also ceased. This was evidently due to great pressure upon the axillary artery by the greatly increased size of the tumor. An exploring needle was now introduced, and a few drops of grumous blood escaped, but no trace of pus could be detected. The diagnosis being still doubtful, he was suffered to remain until the 15th. A trocar Avas then introduced, when, as before, dark blood only escaped. It Avas then determined to ligate the subclavian. The operation was performed on the 16th, by Assistant 512 WOUNDS AND INJURIES OF THE CHEST. Surgeon J. C. Baylor, the artery being tied in the third part of its course. After the application of the ligature, a consultation was held as to the propriety of opening the sac, which, by the great pressure it exerted over the axillary plexus of nerves, was rapidly exhausting the patient. It was decided to lay it open by a free incision. This Avas accordingly done, and an immense clot exposed. On passing the finger into the clot, the artery spouted, and profuse haemorrhage ensued that threatened a speedy termination to life. The clot was quickly turned out and several attempts made to secure the bleeding vessel, but they proved ineffectual, and as a last resort the tampon was used. The haemorrhage Avas thus arrested, but the patient Avas left in an exceedingly feeble and prostrated condition. Stimulants were freely administered, but he sank rapidly, and died in eighteen hours after the operation. An autopsy held the next day reA'ealed a lesion of the axillary artery just beloAV the origin of the subscapular. The ligature was found firmly fastened around the subclavian, the inner and middle coats of which AA'ere divided. But, as a week had elapsed since all pulsation had ceased in the tumor and in the arteries below it before the operation was performed, time had been given for the establishment of anastomotic communication, and hence the haemorrhage." Surgeon P. F. Browne, P. A. C. S., reports the case.1 Case 19.—" Private K. P. Eahea, Co. B, Jeff DaATis Legion, aged 29 years, very large and muscular, Avhile acting as scout near the Peaks of Otter, on June 14th, 1864, Avas shot with a mini6 ball through the left axilla;, haemorrhage represented as very profuse, notwithstanding Avhich he rode eight miles, closely pursued for three miles. He spent several days in a private house, and was admitted to Campbell's Hospital on June 19th. The ball had passed through the tendons of the pectoralis major and latissimus dorsi, severing the axillary artery, apparently in its lower third; the haemorrhage had ceased spontaneously on the first day and had not recurred ; pulse imperceptible; very great SAvelling and hardness in the axilla, extending to the elbow, Avith great discoloration from ecchymosis; severe pain from shoulder to hand, with a sense of numbness, but not complete loss of sensation; the capillary circulation but little impaired, and temperature normal; when he*sat up the veins ofthe forearm became much distended; wounds healthy and healing; pulse in the right arm feeble and frequent—aboA'e 100; appetite feeble; he slept but little, and then from the influence of opium. He continued in the same state, with little variation, for three weeks; some- times Ave thought that Ave could feel a faint pulsation in the radial artery, but it was so slight as to be doubtful. Early in July, Avhile the general swelling of the arm diminished, the tumor in the axilla Avas obviously enlarging and extending under the pectoral muscle, when, by the 8th, it became very prominent and as large as the fist. On the night of the 10th, a free arterial haemorrhage took place from the posterior Avound; after the loss of about a pint of blood, it Avas arrested by pressure, for an hour, upon the subclavian above the clavicle, and did not return; his pulse very feeble,-and above 120; he Avas very much alarmed about his condition, indeed he had been unusually loAV-spirited from the first. On the llth, for the first time, a distinct pulsation Avas felt in the tumor, both in the axilla and over the pectoral muscle; there was no perceptible thrill or bruit; from this time the tumor steadily increased in size, and the pulsation daily became stronger; there was also increase of the pain and numbness in the limb; constant fever and sleeplessness, and loss of appetite. It Avas decided, in consultation, to tie the subclavian above the clavicle, as affording him the best chance of recovery, although his general condition was not favorable for an operation. Accordingly on the 23d July, assisted by Surgeon Blackford and the rest of the surgical staff of this post, I ligated the artery where it passes over the first rib. The operation was rendered someAvhat difficult by the unusual number of superficial arteries that required to be tied, and by the elevation of the clavicle from the tumor in the axilla. The pulsation in the tumor immediately ceased, and did not return; the swelling became less tense, but the pain continued, and the fever increased; the capillary circulation in the limb continued good, and its temperature appeared to be little, if at all, diminished (we had no thermometer to test it accurately), for a feAV days he seemed doing pretty well, but on the 26th, the incision presented an unhealthy appearance, with a slight erysipelatous blush and some swelling beloAV the clavicle. By the 28th, the shoulder and breast became enormously swollen, so as completely to conceal the aneurismal tumor. On the next day there Avas extensive erysipelas on the outside and back of shoulder, which spread rapidly over the breast and down the arm to the elboAV; the incision suppurating and unhealthy. On the same day, he was seized with a severe pleuritic pain on the left side, and great difficulty of breathing, but without cough; the respiratory motion Avas confined so exclusively to the right side, that the left seemed paralyzed, and was obviously several inches smaller than the right side, although auscultation shoAved the presence of effusion in the left thorax; boAvels torpid and tympanitic; pulse 150, and very feeble. July 30th: No improvement in his condition, although the pain in the side had nearly ceased. July 31st: Prostration extreme; respiration more difficult; died soon after midnight. Autopsy: Axillary artery and vein both severed by the ball in their loAver third; the axilla filled with a large clot extending to Avithin three inches of the elbow and considerably beneath the pectoralis major. The coagulum Avas moder- ately firm, and contained in a thin adventitious sac of cellular tissue, but without any fibrinous deposit. The median nerve had escaped division, but was very much discolored, as were also the other nerves in the axilla. The artery, where ligated, had united, but not very firmly; no clot had formed within it, owing, probably, to the fact that the posterior scapular artery, instead of being a branch from the transversalis colli, arose directly from the subclavian, betAveen the scaleni, and about two-thirds of an inch above the point of ligation; this Avould, probably, have led to secondary haemorrhage after the separation ofthe ligature. There Avas a large serous effusion in the left side of the thorax, with a deposit of a thick layer of fibrin over a large surface of the lung; phrenic nerve healthy. There AA'as also slight deposit in the pericardium, and some effusion. The only treatment that avus admissible after the operation was morphine, stimulants, and tinct. mur. ferri. It would, probably, have been better to haATe tied the subclavian soon after his admission, when his general health was less impaired. But Avould the rules of surgery have justified the ligation of a large artery AA'hen there was no haemorrhage and no pulsation in the tumor? The axillary swelling and absence of pulse at the Avrist afforded strong presumptive evidence that the artery was divided, but Ave could not be sure that the absence of pulse was not OAving to the pressure ofthe tumor, which might have arisen from the division of a branch of the axillary, and if so Ave might reasonably hope that in time it Avould be absorbed and the circulation restored. It was not until the tumor began to increase in size, AA'ith distinct pulsation, that we felt satisfied that an operation Avas indispensable, and our choice then lay between disarticulation and ligature of the subclavian—the ligature of the axillary in the midst of such i Buowxl, 1*. F., Confederate Status Medical and Sugicol Journal, Vol. I, p. 23, 1S64. LIGATIONS OF THE SUBCLAVIAN. 543 swelling and altered relation of parts Avas out of the question. AVe decided upon the ligation of the artery as being sanctioned by the highest authority; the more especially as his constitutional condition almost forbade the hope of successful amputation. I Avould suggest that, in a similar case, where the posterior scapular arose directly from the subclavian, it would be proper to tie it, as Avell as the main artery ; in this case it could have been done Avithout difficulty, as it could be plainly seen and felt Avhere it crossed the cervical plexus. The other branches of the transversus colli and the supra-scapular would probably be sufficient to supply the anastomosing circulation. The immediate cause of death in this case was pleuritis, Avhich has been observed to be far the most frequent cause of death after ligation of the subclavian. The erysipelas, to which there has latterly been some tendency in this neighborhood, no doubt also contributed to the fatal termination." Surgeon Wm. Selden, P. A. C. S., reported the case.1 The next case refers to a ligation of the left subclavian, by Surgeon John'A. Lidell, U. S. V., for circumscribed traumatic aneurism folloAving the division of the axillary by a carbine ball. The complete report is given in the author's own language:2 Case 20.—" Captain John F. Jordan, Co. B, 13th A'irginia Cavalry, aged 31 years, and of sound constitution, was admitted to Stanton United States Army General Hospital, June 23d, 1^:33. He had been wounded on June*21st, in action near Middleburgh, A'irginia, by a shot from a carbine. The bullet, Avhich, by the way, Avas conical in shape, penetrated the pectoralis major muscle of the left side, at a point on a level Avith the axillary artery, and about one and a half inches from the margin of the armpit, passed directly backAvard beneath the shoulder, Avounding the axillary artery, together Avith the brachial plexus of nerves, and escaped behind. Patient said he lost a great deal of blood immediately after the Avound was inflicted, so much indeed that he fainted, Avhen the haemorrhage ceased of itself, and did not return. On admission to hospital, his left arm exhibited some SAvelling, cedematous in character, and its inner side was ecchymosed nearly down to the elbow-joint. It Avas also paralyzed, the loss of buth sensibilty and mobility being complete. There was no radial pulse in that arm, and pulsation could not be detected in the brachial or any other artery thereof. From this we inferred that the axillary artery had been severed by the bullet. The temperature of the limb Avas not below the normal standard; on the contrary, Ave thought it to be someAvhat warmer than the limb of the opposite side. There was nothing remarkable in the appearance of the Avound. The patient's general condition Avas good. He did not look as if he had suffered from haemorrhage. His boAvels were constipated ; ordered a saline purge, together Avith a spare diet, and, Avith a view to lessen the tendency to secondary haemorrhage, he Avas directed to remain quiet in bed, to exert himself as little as possible, and to have ice applied constantly over the injured artery. He was also directed to take morphine at night if necessary to procure rest. Under this treatment the patient progressed without an unfavorable symptom ; the Avound cleaned itself and closed up in a satisfactory manner, and we congratulated the patient in that he AA'as likely to get well without suffering the terrible secondary haemorrhage, which frequently attends gunshot wounds of the axillary artery. The limb continued to be completely paralyzed as to motion, but sensation had gradually been restored to the fingers, hand, and forearm. On the morning ofthe 12th of July, we noticed the appearance of a small, rounded, circumscribed SAvelling of the size of an egg, at the seat of injury to the artery. The scar of the anterior, orifice of the gunshot wound Avas exactly on the summit of the convexity of the swelling, as the patient lay in bed. The tumor Avas tense in feel, and pulsated distinctly and synchronously with the heart. There was, however, an entire absence of the aneurismal thrill and aneurismal bruit. By compressing the subclavian artery against the first rib, the tumor became soft, much less in size, and ceased to pulsate. On Avithdrawing compression the tumor speedily filled up, became tense, and pulsated again. Patient stated that during the preceding night he felt something "give way" in his left armpit,,,while attempting to change the position of this arm by the aid of the right hand. During the day the aneurism increased rapidly in size, and in the evening Avas fully tAvice as large as Avhen first notice'd.in the morning. July 13th, the aneurism continued to increase steadily in size, and in the evening AA'as about half as large as the clenched fist. July llth, the aneurism had grown but little since previous day; it was still rounded, distinctly circumscribed, and somewhat oval in shape. By compressing the subclavian, it ceased to pulsate, became soft and much shrunken, but the prior condition of things Avas restored speedily on withdraAving compression ; as on a previous occasion, there Avas still no thrill or bruit. Diagnosis : Circumscribed traumatic aneurism of the axillary artery. From the entire absence of pulsation in all the arteries beyond the aneurism, which existed even at the time of admission to hospital, and the complete Avant of thrill and bruit in the aneurism itself, Ave believed that the aneurism had been developed from the proximal end of the severed artery, and that opinion Avas strengthened by the fact that the SAvelling had not expanded outward and doAvmvard into the armpit, AA'here there Avas but little in the anatomical structure of the parts to obstruct its groAvth, any more rapidly than it had done in another direction, where it was covered over and bound down by the pectoral muscles. The swelling had expanded so equally in all directions, that the scar of the anterior wound still remained exactly over the centre of the tumor, as when Ave first saAV it. The *' aneurism Avas so distinctly circumscribed that, although its origin Avas traumatic, it was deemed advisable to attempt a cure of it by the Hunterian method. As there Avas not sufficient space to secure the artery beloAV the clavicle without opening the sac, I proceeded to tie the left subclavian artery external to the scalenus, on the afternoon of that day (July 14th). The patient being under sulphuric ether, that operation Avas perfonned Avithout difficulty by the ordinary method. On tightening the ligature the tumor ceased to pulsate, shrunk a good deal, and became soft. The left arm Avas directed to be wrapped in cotton avooI, and to be kept warm by the further aid of bottles of Avarm water, to be reneAved from time to time as occasion might require. A full dose of morphia was prescribed. He was enjoined to preserve the recumbent posture, and to avoid exertion of every kind. A milk diet was alloAved. July 15th, patient had a comfortable night; temperature of arm not diminished ; discontinued the Avarm water. July 16th, patient doing well in every respect; arm Avarm; color thereof good; discontinued the cotton avooI. July 17th, boAvels being confined, he took an ounce of sulphate of magnesia. July 19th, aneurismal sac opened spontaneously last l Selden, W., Confederate States Medical and Surgical Journal, A'ol. I, No. 9, p. 134, September, 1804. 2 Lidell, On the Wounds of Blood-vessels, Traumatic Hemorrhage, Traumatic Aneurism, and Traumatic Gangrene. In Surgical Memoirs of the War of the Rebellion, Vol. I, p. 101, New York, 1870. 541 WOUNDS AND INJURIES OF THE CHEST. night through the anterior scar of the gunshot wound, and discharged two or three ounces ot very dark-colored blood, mixed with pus. Suppuration of the sac had been threatened ever since the day after the operation. He Avas allowed a full diet. July 20th, a moderate discharge of old blood and pus, accompanied with a gradual diminution in the size of the aneurism, and hut a moderate degree of inflammation of the sac continued on this and several days folloAving, the patient's general condition being unexceptionable all the Avhile. July 27th, the aneurismal swelling had entirely disappeared; suppuration of the sac, moderate in quantity, still continued, the pus being cf a good quality. August 1st, the ligature separated and was removed to-day, vithmit the occurrence of haemorrhage or any other difficulty; discharge from sac good in quality and steadily diminishing in quantity; discovered some excoriation at the inner side of the left elbow, occasioned probably by pressure, the patient having folloAved very closely the injunction to keep as still as possible in the recumbent posture; directed a stimulating plaster to be applied, and tlie pressure to be removed to other situations by arranging pilloAvs. August 5th, discharge from sac had subsided to a small quantity of healthy pus, and the orifice Avas manifestly contracting. AVe hoped that adhesion of the sac was taking place. Patient's condition seemed to be favorable in every respect, except that he had been losing flesh rapidly for several days Avithout obvious cause. For want of any other reason, we attributed it to the extreme heat of the weather, the temperature both day and night having been unprecedented ever since July 25th, the mercury at midday ranging from 90° to 100° in the shade, and seldom falling beloAV 80° at night. August 6th: a profuse Aoav of blood from the sac came on this morning Avithout Avarning; the loss of blood being so rapid as to threaten speedy death. The officer ofthe day Avas close at hand, and stepped the bleeding by injecting about one ounce of liquor ferri persulphatis into the bottom of the sac, through a female catheter, introduced for the purpose. The haemorrhage ceased immediately. AVe had been emboldened to use the persulphate of iron freely in this way, because Ave had a few Aveeks before (June 22d) stopped a troublesome secondary flow, in alarming quantity, of arterial blood from the cavity of a large abscess, associated with gunshot fracture ofthe right thigh, by injecting about tAvo drachms of liquor ferri persulphatis through a catheter, carried into the neighborhood of the supposed source of the haemorrhage, a branch of the profunda artery, and no unpleasant effect of any kind followed it. Again, about the same time, we had been troubled to manage a case of general oozing of blood from the cut surface of a thigh, amputated secondarily for gunshot injury. After trying exposure to the air, ice-Avater, and even ice, Avithout effect, we stopped this bleeding immediately by covering the end of the stump Avith pledgets of lint soaked in liquor ferri persulphatis. Aside from pretty severe pain, Avhich soon subsided, no unpleasant consequence of any kind folloAved. AA'e did not discover any evidence of even the feeblest action as an escharotic, and indeed have since thought that ttfe case progressed better than other amputations of the same class. In consequence of the secondary haemorrhage and the efforts to repress it, the aneurismal sac became filled up again to the original size. August 10th, another severe haemorrhage occurred from the same orifice; it Avas readily stopped by again, injecting persulphate of iron in solution. August llth : profuse haemorrhage occurred to-day through the opening of the posterior orifice made by the bullet, after it had'been healed for more than a month. This bleeding Avas also suppressed immediately by injecting liquor ferri persulphatis through a catheter. After this there was no more haemorrhage. During the next few days he seemed to rally from the depression produced by these repeated losses of blood. He was ordered to have Avine, and anything in the line of supporting treatment that he would take. August 18th: the aneurismal sac has again suppurated, and there is a profuse discharge of dark-colored and very offensive pus. August 25th: patient failing rapidly; suppuration very profuse and extremely offensive in character. August 29th, he died Avorn out Avith the suppuration and the haemorrhages, forty-six days after the operation, and twenty-eight days after the ligature came aAvay. Autopsy eighteen hours after death : Emaciation extreme; rigor mortis moderate; a large elongated cavity, with ragged dark-colored Avails, occupies the original seat of the aneurism, and extends beyond it outward into the axilla; the axillary artery is found to have been severed obliquely by the bullet about one and one-half inches aboA'e its termination in the brachial; the divided extremities are separated Avidely apart (to the extent of about three inches); the distal end appears to have been pushed aAvay from the prox- imal end, either by the original aneurism, or the subse- quent haemorrhages and suppuration; the proximal end is oblique and closed, while the bruised and lacerated portion of it appears about to be cast off by the ulcer- ative process, as a distinct line of demarcation has been formed ; the distal end is oblique and unclosed, but the calibre of the artery is contracted down to about a line in diameter, and it is blocked up by a coagulum three-eighths of an inch long; the branches of the axillary given off above the point of injury, especially the superior thoracic and the acromial thoracic, are much enlarged; the axillary vein is greatly diminished in size about the track of the bullet, but it is still pervious; the brachial plexus of nerves was also Avounded by the bullet, all the trunks being cut off except that of the musculo-spiral and circumflex nerves. The proximal extremities of the divided trunks were someAvhat bulbous. At the seat of the operation the Avound, which at one time Avas nearly closed, is now open quite doAvn to the artery at the point of ligation, the neAV granulations having been reabsorbed to that extent, but the artery for a distance on each side thereof is surrounded by a dense mass of new connective tissue, so thick anjl dense as to make it a little difficult to get at and remove the specimen Avithout injury. On the proximal side of the ligature the vessel is blocked up to a distance of about five-eighths of an inch ; on the other side ot the ligature it is blocked up to the extent of about tAvo-eighths of an inch. In the cavity of the thorax Ave find old pleuritic adhesions on both sides, and old tuberculous cicatrices at the apex of each lung ; but both lungs are hoav entirely free from tuberculous deposits: abdomen not opened." The specimen, represented in the above wood-cut (Fig. 249), and also specimen 3243, showing the brachial plexus, Avere contributed by the operator. Fio. 240.—Drawing of the arterial preparation from Dr. Lidell's case of ligation of the left subclavian. Spec. 1684, Sect. I, A. M. M. LIGATIONS OF THE SUBCLAVIAN. 545 Case 21.—Sergeant Henry Grothenn, Co. K, 5th United States Cavalry, aged 28 years, Avas admitted into the McClellan Hospital, Philadelphia, June 23d, 1S63, from Lincoln Hospital, Washington, Avith an aneurism of the right axillary artery, the result of a gunshot Avound received at Beverly Ford, A'irginia, June 9th, 1863. The ball had passed in on the anterior part ot • the arm, near the shoulder-joint, and was cut out at Lincoln Hospital an inch beloAV the inferior angle of the scapula. In a report ofthe ease in the Anurican Journal of Medical Spruces, Vol. XLVII, p. 128, N. S., Acting Assistant Surgeon Isaac Norris says: "AA'hen I took charge of the ward, on July 26th, the patient Avas absent. He returned on the 28th, and after making a careful examination of the arm, the true nature of the disease became manifest, as the pulsation of tlie tumor—at that time about the size of a large horse-chestnut —was very apparent, and, upon auscultation, the aneurismal thrill could be distinctly heard, corresponding with the contraction of the left ventricle of the heart. My predecessor had had made an apparatus composed of a compress of lead AA'ith screws so arranged that by tightening them any amount of pressure desired could be placed upon the part. The apparatus was adjusted, but after a trial of some thirty hours, it Avas abandoned on account of the pain it gave the patient, and a padded bandage Avas substituted, in the fiint hope that it might be of use. This Avas worn for nearly ten days, but it Avas finally left off, and the treatment Avas reduced to keeping the arm, as nearly as possible, at perfect rest. On the 16th of August last, the aneurism became much larger, and from the pressure upon the axillary plexus of nerves, caused him great pain. The following evening it was decided to operate and tie the subclavian, despite the hazard attending it. The aneurism broke, unfortunately, early the next morning, before the operation could be performed, and the patient lost from thirty to forty ounces of blood. The haemorrhage finally ceased of its oavii accord, but he Avas so weakened and exhausted from the great loss he had sustained, that it AA'as the opinion of the medical staff of the hospital, upon consultation, that, if anything Avas attempted then, he would die under the operation, and that his life might be prolonged for a few hours more by keeping up digital compression upon the artery. This was accordingly done, and the assistants appointed, relieved each other every hour or two, until the arrival of Surgeon R. H. Coolidge, medical inspector ofthe Army, on a chance visit to the hospital, who at once became interested in the case, and thought the subclavian should be tied Avithout delay; the temporary absence of Dr. Taylor, the surgeon in charge, being the objection to its performance. As the patient seemed to be rallying each hour, Dr. Coolidge decided to return to the hospital in the afternoon, and operate, if no objection then existed. Upon his return, the haemorrhage again having commenced, he proceeded to ligate the subclavian in the third part of its course. I herfe give the account of the operation as furnished by the Doctor: "The patient came easily under the influence of the chloroform, and the operation Avas performed carefully and deliberately. The loss of blood amounted to a few drops only, haemorrhage'from the aneurism having been completely arrested by a tourniquet. Chloroform Avas not administered after the operation began. The artery, on being exposed, Avas found closer to the brachial plexus than usual, aud it Avas also quite deeply seated, the patient being a large muscular man. An armed artery needle haA'ing been passed beneath the A'essel from beloAV upward and'outward and AvithdraAvn, it Avas found by the operator, and his assistants also, that the inferior cord of the brachial plexus was included in the ligature, a result attributed in part to the want of sufficient curve in the needle. Another one, having a more abrupt curve, being armed and passed beneath the artery, it was elevated by the first ligature, and care taken to exclude the nerve above mentioned. The first ligature Avas then AAdthdrawn, and several of the medical officers present, having examined the parts, and satisfied themselves that nothing but the artery was embraced in the ligature, the knot was tied, the lips of the incision draAvn together, and the patient placed in bed.' Everything seemed to do Avell until about eight o'clock p. M., Avhen the patient complained of consider- able pain in the region of the Avound. Morphia was giA'en to him freely, and repeated the following hour, but Avithout the effect of quieting him. The patient, from that time, greAV rapidly worse, suffering Avith great dyspncea, and at midnight expired, six hours after the operation. The post-mortem revealed the unexpected fact that a nerve of considerable size, lying immediately posterior to the artery, had been included in the ligature despite the care that had been taken to prevent it. It is to be regretted that this nerve was ligature Avas directly FlG. 250.—Traumatic aneurism of the right axillary, with ligation of the subclavian. Spec 2609, Sect. I, A. M. JF. oppositetheknot, and cannot be seen Avhen the artery was placed in its proper position. It is scarcely necessary to add that no Avriter on anatomy has described such a nerve, nor has any dissection on record shown the existence of one, previous to this. At the time the ligature avus tied, the patient was but slightly under the influence of chloroform, and no pain Avas manifested until several hours after- Avards. The preparation is an exceedingly instructive one. the aneurismal sac being very large, and the course of the artery well shown. The infiltration of blood also into the surrounding cellular tissue was very great." The specimen, consisting ofthe aneurismal sac and the subclavian, with a ligature on the third portion, is represented in the accompanying wood-cut (Fig. 250.) It Avas contributed, with the notes of the case, as subsequently published by Acting Assistant Surgeon Isaac Norris, jr. G9 546 WOUNDS AND INJURIES OF THE CHEST. Some surgeons describe-the ligation of the subclavian behind or between tlie scaleni as a distinct operation. The vessel appears to have been secured on the left side, in this portion of its course in the two following cases. They are both illustrations of Anel's method unsuccessfully applied to wxmnded arteries. The first was for intermediary hemorrhage on the eighth day ;■ the second for secondary htomorrhage on the eighty-ninth day, the result of gangrene : Case 22.—Corporal George AI. Klechner, Co. D, 93d Illinois Volunteers, aged 23 years, received at Allatoona, Georgia, on October 5th, 1854, a gunshot Avound of the left arm ; the ball entering*at insertion of deltoid muscle, lodged betAveen the clavicle and first rib, over the tubercle of the rib. He wa? admitted to the general hospital at Rome, Georgia, October 8th, 1864, andj ton October 13th, the subclaA'ian artery AA-as ligated behind the scalenus anticus and the ball removed; chloroform and .ether Avere administered. At the time of operation, there Avas excessive infiltration of serum in all the parts involved in the operation, and profuse secondary haemorrhage, Avith extreme prostration therefrom. Stimulants Avere freely administered, but he died six hours after the operation. The case is reported by the operator, Surgeon J. H. Grove, U. S. V. Case 23.—Sergeant W. H. Holshowes, 3d South Carolina Battery, Avas Avounded at Franklin, Tennessee, November 30th, 1864, by a conoidal ball, AA'hich entered about an inch beloAV the left clavicle and lodged in the substance of the lung. He Avas treated in the field until December 26th, Avhen he Avas transferred to No. 1 hospital, Nashville. About February 23d, 1865, a large gangrenous ulcer formed, Avhich spread rapidly, involving the tissues from the inner third of the clavicle to the axilla, exposing the blood-vessels and nerves. The subclavian artery sloughed in its distal third on February 27th; about twelve ounces of blood Avere lost. The patient Avas much reduced. Surgeon B. B. Breed, U. S. V., administered chloroform and ligated the left sub- clavian artery betAveen the scaleni through an incision above the clavicle. Tonics, stimulants, and a nutritious diet Avere given and disinfectant dressings Avere applied. The gangrene Avas arrested with difficulty. The patient did well until the eighth day after the oparation, when he Avas attacked AA'ith seA'ere rigors, Avhich occurred at irregular intervals until March llth, 1865, when death resulted from pyaemia. The necropsy showed a firm clot in artery. Multiple abscesses existed throughout both lungs. Thrombi in the subclaA'ian. Two cases of ligation of the right subclavian on the tracheal side of the scaleni are recorded. In the first of these formidable operations, the patient survived the operation half an hour: -, a scout for General Milroy, Avas admitted into Cumberland Hospital, Nashville, December 1st, only Case 24.—AVilliam S- 1864, having been wounded Avhile on a scouting expedition on or about November 15th; while taking supper at a farm-house he Avas fired at through the Avindow, the ball striking about the external third of the right clavicle, fractured it, passed obliquely inward and backward, and emerged on the back near the cervical vertebrae. The pleural caA'ity Avas opened by the ball, and whenever he changed his position a quantity of fluid, having the appearance of blood mixed with serum, Avould flow out. Compresses were kept on the Avound, and Avhenever they were taken off there Avcruld be a discharge of the bloody fluid. Ihe quantity lost at different times Avas great, and the patient's strength failed rapidly. On the evening of December 14th, a severe haemorrhage occurred from the subclavian artery, which was controlled for some time by pressure. The necessity of surgical interference Avas urgent, as the patient had already lost a large amount of blood. Assistant Surgeon S. C. Ayres, U. S. V., immediately operated. A triangular flap Avas made by cutting parallel with the upper border ofthe clavicle and along the inner border of the sterno-mastoid—the two incisions meeting at the sterno-clavicular articulation. The sternal and part of the clavicular insertion ofthe sterno-mastoid, as well as the sternal attachments ofthe sterno-hyoid and sterno-thyroid muscles, Avere diA'ided and turned backward Avith the ends of the fingers and the cellular tissue carefully divided with a grooved director. The par vagum Avas recognized and drawn inward, and the internal jugular vein outward. The artery Avas found lying quite deep below the clavicle ; Avith some difficulty the aneurism needle was passed around the artery from below upward and the ligature drawn. Haemorrhage ceased from this moment, but it was evident that the patient Avas sinking rapidly. He died in about half an hour. If the haemorrhage had not.occurred he could not in all probability have lived many days-. Autopsy tAvelve hours after death: Body much emaciated. The ball had fractured the outer third of the clavicle and the first rib. It had opened the pleural cavity in its course and had fractured the spinous processes of the seventh and eighth cervical vertebrae, and had made its exit on the left side of the spinal column. The haemorrhage from the subclavian Avas occasioned by a sharp spicula of hone which had caused ulceration of the coats of the artery. The right pleural cavity contained a large quantity of bloody serum, such as was discharged from the AA'ound previous to death, and the lung Avas found completely hepatized. It is probable that a vein Avas ruptured by the ball in its course, and that the bloody • fluid discharged from the pleural cavity before the arterial haemor- rhage occurred Avas a mixture of venous blood and serum ; but, from the disorganized condition of the tissues, it was impossible to tell which branch had been severed. The wood-cut (l-'iG. 251) shows tlie innominata, right carotid, and subclavian arteries, with a ligature in situ on the subclavian three-fourths of an inch from its origin. It AA-as contributed, with a history of the case, by the operator. Fig. 2.11.—Ligiiture on the first portion of the right subclavian Sjjcc. 472U, Sect. I, A. M. M. LIGATIONS OF THE SUBCLAVIAN. 547 (/ask 25.—Private Adam Grimm, Co. D, 7th Connecticut Volunteers, aged 21 years, was wounded before Petersburg, Viririnia, June 9th, 1864, by a rifle ball, which fractured the acromion end of the right clavicle, passed beneath the scapula and out below the loAver border, and, on the llth. admitted to Hampton Hospital at Fort Monroe, and some fragments of bone Avere removed. The Avound looked healthy and continued discharging laudable pus and granulating until June 28th at 11a. m., Avhen secondary haemorrhage occurred and the patient lost about six ounces of arterial blood, before the bleeding could be arrested bv pressure. "On the 29th, haemorrhage again occurred, more seA-erely than before, losing from fourteen to sixteen ounces of blood. The cavity ofthe wound Avas by this time much enlarged. The haemorrhage was again apparently checked by plugging the AA'ound Avith lint saturated with perchloride of iron, but in two hours the whole ofthe tissues between theAvound and the neck were engorged with blood, the SAvelling rapidly increasing, and thus shoAving that he was still bleeding. After consultation it was decided to stimulate freely and give narcotics to relieve pain, and let him remain till morning. June 30th, 11 A. ai., being in about the same condition—the tongue dry and glazed, pulse 120 and very Aveak, and with the engorgement gradually increasing— the subclavian AA'as ligated successfully in the first part of its course. Coagula were then removed from the cavity ofthe wound, and it AA'as syringed Avith ice water, no bleeding being apparent. Immediately after the operation he rallied ; the tongue became moist; pulse at left Avrist 110, at right Avrist none. The temperature of both arms was the same and continued SO throughout. Jul a* 1st. 10 P. m., left pulse 110, right barely perceptible. Patient in good spirits ; takes nourishment freely, but complains of pain in swalloAving. 10 r. >r., left pulse 112, right same as in the morning. A sedative Avas administered. July 2d, left pulse 11(1, rio-ht increasing a little in strength. The patient improved someAA'hat until the 7th, at Avhich time the left pulse Avas 90 and the right still increasing in strength. He complained of pain in the region of the heart, but no abnormal sounds Avere heard. July 8th, left pulse 120; tongue dry and glazed ; at 9 P. .ai., he had a rigor. July 8th, 7 A. m., a slight haemorrhage! occurred from the point Avhere the artery Avas ligated; the Avound Avas plugged and pressure employed; at 10 a. ai., the haemorrhage recurred more severely than before. From this time until evening there Avere repeated haemorrhages; the patient gradually sank and died at 8 P. m., remaining sensible to the last. Necropsy: Both the supra-scapular and posterior scapular arteries Avere found to be in a sloughing condition, Avhich was apparently the cause of the last haemorrhages. The subclavian was ligated about half an inch from its origin. The ligature had come aAvay and the coats of the artery were ulcerated through. On the cardiac side a slight clot had formed, but on the distal side the clot Avas larger, firmer, and more perfectly organized. The case is reported by Dr. Alexander R. Becker,* of Prewidence, Rhode Island, from notes by Acting Assistant Surgeon C. H. Bullen. In the twenty-five foregoing cases, the ligations were on the right side in thirteen, in twelve on the left. The patients were from nineteen to thirty-nine years of age, the average being twenty-five years. The-interval between the reception of the injury to the date of ligation varied from one to two hundred and sixty days. The average was about twenty days in twenty-three cases, the two cases of traumatic aneurism in which the operation was done at a late date being abstracted. The operations were all for the results of gunshot injuries; in one case for primary hsemorrhage, and in two for intermediary hsemorrhage from the third portion of the subclavian; in eleven, for intermediary haemor- rhage, from the axillary or its branches; in two cases, for secondary haemorrhage from ulceration of the axillary, and in nine cases for false aneurism of the axillary. The intervals between the operation and the fatal termination in five of the unsuccessful cases were less than one day; in one of the fifteen remaining cases, death took place on the third day; in six, from the fifth to the eighth; in one, on the tenth; in five, from the twelfth to the fifteenth; in one, on the twentieth, and in one on the forty-sixth day. Twelve patients died from recurring haemorrhage from the distal side of the ligated point; three died from pyaemia, and three from exhaustion from the preceding haemorrhages ; .one from gangrene, and one from pleuritis. The assertion of Surgeon Selden that the latter is the most frequent cause of death in ligation of the subclavian, is not supported by these facts. The percentage of mortality is 80 per cent., or, including only the twenty-one cases of ligation outside of the scaleni, 76 per cent.*}* * Becker, On Gunshot Wounds, Fiske Fund Prize Essay, 1864, p. 10. tin Dr. George W. Norris's table (Am. Jour. Med. Sci., N. S., Vol. X, p. 13, July, 1845), compiled with the conscientious care that characterizes all of his statistical contributions to surgery, sixty-nine cases of ligation of the subclavian for all causes are recorded, of which thirty-three, or 47.8 per cent., were fatal. Dr. Wilhelm Koch's exhaustive paper (Ueber Umerbindungeu und Ancurismcn der Arteria subclqvia, Arch. f. d. kl. Chir., B. X, H. I, S. 195, 280, Berlin, 1869) tabulates two hundred and twelve cases, and classifies them according to the indications for operation. Of seventy-three ligations' for injury, forty-eight, or 65.7 per cent., were fatal. Professor Willard Parker's statistics (Transactions Am. Med. Assoc, A'ol. XVIII, p. 246) give one hundred and ninety-six ligations of the subclavian, with a mortality of 54.5 per cent. Of seventy of these operations performed for other causes than aneurism, the mortality was 68.5. At page 422, a case of ligation of the left subclavian in the third portion for gunshot wound of the neck is recorded, and in treating of Wounds ofthe Upper Extremities, in the second volume, I shall enumerate twenty-six additional cases, a total of fifty-two cases, with forty-one deaths, a mortality rate of 78.8, or nearly that reported in Circular No. 6, S. G. G., 1865, p. 78, from an analysis of thirty-five cases. Dr. Biiroth, in his Chirurgisclie Briefe, 1870, S. 124, gives a most vivid and interesting account of five ligatious of the subclavian in which he operated or assisted at AA'eissenburg and Mannheim. One patient was probably saved. 548 WOUNDS AND INJURIES OF THE CHEST. Ligations of the Internal Mammary Artery.—Tn referring, on page 523, to wounds of this vessel, four examples were cited in which pressure and styptics failed to control the bleeding. In the two following cases the ligature was equally ineffectual: Case.—Private Ambrose Campbell, Co. A, 2d Pennsylvania Heavy Artillery, aged 21 years, was Avounded near Peters- burg, June 29th, 18(14. by a conoidal ball, Avhich entered the left side near the junction of the osseous -with the cartilaginous portion of theksecond rib, and (.merged near the etti no-costal articulation of the second rib on the opposite side ofthe chest, tearing aAvay in its course the cartilage of the rib on the left side, producing an extensive comminuted fracture of the sternum and separating the cartilaginous attachment ofthe second rib on the right side of the chest. The cavity of the left pleura was laid open to the extent of tAvo inches, and the corresponding lung Avounded by a spicula of bone driven imvard from the sternum at the time of injury. He was at once conveyed to the hospital ofthe 1st division, Ninth Corps, and thence transferred, on July 3d, and admitted into Carver Hospital, Washington, on July 5th. On admission, patient manifested symptoms of pleuro- pneumonia, accompanied Avith Ioav muttering delirium with a tendency to sleep, with someAvhat lucid intervals. There Avas involuntary discharge of urine ever after admission, as also of feces, with some two or three exceptions. Pulse not more frequent than in health, full, yet more hard ; skin harsh and dry, yet not much above the natural temperature; respiration oppressed, but not labored. The cavity of left pleura Avas filled with a dark-broAvn fluid, which Avas occasionally removed by gently placing the patient in a prone position, allowing the fluid to escape through the orifice of the Avound, but for four or five days prior to death it was partially removed by the use of a syringe. In the hitter stage of the disease, fully four ounces of serum were effused into the cavity daily. These symptoms continued with little variation until July 13th, when profuse hamiorrhage occurred, probably from the internal mammary, which Avas ligated by Surgeon O. A. Judson, U. S. V.; there Avas not k;ss than tAvelve ounces of blood lost, and the patient sank more rapidly, and died on July 19th, 1864. Autopsy showed the following: Condition of right lung, normal; left lung in situ, firmly bound doAvn to Avail of chest by recent adhesion; a lacerated Avound of upper surface of upper lobe about tAvo inches in extent, Avhich was gangrenous; lower anterior portion of upper lobe gangrenous; this lobe Avas congested elsewhere, except at apex; lower lobe in a state of red hepatization; liver enlarged, pale, and of a nutmeg appearance; spleen enlarged, did not present its usual granular appearance. During life, the pulsations of the aorta and heart Avere exposed Avhenever the effused fluid was removed. The treatment of the case consisted, in the earlier stages, of moderate doses of quinine, Avith punch, castor oil, and cough mixture; in latter stages, diffusible stimulants and nourishing diet. Specimen No. 292."), Sect. 1, Army Medical Museum, consists of the seventh cervical and first three dorsal vertebrae, Avith the corresponding ribs and part of the sternum. The second left rib was struck at its costal extremity by a bullet, which, passing transversely, tore awayithe cartilage, comminuted the sternum, and separated the cartilaginous attachment ofthe second right rib; the sternum is extensively necrosed, especially on its internal surface, the second portion of which shows traces of periosteal disturbance. The specimen and history Avere contributed by the operator. As is well known, ligation of the internal mammary is esteemed of easy performance in the first three intercostal spaces, difficult in the fourth, very difficult in the fifth, almost impracticable in the sixth (Goyrand). I do not know that it has occurred to any one to adopt, in securing the internal mammary near the xiphoid appendix, Gerard's method for tying the intercostal, until the following operation was practiced by Surgeon R. B. Bontecou, U. S. V. One would suppose that the mammary, at the fifth intercostal space, would be too distant from the ensiform cartilage, to permit a mediate ligature of this sort to be placed effectually. The ligature did not control the bleeding in Dr. Bontecou's case: Case.—Private John Gallin, Co. F, 65th NeAV York Volunteers, aged 30 years, was Avounded at Spottsylvania, Virginia, May 8th, 1864, by a conoidal ball, which entered the chest on the left side between the sixfrli and seventh ribs, five inches below the nipple, and emerged between the fifth and sixth ribs on the right side, four inches beloAV the nipple, passing under the ensiform cartilage, Avounding the internal mammary artery, and opening the right chest cavity and loAver lobe of the lung on that side. He was conveyed to the hospital of the 1st division, Sixth Corps, and on the 14th Avas transferred to Harewood Hospital, "Washington. On admission, the parts Avere in a very bad condition. The patient Avas anaemic and feeble from haemorrhage. On the 19th, Surgeon E. B. Bontecou, U. S. V., administered sulphuric ether, enlarged the wound of entrance, and passed a piece of bandage through and tied it over the ensiform cartilage, ligating the internal mammary artery. Simple dressings and cold applications Avere applied, and supporting treatment administered. The patient gradually sank, and died May 24th, 1861. from recurring haemorrhage and pneumonia of the right lung. The case is reported by the operator. We are indebted to Goyrand for the best method of proceeding in ligation of the internal mammary.1 "An incision two inches in length is to be made near the edge of the sternum obliquely from above downward and from without inward, forming with the I It was first published in the Lancette Francaise, September 30th, 1834, and is quoted by Guthrie (Commentaries, p. 518) and others. It is gratifying to know that his nephew, Dr. Siebert, has lately published, in a collected form, the scattered memoirs of the surgeon of Aix, who attainedr in his provincial sphere, a celebrity scarcely second to that of any of the pupils of Dupuytren. In this volume, (Clinique Chirurgicale, du Docteur Goykand (d'Aix), Paris, 1870, 8vo., pp. CSS), the modest author states (p. 323) that he conceived and practiced this operation on the cadaver ten years before he printed an account of the manual procedure, and he details a highly interesting account of a sabre wound of the internal mammary. LIGATIONS OF THE INTERNAL MAMMARY. 549 axis of the body an angle of forty-five degrees. The middle part of this incision should be three or four lines distant from the margin of the sternum, and in the centre of the sterna] extremity of the intercostal space. Dividing successively the skin, the cellulo- adipose subcutaneous tissue, and the great pectoral muscle, the intercostal space is exposed. An incision is then to be made in the same direction and over the entire width of the space of the aponeurotic layer which continues the external intercostal muscle and the superficial fasciculi of the internal intercostal. With a grooved director, the fibres of the latter muscle are to be separated and torn through, and the artery and its two vense comites are laid bare at three lines from the edge of the sternum, which separates these fibres from the pleura. Then, nothing is easier than to isolate the artery and to slide beneath it the curved end of a grooved director or other suitable instrument for passing the thread " By following these directions strictly, the operator can scarcely miss the artery on the injected dead subject, and the operation is not difficult in the upper intercostal spaces on the living subject, except in those cases of gunshot fractures of the sternum, Cartilages, and adjacent structures, in which the relations of the parts are disturbed. When there is an open wound and the adjacent soft tissues are swollen and infiltrated, and the vessel lacerated and displaced, the operation becomes very difficult. Then it is best to have recourse to the plan of Desault1 and Zang2 and to place over-the wound a fine compress, four or five inches square, to press the centre of this through the wound, and to stuff the glove-finger or sac thus formed with lint; the angles of the compress are then put together, and the pad or ball of lint is drawn gently outward, and made to compress the wounded vessel against the sternum. To keep the pad in place, the compress may be tied like a purse, and the ligature secured around a roller or other convenient cylinder. Nelaton3' advises that an air-compressor in the shape of a bag of rubber or gold-beaters' skin be introduced and insufflated within the chest. Ligation of the Suprascapular Artery.—An instance in which this vessel was successfully tied, on account of intermediary haemorrhage following a gunshot, wound of the neck, is recorded on page 422. In the following case, the same sound practice of exposing the bleeding vessel and placing a ligature above and below the wound, was, if the brief notes are correctly interpreted, again adopted and rewarded by a successful issue: Case.—Private Solomon Sickles, Co. H, 14th Ncav Jersey Volunteers, aged 27 years, Avas wounded at Momcacv. Mary- land, July 9th, 1864, by a conoidal ball, which penetrated the lung and fractured the scapula. He Avas received at General Hospital, Frederick, Maryland, on the next day, and thence transferred to Jarvis Hospital, Baltimore, Avhere he Avas admitted on July 25th. On August 1st, intermediary haemorrhage occurred, probably from a diffused traumatic aneurism, and sixteen ounces of blood Avas lost; both ends of the posterior and superior scapular arteries were then ligated. There Avas no recurrence of the haemorrhage and the patient Avas doing Avell Avhen transferred to Philadelphia, September llth, 1864. He Avas admitted to General Hospital, Beverly, New Jersey, September 13th, 1864, and thence transferred to Whitehall Hospital, Bristol, Pennsyl- vania, where he was admitted April 5th, 1865. He Avas discharged the service July 6th, 1865. The case is reported by Assistant Surgeon De Witt C. Peters, U. S. A*. Examining Surgeon James B. Coleman, Trenton, NeAV Jersey, reports, October 26th, 1868: " Musket ball entered the left side about tAvo inches from the sternum, broke the upper surface of the clavicle, passed through the loAver part of the neck, and came out through the upper edge of the scapula, carrying aAvay more than an inch ofthe bone down to its spine ; many fragments of bone were discharged from the Avounds, front and back. The shoulder is much emaciated, weak, and muscles 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." 1 Desault, Journal de Chirurgie, Paris. 1771. = Zang, C. B., Darstellung blutiger heilkunstlerischer Operationen, A\rien, 1823, Theil I, S. 233. 3NELATON, Elem. de Path. Chir., T. Ill, p. 452. The instruments of this description designed for the treatment of epistaxis or the dilatation of the uterine canal arc fragile and unreliable. The materials for Desault's tampon are always at hand, and the compress can be made strong and safe. If the attempt to ligate the vessel fails, this is the best resource. The hazard of exciting inflammation in the pleura and lung is less to be dreaded than the danger of hemothorax. It is approved by Velpeau (op. cit., T. II, p. 267). 550 WOUNDS AND INJURIES OF THE CHEST. Ligations of the Lntercostal Artery.—Seven cases of gunshot 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 Gerard,1 of including the rib. nerve, and veins in the ligature was.adopted: Cask.—Private Smith Scofield, Co. D, 6th Connecticut Volunteers, aged 21 years, Avas wounded at Drury's Bluff, Virginia, May 14th, 1864. by a round ball, Avhich entered 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. lie Avas treated in the field, and, on the 19th, sent to the hospital at Point Lookout, Maryland. On May 27th, profuse haemorrhage from both Avounds occurred, which Avas only controlled by cutting down and joining the Avounds of entrance and exit in the track of the ball, and ligating the tenth intercostal artery by passing a ligature around both vessel and rib. The operation was performed by Assistant Surgeon William H. Gardner, U. S. A. Cold-water dressings Avere applied. The hsemorrhage did not recur. The patient Avas transferred, on September 3d, 1864, to Connecticut for muster out of service. Examining Surgeon (J. 13. Upham, of Yonkers, NeAV 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 tAvo wounds incapacitate the applicantone:half and permanently." One great objection to the use of styptics in this class of wounds is the danger of their falling into the pleural cavity, and the employment 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 25 years, received a gunshot Avound of the left side, betAveen the tenth and eleventh ribs, at Fredericksburg, Virginia, December 12th, 1862. He Avas treated in the field and was transferred to Finley Hospital, Washington, on the 24th, and to Convalescent Hospital, Philadelphia, on January llth, 1863. On January 20th, secondary hsemorrhage occurred from the intercostal artery to the amount of four ounces. Acting Assistant Surgeon EdAvard L. Duer, tied the artery at one extremity in the Avound; the haemorrhage did not recur. After the ligation the wound Avas filled with subnitrate of bismuth and a compress applied. This dressing Avas alloAved to remain seventy- two hours, Avhen the slough came aAvay Avith the dressing and the sore presented a perfectly healthy appearance. He Avas discharged from service June 13th, 1863. The case is reported 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 tAvo ribs. Disability one-half." He was last paid on March 3d, 1872. In the next case, the attempt to tie the vessel was unsuccessful, though undertaken by Surgeon T. Antisell, TJ. S. V.: Case.—Private Alfred McClay, Co. E, 114th Pennsylvania Volunteers, aged 17 years, was wounded at Fredericksburg, Virginia, December 13th, 1862, by a conoidal ball, Avhich entered the right side at the costal cartilage, and emerged at the angle of the ninth rib, fracturing the rib betAveen the point of entrance and exit. He Avas treated in the field, and, on December 17th, AA'as sent to HareAvood Hospital. When admitted, he suffered from traumatic penumonia, which was treated by venesection and the administration of morphia and antimony. He recovered sufficiently to be able to move about the ward. The AA'ound healed kindly. On January llth, a profuse haemorrhage occurred from the wound, probably from intercostal artery, which continued in spite of compression. An unsuccessful attempt was made to ligate the artery. The haemorrhage was finally suppressed, after an alarming loss of blood, by tight bandaging and styptics. The stoppage of the haemorrhage Avas immediately followed by pain on both sides, cough, and expectoration. Pyaemia 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, Avhich was also in a very congested condition. Case.—Private J. B. Bruce, Co. C, 31st Alabama Regiment, aged 17 years, was wounded in the chest by a minie 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 Avas specially called to his case the second day out from Pittsburg Landing by my friend Dr. Bush, sr.. of Lexington, Kentucky, because, of the many cases of wounds of the chest on board the transport, this was one ofthe very feAV in Avhich the ball had lodged. The patient had a rather favorable appearance, and the wound looked well, with no tendency to haemorrhage. April 17th, patient was admitted to Ceneral 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 ofthe lung'which Avere present gradually disappeared ; the hectic which ensued had ceased, and the patient, though very Aveak, Avas 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 : Calling accidentally at the hospital at about one o'clock p. m., I was informed an orderly had been dispatched to request me to visit the patient immediately. Secondary haemorrhage had suddenly occurred, the bed Avas already saturated Avith 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 Avhen I 1 Gerard, in Dionis, Cours d!Operations de Chirurgie, 6d. LaFaye, Paris, 1771, p. 341. LIGATIONS OF THE INTERCOSTAL. 551 entered av:is controlling it by pressure on the wound. I slightly enlarged the wound, and discovering with my little finger a good many small fragments of comminuted bone, carefully removed some of them Avith dressing forceps. Meamvhile, the arterial jet avus becoming stronger and the patient momentarily weaker. There Avas evidently no time to be lost. Pressure at the wound was quickly supplied and steadily kept up. Stimulus Avas administered, and the patient being placed upon the table was put under chloroform. An incision was then made on the proximal side of the Avound about an inch and a half in length, beginning about half an inch to the right of the margin of the Avound and extending along the middle of the posterior surface of the ninth rib, the middle of the incision being about an inch and a quarter from the Avound in order that, spicula of bone might not interfere with the subsequent steps of the operation. Having laid bare that part of the rib and carefully defined its superior margin, I took the blunt-pointed strongly-curved needle belonging to the chain saw, armed it with a well-waxed ligature, and introduced it, passing it immediately over the superior margin of the rib at the middle of the incision. The lips of the incised Avound Avere Avell retracted, so that the eye ofthe needle could be sufficiently depressed to maintain the contact of its blunt point Avith the inner surface of the rib until it emerged at its inferior margin opposite the point of entrance. The ligature Avas then tied, including both the rib and artery. The bleeding stopped instantly. In order to make the success secure, I repeated the operation in the same maimer at the distal side of the gunshot Avound. The soft parts were then brought together and secured by sutures and adhesive straps. The patient rallied from the effects of the chloroform, conversed rationally, but sank from exhaustion and died about three o'clock P. m. The autopsy relieved me of the chief objection which appeared to present itself to the operation, for after careful examination it Avas found that in the case of both ligatures the pleura costalis was not pierced. When the usual means had failed, a tedious attempt Avas made in a case that came under my observation to secure the bleeding ends ofthe artery, but Avithout success. In such a proceeding there must be great danger either of creating an opening, or of enlarging one already made into the caA'ity of the chest. The operation with the needle as described above, has the folloAving advantages AA'here ordinary means haATe failed: The bleeding is stopped from the first moment of seeing the patient, as it can always be controlled by pressure at the wound until the operation is completed. Pneumothorax need not be apprehended, as the pleural cavity is not penetrated, and even though it were, the operation being subcutaneous, Avould not be likely to cause it. A sih-erwire ligature, which it Avould be better to use, Avould not produce pleuritis of a serious character even though the pleura were pierced; the ligature could be twisted as tightly as necessary Avithout danger of breaking and be withdraAvn at pleasure. From the relation ofthe artery to the rib, more certain success might be anticipated from this operation anterior to the angle of the rib. In the case given above, after all other means had been tried in vain, the success of the operation was instant and complete, and but for the previous loss of blood would probably have saved the life of the patient." Case.—Private Patrick F. W------, Co. A, 33d Ohio Volunteers, received a penetrating gunshot wound of the chest at Chickamauga, Georgia, September 20th, 1863; the missile entered four inches below the right axilla, passed backAvard, and emerged at the loAver angle of the scapula. He Avas taken prisoner and remained in the hands of the enemy until September 3Cth, Avheu he Avas paroled and scut to the hospital at Chattanooga, Tennessee. Haemorrhage occurred several times during the night of October 4th; an examination on the next day shoAved the skin to be SAvollen with an accumulation of blood; the patient was exceedingly feeble and almost deadly pale. Surgeon I. Moses, U. S. V., administered ether, dilated the wound, turned out all the clots, and, after some difficulty, succeeding in ligating the intercostal artery. Some spiculae AA'ere removed, but it Avas not deemed safe to continue the use of the anaesthetic longer and the patient Avas aroused. No further haemorrhage occurred and he promised admirably, but about the end of the month he began to fail, and died of empyema ofthe same side. Necropsy : The lung had been wounded and adhered closely to the edges of the wound. The loAver part ofthe pleura contained dark unhealthy pus, while the upper part Avas filled Avith an inflammatory secretion. The pathological specimen showing the lower third of the right scapula and the adjoining portions of the seventh, eighth, ninth, and tenth ribs, is represented in the wood-cut (Fig. 252). The extremity of the scapula is carried aAvay, the tenth rib comminuted, and the ninth contused. The fractured extremities are necrosed. The thoracic surfaces sIioav free deposits of osseous matter, Avhich agglutinate them. It was contributed, with a history of the case, by the operator. Case.-Private James Mahew, Co. D, 100th Pennsylvania Volunteers, Avas Avounded at the battle of North Anna River, Virginia, May 24th, 1864, by a conoidal musket ball, which entered the left side and fractured the twelfth rib. He Avas received into the field hospital of the 1st division, Ninth Corps. Spiculae of bone were removed and an intercostal artery was ligated. Death supervened tAvo days after the reception ofthe injury. The case is reported by Surgeon M. K. Hogan, IL 8. V. CASE.-Private J. H. Butterfield, Co. F, 3d Vermont Volunteers, aged 26 years, was Avounded at Lee's Mills, Virginia, April 16th, 1862; the ball entered the integuments at the seventh rib, a little posterior to the nipple, and emerged six inches posteriorly, fracturing in its course the eighth and ninth ribs. He Avas treated in the field until the 20th, when he Avas transferred to Hygeia Hospital, Old Point Comfort, Virginia. When admitted the patient Avas suffering from chills, folloAved by profuse perspiration. April 25th, considerable haemorrhage occurred from the intercostal artery. Surgeon R. B. Bontecou, U. S. V., operated by uniting the wounds of entrance and exit by incision, and cutting off the fractured ends of the ribs Avith the bone forceps, leaving the periosteum and vessel untouched. The intercostal artery Avas picked up by the tenaculum and ligated. The pleural cavity did not seem to have been opened by the ball, but the motion of the cut end of the rib wore an opening and also divided the artery, and haemorrhage again occurred. Two days after, the vessel Avas again tied and the rib cut off still further. Only supporting treatment was used, together Avith quinine. The patient continued to sink, and died May 4th, 1862, from exhaustion. Fig. 252.—Portions of right scapula and ribs, show- ing gunshot fractures of exit. Spec. xiliM, Sect. I, A. SI. M. 552 WOUNDS AND INJURIES OF THE CHEST. Case —Private Thomas Adams, Co. C, 7th Wisconsin Volunteers, aged 18 years, Avas Avounded at the battle of the Wilderness, Virginia, May 10th, 1864, by a conoidal musket ball, which passed through the left arm and lodged in the lun4) 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. Professor GROSS (Op. cit., 5th ed., Vol. II, 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. Chelius (South's Translation, Am. ed , I. c, T. I, p. 492) well observes that bleeding from the intercostal aitery is often observed by the military surgeon in connection with laceration of the lung, and that most of the methods above mentioned increase the bleeding from that organ. When 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; but posteriorly a wound almost invariably causes profuse bleediug, and here the vessel is secured with much difficulty on account of its depth.—Ed. LIGATIONS OF TEE AXILLARY. 553 Ligations of the Axillary Artery.—Besides the large number of ligations of the axillary after wounds of the arm, which will be detailed hereafter, there were thirteen cases in which this vessel was tied for hsemorrhage attending gunshot wounds of the chest. The result was unsuccessful in every instance The patients were from eighteen to twenty- five years of age, the average being twenty-one. The operation was on the right side in five, on the left in eight instances. It was performed for early bleeding, from wounds of the axillary or brachial in three cases; in ten, for intermediary hsemorrhage, occurring from the tenth to the eighteenth day after the reception of the injury. Three of the patients died on the day of the operation, tlie others from the third to the thirteenth day. In the first case the operation was performed for primary bleeding from the brachial: Case 1.—Private James Leddie, Co. E, 118th New York Volunteers, Avas wounded at Petersburg, Virginia, June 30th, 1864, by a musket ball, Avhich entered the upper third of the left arm, passed behind the bone, wounding the brachial artery, and emerged two inches beloAV the middle ofthe clavicle. He Avas conveyed to the hospital ofthe 1st division, Eighteenth Corps, where the left axillary artery was ligated in the axilla on account of persistent hsemorrhage on July 1st. Patient pale, arm cold, forearm almost pulseless. Sensation absent from hand and part of forearm. Death resulted on July 2d, 1864. The case was reported by the operator, Surgeon T. H. Squire, 89th NeAV York Volunteers Case 2.—Private Michael Foley, Co. K, llth Illinois Cavalry, aged 20 years, a robust and healthy man, Avas wounded near Vicksburg, Mississippi, March 3d, 1864; the ball struck near the margin of the pectoral, passed backward, inward, and upward, and lodged in the muscles of the back, between the scapula and spinal column; the axillary artery was severed in its lower third. He fainted from loss of blood, Avhen Avounded. On the 5th, he was conveyed to Hospital No. 2, Vicksburg. When admitted, there was some fever; pulse 90, full and moderately strong. Skin, secretions, and appetite in tolerably good condition. The Avound was painful, but he had slept some, was cheerful, and did not suppose himself dangerously Avounded. The arm was considerably SAvollen; extensive ecchymosis of arm and chest; no hsemorrhage; wound healthy; suppuration commencing. No pulsation below the wound; arm, forearm, and hand warm. Collateral circulation good. Assistant Surgeon W. B. Trull, U. S. V., administered chloroform, enlarged the wound, and ligated the proximal end of the axillary artery in the wound three-fourths of an inch above the injury. Very little hsemorrhage occurred. The patient reacted finely. On the 7th, the UallAvas cut down upon and removed. He did well until the 9th, whei>fhe ligature separated, and intermediary ha?morrhage came on to the amount of thirty-tAVO ounces. The arm was considerably swollen but the Avound was not unhealthy. The patient was feeble, pale, and anxious; pulse rapid and Aveak. Chloroform was again administered, and the artery religated half an inch higher up in the Avound. He gradually sank, and died on March 10th, 1864, from exhaustion, the axillary artery having sloughed after the first ligation. The post-morten examination revealed nothing additional except the precise points of the ligations of the artery. The second ligation Avas one-third of an inch aboA'ethe external circumflex artery. The case is reported by Surgeon EdAvard L. Hill, 20th Ohio Volunteers. Case 3.—Corporal Alfred Hollingshead, Co. H, 12th Kentucky Volunteers, Avas wounded at Marietta, Georgia, June 21st, 1834, by a pistol ball, which entered at the upper third of the right arm, passed inward to the chest, and emerged at the third dorsal vertebra. He was taken to the field hospital of the TAventy-third Corps. On June 23d, paralysis of motion and sensa- tion in the arm ensued. Surgeon EdAvard Shippen, U. S. V., enlarged the Avound and ligated the axillary artery; the brachial artery was also ligated beloAV the wound. Mortification supervened in the course of forty-eight hours, and death resulted on June 26th, 1864. The case is reported by Surgeon A. M. Wilder, U. S. V. Case 4.—Private William Hall, Co. H, 15th United States Infantry, aged 19 years, Avhile lying in his tent at Mobile, Alabama, January llth, 1866, was wounded by the accidental discharge of a musket in the hands of a comrade. The ball entered the right side just below the cartilages of the false ribs, fracturing in its passage the eighth rib; it then emerged, and entering the axilla, traversed the arm, and passed out posteriorly at the top of the shoulder. The humerus was not injured. He Avas taken to the post hospital at Mobile. Before admission he was said -to have lost a bucketful of blood. When admitted he was in a state of syncope, was unable to speak, and almost pulseless. The extremities Avere cold. Powerful stimulants were immediately administered. Very slight haemorrhage occurred from either Avound. He continued to improve steadily until the morning of the 20th, Avhen he Avas attacked with profuse haemorrhage, which came from the neighborhood of the axillary artery. He lost about fifteen ounces of blood. The usual compression was applied and the hsemorrhage ceased. On the morning of the 21st, a second hsemorrhage occurred, by Avhich he lost about twenty ounces of blood. On the 22d, the prostration was so extreme and the prospects of controlling the continued oozing so remote, that a consultation was held, and it was* determined to put him under the influence of chloroform and tie the artery. A very small quantity of the vapor sufficed, and after a great deal of difficulty, OAving to the great SAvelling and purulent matter in the wound, the artery was tied Avith a single ligature by Acting Assistant Surgeon R. W. Coale. During the operation several pieces of cloth Avere extracted, and also two pieces of substance which had the appearance of portions of an artery and which subsequently proved to be such. On the extraction of the cloth, hsemorrhage per saltum commenced, Avhich, hoAvever, Avas easily controlled by pressure on the subclavian above the clavicle by means of a door-key. The patient only survived the 70 Fig. 253.—Portion of right axillary artery, its coats ulcerated through, after gun- shot contusion. Spec. 2674, Sect. I, A. .Ai. M 554 WOUNDS AND INJURIES OF THE CHEST. operation a fi-Av minutes. Necropsy : A large semi-circular portion ofthe axillary artery, corresponding to about half the calibre of the vessel, was clearly cut out by the ball, about an inch below where it is called the subclavian. The bone and brachial plexus AA'ere uninjured. The lower dissection showed the fractured rib, Avith suppurating soft parts, corresponding to the course of the ball. The most important fact connected Avith the case was the great length of time before intermediary haemorrha"e took place—nine days. There is no doubt that the cloth Avas driven into the artery, and, possibly, by some movement of the patient afterward, or from suppuration of surrounding tissues, this and the coagula Avere dislodged. Almost invariably such a Avound in an artery of this calibre Avould cause death in less than five minutes. The Avood-cut (Fig. 253) on the preceding pace represents a preparation of the axillary artery. It Avas 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, Avas 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 beloAV the insertion of the pectoralis minor. He was carried to the field hospital, Avhere the ball was removed a few hours after the reception of the injury. Simple dressings were applied. On the 17th, heAvas transferred to Harewood Hospital, Washington. The case progressed Avell until the 23d, when haemorrhage to the amount of about six ounces occurred from the posterior wound. The Avound Avas enlarged and the bleeding vessel searched for, but it could not be found, although it was supposed to be the suprascapular artery, as pressure below the clavicle arrested the haemorrhage. The edge of the scapula was denuded and rough for about one inch. The axillary artery Avas ligated immediately after ita 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 aud 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 be administered to him, as he closed his teeth and rejected everything. He continued in this condition until the 29th, Avhen a capillary hsemorrhage occurred to the amount of about one ounce from the posterior Avound. Compress and bandage Avere applied, which entirely arrested it. He would occasionally take a spoonful of milk punch Avith a small quantity of morphia in it. Death resulted on the night of December 29th, 1862. The ligatures had not come aAvay. The wound of incision had suppurated freely but there was no attempt at union. Surgeon Thomas Antisell, U. S. V., reports the case. Case C>.—Sergeant John Maekey, Co. I, 50th Pennsylvania Volunteers, aged 23 years, was admitted to Mount Pleasant Hospital, Washington, May 29th, 1864, Avith a gunshot Avound 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 axillary artery was divided about Avhere it becomes the brachial. June 5th : Arm and forearm immensely SAVollen from erysipelas and extravasation, and in a sloughing condition. The patient Avas nearly exjiausted from excessive haemorrhage from the axillary artery. Acting Assistant Surgeon H. Craft attempted to ligate the axillary artery. An incision of three inches Avas 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 minie ball entered over the anterior border ofthe right scapula, fractured the bone, passed doAvmvard, and emerged at lower angle of scapula. He Avas admitted on the next day to Hospital No. 3, Nashville. Tonics and nourishing diet were administered. On December 12th, intermediary hsemorrhage occurred from enlarged vessels of the collateral circulation; pressure was applied and the bleeding arrested until the 14th, when it again occurred. 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 Avound was plugged Avith lint saturated with tincture of iron aud pressure was applied. The haemorrhage did not recur, but the patient failed to recuperate, and died December 21st, 1864, from exhaustion. The case is reported by Surgeon J. R. Ludlow, U. S. V. Case 8.—Private Asahel A-----, Co. F, 25th Massachusetts Volunteers, aged 25 years, was wounded at Cold Harbor, Virginia, June 3d, 1864 ; a conoidal 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 the ball was removed and simple dressings Avere applied. On June llth, 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 Avound. Pulse regular, but weak; patient looked pale. Anodynes and stimulants Avere administered. On the next day haemorrhage again occurred, which yielded to strong pressure on the compress. June 17th, 10 A. M.: Patient very pale, anaemic, 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 Avhole calibre of the artery. The adjacent wood-cut f FiG. 254) represents a preparation of the left axillary artery, Avith a large and deep ulceration, involving nearly half of the cylinder ofthe vessel, about an inch above the origin of the subscapularis. It Avas Fig. 254 -Portion of a left axillary artery, showing au ulceration after ™»tributed> with a history of the case, by Acting Assistant ligation. Spec. 2576, Sect. I, A. .ai. u. Surgeon W. L. Herriman. LIGATIONS OF THE AXILLARY. 555 Case 9.—Private James T. Shepherd, Co. A, 18th Massachusetts Volunteers, aged 18 years, of a naturally strong and vigorous constitution, Avas Avounded at Gettysburg, Pennsylvania, July 2d, 18G3 ; the ball entered at the inner edge of the deltoid of the left side, at the curve of the'armpit, passed through the axillary space, and emerged three inches below on the outer side of the arm; a great quantity of blood was lost at the time ofthe injury. He Avas treated in the field until the 8th, Avhen he was transferred to Satterlee Hospital, Philadelphia. The patient was kept as quiet as possible, and cold Avater applied to the wound. On the llth. arterial hsemorrhage took place, Avhen about a pint of blood was lost. The wound was immediately cut do\ATi upon, and the bleeding vessel, supposed to be the axillary artery, Avas tied. On the 19th, hsemorrhage to the amount of about eighteen ounces occurred; the Avound was again opened and the vessel secured higher up. On the 23d, hsemorrhage recurred again, and the vessel Avas ligated still higher up. It was only after the third ligation that the pulsation at the wrist was stopped; during the intervals of the hsemorrhage he was kept up Avith beef tea, brandy, milk, etc. After the third haemorrhage he Avas excessively exhausted, and it seemed as if he Avould hardly rally. A fourth hsemorrhage, on July 24th, caused death. The case is reported by Acting Assistant Surgeon T. G. Morton. Case 10.—Private David Walsh, Co. D, 106th Ncav York Volunteers, aged 23 years, was admitted to Filbert Street Hospital, October 24th, 1864, with a gunshot Avound 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, Avhich Avas good primarily, Avas greatly reduced by hsemorrhage. Acting Assistant Surgeon EdAvard L. Duer administered chloroform and ether, and ligated the left axillary artery immediately under the clavicle, in the triangle formed by the pectoralis minor muscle, thorax, and clavicle. Under the free use of cream, butter, and Avines the progress of the case Avas very encouraging, but haemorrhage recurred on November loth; death resulted on the same day. Surgeon Thomas B. Reed, U. S. V., reports the case. Case 11.—Private Charles Tighe, Co. F, 56th Massachusetts Volunteers, aged 18 years, received a gunshot wound ofthe left chest and arm at Petersburg, Virginia, June 16th, 1864. The ball entered at the middle ofthe pectoralis major of right side, passed through the left axilla, and emerged at the upper third of the arm, outer aspect, Avomiding the axillary artery. He was at once admitted to the hospital of the 1st division, Ninth Corps, where simple dressings Avere applied to the Avound. On the 19th, he Avas transferred to Harewood Hospital, Washington. On July 1st, intermediary hsemorrhage to the amount of twelve ounces occurred, and ou the next day Surgeon R. B. Bontecou, U. S. V., ligated the axillary artery. The haemorrhage did not recur, but the patient died July 4th, 1864, from exhaustion. The case is reported by the operator. Case 12.—Private William E. DoAvning, Co. 1,16th Pennsylvania Cavalry, aged 19 years, Avounded at Hanover, Virginia, on May 28th, 1864, by a conoidal ball, which passed through the left axillary space. He was conveyed to the field hospital of the 2d division, Cavalry Corps, Avhere the avouih! Avas dressed. On June 4th, he Avas transferred to De Camp Hospital, New York Harbor. On the 12th, intermediary haemorrhage to the amount of twenty ounces occurred from the axillary artery. On the 15th, the patient was put under the influence of chloroform and the axillary artery was ligated above and below the wound. The vein Avas found injured, and was also ligated. The haemorrhage* did not recur. Death ensued on June 28th, 1864. Assistant Surgeon Warren Webster, U. S. A., reports the case. There was no evidence at the post mortem examination of the phlebitis or of pysemia. Case 13.—Private E. C. Melley, Co. K, 2d West Virginia Mounted Infantry, was Avounded at Droop Mountain, Virginia, November 6th, 1863, by a musket ball, AA'hich entered one and one-fourth inches below the junction of the inner and middle thirds of the clavicle, passed downward and backAvard, and made its exit about midway of the inferior costa of the scapula, 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 axilla, burroAving under and between the pectoral muscles as well as the scapula and latissimus dorsi, filling up the space below the clavicle, and rendering all the tissues tense. The superficial veins Avere enlarged. The patient had'lost considerable blood while being removed from Beverly. He passed the night tolerably well. Pulse quite full at both wrists. The hsemorrhage proceeded from the anterior orifice; the posterior one Avas closed and nearly healed. On November 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, which was promptly arrested by compression above the clavicle. The clavicular portion of the muscle Avas partly divided at right angles to the first incision. The depth of the Avound Avas consid- erable, rendered so by the swollen condition of the parts; the tissues were greatly disorganized. Pulsation of the artery was arrested by compression above the clavicle. In searching for the artery the subclavian vein Avas opened, the entrance of air caused syncope, and death ensued in from seven to ten minutes. The necropsy revealed the axillary artery almost entirely diA'ided 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, o.r the " old operation," might have given less disastrous results, or at least would have been more correct practice. Of Case 3, Surgeon C. 8. Frink remarks : "The patient was not iu a fa Adorable condition. The arm was cold, and perfectly paralyzed; at one time there was a slight movement of the fingers possible, but this was soon gone, and although 550 WOUND3 AND INJURIES OF THE CHEST. there ayms no direct injury of the axillary plexus, sensation and motion were not restored after tho 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."1—{Medical Director II. S. IIewit'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 scapular, 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 secendary hsemorrhage: Fio. 255.—Portions of left axil- lary and brachial, shewing the sloughing- off of the subscapular at its origin. Spec. 2835, Sect. I, A. M. M. Case.—Private F. M. Brake, Co. D, 35th North Carolina Eegiment, 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 Avas 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 ot persulphate of iron, and applying compresses tightly bandaged in the arm-pit. 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 H. M. Dean; the notes of the case by Acting Assistant Surgeon Thaddeus L. Leavitt, U. S. V. Case.—Private Daniel Hughes, Co. K, 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 AA'ith a knife at New Berne on the same day. On admission, there was haemorrhage 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 aud the fourth rib, passed into the loAver lobe of the right lung,'and lodged. He was taken to the field hospital of the Ninth Corps, and, on April 6tb, was transferred to Slough Hospital, Alexandria. Light cold-water dressings and stimulants were used until April 14th, Avhen * Dr. Theodor Bilroth Avould, perhaps, contest the distal origin of the fatal haBmorrhages in some of these cases. See the fifteenth letter of his recent Chirurgische Briefe. But I think the preparations in the Museum would convince him of the frequency of bleeding of this nature. EXCISIONS OF THE CLAVICLE. 557 hsemorrhage occurred from a small branch of the circumflex artery, which was ligated at the time. On the 16th, hsemorrhage 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 lAventy ounces of blood. Nourishment and stimulants were administered. Death resulted on April 21st, 1865. The necropsy revealed the course of the ball. The lower lobe of the right lung had undergone decomposition; the upper lobe Avas 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 practiced 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.f 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, 1802, 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, Avith 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, 1864. 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 Rivas, Nicaragua, April, 1856, by I. Moses, M. D., late Surgeon General of the Nicaraguan Army. Besides the authors already cited, consult, on this subject: NOTT, J. C, Ligature of Subclavian Artery for ihe cure of Axillary Aneurism caused by Gunshot wound, Am. Jour. Med. Sci., p. Ill, Vol. II, 1841; Sir William FERGUSSOS'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 observations in the fifth edition of his Science and Art of Surgery, London, 1869, Vol. II, p. 86; 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, Philadelphia, 1872, Vol. I, p. 804, Vol. II, p. 450 ; Dr. J. Ashhurst's excellent summary of the present state of our information in his new Principles and Practice of Surgery, Philadelphia, 1871, p. 547; BlLUOTH, Chirurgische Briefe, U. S. V., Berlin, 1872, S. 113; GEORGE Fischer, in Dr. von Pitha's Handbuch. t Professor Gross informs us (System of Surgery, Vol. II, p. 1077; that Itemmer extirpated the clavicle for osteosarcoma as far hack as 1732. Dr. O. Heyfelder (Lehrbuch der Resectionem, AVien, 1863, 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 Meyer, who operated, in 1823 (Encyc. Worterbuch de Med. Wiss., B. 29), successfully on a man of 34 years, with caries; but he ascribes a partial resection of the diaphysis to Cassebohm, in 1719 (Act. Med. Berol., B. I). In 1813, Dr. Charles McCreary, of Kentucky, excised the right collar-bone of a boy of 14 years, for scrofulous caries. The boy survived many years, with an excellent use of the corres- . ponding limb. The specimen is in Professor Gross's private collection. Drs. Wedderburn, of New Orleans, in 1852 ; Blackman, in 1856, and Fuqua, of Richmond, in 1860, had like success in similar cases. Mott, in 1828; J. C. Warren; in 1832, and Dr. E. S. Cooper, in 1837 ; Dr. Curtis, of Chicago, about the same year, and Dr. Eve, of Nashville, in 1870, performed the operation for 'malignant tumors. Mott's case 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 WOUNDS AND TNJUEIES OF THE CHEST. Of the next operation of this nature, more particulars are furnished. The operator was Dr. James C. 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 Avound ofthe chest in action at Mobile Bay, August 5th, 1864. In a communication to the American Journal of Medical Sciences for April 1865, Assistant Surgeon J. R. Tryon, U. S. N., says: " The patient was supposed to have been Avounded by a fragment of shell, which entered midAvay betAveen the articulations ofthe clavicle ofthe right side, splintered the bone to both sternal and acromial extremities, 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, Avitli the fractured extremities of the clavicle pressing downward and inAvard 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 pro.truding. Six hours after the injury, the patient (being quieted 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 bone. 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 Avound Avere brought carefully together by the interrupted suture and water dressings applied; the spiculae 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 6th, Avhen admitted into the Naval Hospital at Pensacola, symptoms were quite favorable. August 8th: Many additional pieces of bone were removed from the Avound 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. HoAvever, on the 19th, the patient was fully convalescent from the pneumonia; Avounds 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 emaciat d, and died of exhaustion at twenty minutes after seven o'clock P. M., August 20th, 1864, twenty-five days after the injury and operation. At the time of his death the Avound of excision had entirely healed near the sternal end, and Avas filling up rapidly by healthy granulations near its outer extremity. With this CA'idence of repair Ave can safely state the perfect success ofthe operation, and but for the severe Avound ofthe scapula the poobable recovery of the patient. Treatment throughout: Tonics, stimulants and anodynes, and during the different 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 Avas found to have been destroyed, probably by the missile, in conjunction Avith the subsequent suppuration. This cavity Avas lined Avith a tough membrane three lines in thickness, dividing it from the loAver portion of the lung, Avhich was found to be perfectly healthy. Direct communication had existed between the anterior and posterior wounds. Unless complicated by serious injury of the 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. S. 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, Avas Avounded at the battle of Spanish Fort, Alabama, April 3d, 1865, 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, Avhere resection of the outer third ofthe clavicle was performed by Surgeon EdAvin Powell, 72d Illinois Volunteers. Several days aftenvard the wounded man was transferred to the Marine Hospital at NeAV Orleans, Louisiana, Avhere he died on April 12th, 1855. Case 4.—Private Charles Baker, Co. D, 31st United States Colored Troops, aged 20 years, was wounded at Petersburg, Virginia, July 30th, 1S64, by a conoidal 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, Avhen he Avas 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 Avere applied, and stimulants and tonics administered. September '25th: System becoming exhausted from the suppuration. October 4th : A pyaemic chill occurred. Death resulted on October 6th, 1864, from pyaemia. The case is reported by Surgeon I. I. Hayes, U. S. V. EXCISIONS OF THE CLAVICLE. 559 Case 5.—Corporal Freeman Scott, Co. L, 21st Pennsylvania Cavalry, aged 18 years, Avas wounded at Chiekahominy River, Virginia, June 2d, 1S64, bv a conoidal ball, which struck the left clavicle about its middle, producing a comminuted fracture, passed doAVirward and backward, and lodged apparently beneath the scapula. He was admitted to Stanton Hospital, Washington, on June 4th. The wound Avas suppurating profusely but of good quality; the broken ends of the clavicle over- lapping each other; they Avere denuded of periosteum and bathed Avith pus; they were surrounded bv a cavity filled Avith pus, which extended doAvn almost to the artery, and there Avas 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 Avas favorable. On June 13th, 1804, ether Avas 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 saAv and the osteotome, great care being taken that the subclavian artery should receive no detriment. The portion resected Avas denuded of periosteum and lying in a cavity filled with pus. Death occurred from pleuritis 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: Cask 6.—Sergeant J. II------. Co. I, 9th NeAV York State Militia, was admitted to the hospital at Frederick, Maryland, September 23d, 1862, Avith a gunshot Avound of the shoulder, received at Antietam on the 17th, by the bursting of a shell. On examination, it Avas found that the outer half of the clavicle had been torn away; this, Avith 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 above the joint had the appearance of having been much torn and lacerated and were in a sloughy condition. Stimulating dressings Avere applied, and in about two weeks the slough separated, leaving a granulating ulcer six inches in length and four in breadth. Although the sloughing had been quite extensive, the joint remained uninjured. Doctor Gordon Buck, of Ncav York, Avhile 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 Avas 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 right angle with the arm, which Avas raised to a level Avith the shoulder and put in position by Smith's anterior splint. Tlie case progressed A'ery favorably; on December 12th, a tubular sequestrum, about tAvo and one-half inches in length, Avas removed; on the 16th, another small piece of bone came away. On January 16th, 1863, the patient's general condition was good. An examination Avith a probe revealed some small fragments of bone, which had prevented the complete cicatrization of the wound. He Avas discharged from service on March 13th, 1863, at which time there was paralysis ofthe arm. The acromial and outer cylindrical portions ofthe necrosed clavicle were fonvarded, with a history of the case, by Assistant Surgeon R. F. Weir, U. S. A., and are represented by the wood-cut (FiG. 256). Pension Examiner W. M. Chamberlain reports, March 20th, 1863: " There is no poAver in the arm, and the Avound is not fairly closed. Disability mostly permanent." Case 7.—Lieutenant Colonel H. N. Whitbeck, 65th Ohio Volunteers, aged 37 years, was wounded at KenesaAV, Georgia, June 27th 1864; the missile fractured the left clavicle in its middle third, and lodged in the cavity of the thorax. He Avas 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 Avound Avas 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 through 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. Pension Examiner A. D. Blein reported, December 2d, 1865: "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 13th, 1870, at Avhich date he stated the wound had not permanently healed. It had re-opened four times during the previous year. He enjoyed comparatively 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 passed through the left shoulder and shattered the acromial half of the claA'icle. He also received a gunshot wound of the left hand. He was taken to the field hospital, where the ring finger Avas 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, Avho 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 Avhole course of the removed bone, and the wound Avas closed by numerous stitches of iron Avire. No adhesive strips were applied. He was discharged from service on January 6th, 1863, at which time perfect neAV bone had formed throughout the Avound. The shoulder drooped forward a little, but the motion Avasgood. This pensioner was paid to June, 1867, and Pension Examiner W. OAven reports his disability total and permanent. The specimen was forwarded by Surgeon W. Varian, U. S. V. Fig. 256.—Sequestra from left clavicle. Spec 3844, Sect. I, A. M. M. Fig. 257.—Shattered acromial half of left clavicle, excised for gun- shot fracture. Spec 372, Sect. I, A. M. M. 560 WOUNDS AND INJURIES OF THE CHEST. 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, 53d Massachusetts Volunteers, aged 45 years, was wounded at Port Hudson, Louisiana, May 27th, 1863; the missile entered near the sternal end of the right clavicle, passed backAvard and outward, com- minuted the clavicle and neck of the scapula, the acromion and coracoid processes of which it fractured, and escaped through the scapula, just below the spine. It also fractured the first aud second ribs at their middle, wounded the subclavian artery and vein, and injured the brachial plexus. The patient Avas conveyed to NeAV Orleans, and admitted, on the 29th, to the University hospital. The loose fragments of bone Avere removed, the fractured ends of the clavicle rounded off, and cold-water dressings applied. Death resulted on June 7th, 1863. While in hospital, and for several hours after death, the right side ofthe chest and right arm were several degrees warmer than the corresponding parts of the left side. The necropsy revealed the injury done by the ball. The subclavian artery Avas not opened, though the inner coats Avere much lacerated, Avhere the artery passed over the first rib, so much so that the vessel Avas torn in removing it. The subclavian vein was torn, and an imperfect coagulum filled up its cavity. The outer cord of the brachial plexus 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, Avith a history of the case, by Assistant Surgeon P. S. Connor, U. S. A. The subject of the following fatal case of partial excision had undergone an amputa- tion at the wrist: Case 10.—Corporal TV. H. Husky, Co. I, 3d South Carolina Regiment, while in the act of firing, November 18th; 1863, was wounded by a ball from an Enfield rifle, which struck the left hand, injuring it severely, and, after passing through many folds of blanket, struck the right clavicle about tAvo inches from the sternal articulation, fracturing and comminuting the bone for the space of about two inches, and splitting 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 R. L. Johnson, P. A. C. S., says: "The case came under my charge on the 4th of December, at which time nothing was knoAvn of the position of the ball. The surgeon who Srst examined the case Avas necessarily ignorant ot the fact that the humerus was injured, for it was not broken in tAvo, but shot through, which caused, hoAvever, some splintering. December 5th : Wrist (stump) doing Avell; right arm very much swollen, probably on account of an abscess in the anterior part of the shoulder, which presses 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 noAV from one to tAvo 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 Humphrey's brigade, and Dr. North, of Anderson's, were consulted to-day, and it Avas agreed : 1st. To put the patient under the influence of chloroform, 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 ofthe clavicle. December 26th : Through the kindness of one ofthe Federal surgeons at Knoxville, I procured a good and complete set of resecting instruments. December -27th : The folloAving operation avus made to-day, Assistant Surgeons Spinks, Bygott, and Cotten, and Dr. Allen, being present: The patient having been anaesthetized, was placed upon the table, and a large gum cathether was introduced into the wound and passed outAvard along the sinus to the anterior part of the shoulder, Avhere there Avas a collection of pus, and where the ball was supposed to be. Nothing more Avas gained by this step than a knoAvledge of the exact position of the abscess. The arm was then moved about to ascertain whether or not the humerus Avas fractured; and as there was no crepitus, no displacement, and no impairment of the movements of the joint, it Avas decided that the humerus and shoulder-joint were intact. An incision about tAvo inches long Avas then made at the anterior edge ofthe deltoid muscle, and parallel with it, reaching from opposite the head of the humerus to below the neck. After cutting nearly an inch deep 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 Avound 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, filthy pus, and the ball, which was extracted. The clavicle was then resected The existing orifice was enlarged by incisions—one extending nearly to the articulation of the left clavicle and sternum, the other extending over the distal fragment for about two inches. The sternal end Avas then disarticulated and removed by dissection. All spiculae were then carefully removed from the wound. These spiculae were generally furnished on one surface with periosteum, by which they greAV to the tissues. Their other surfaces being free, and acting as foreign bodies, were surrounded by pus. There Avas one point, however, at the bottom of the Avound, about one inch and a half long, Avhich was firm and immovable and covered with healthy granulations. This Avas supposed (at the time) to be a portion of the clavicle from the posterior surface that had never been displaced, and as there Avas no collection of pus under or around it it was not removed. A chain saAv 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 feAV sutures were taken ; Avet lint was applied ; the patient was put to bed, and morphine and Avhiskey were administered. December 2-th: Rested Avell last night; very pale and languid to-day ; Avithout appetite and Avith some diarrhoea; a counter opening Avas mude into the abscess from Avhich the ball had been extracted ; prescribed one grain of opium, ordered eggs, whiskey, A.c. December 29th: Has a little more color in his cheeks to-day than he had yesterday; eat squirrel stew with great relish; boAvels better; EXCISIONS OF THE CLAVICLE. 561 prescribed tr. catechu, gave whiskey, eggs, milk, &c.; the openings in the shoulder are discharging freely to-day, the discharge from the wound being much diminished. The sAvelling of the arm is sy much reduced as to slacken the bandages, the first of which Avere applied on the 5th instant, and which had been lv-applied every two or three days since. The arm reduced about one-third. December 30th and 31st: Doing Avell. January 1st, 1861: Doing Avell; appetite good; wound and incisions granulating; discharge from the Avonnd much diminished, there not being enough to overflow the Avound "in twelve hours; the discharge from the anterior incision (in Avhich a tent is kept), Avhich is now the outlet from the abscess in the shoulder, is less than the discharge was from the Avound before the operation. January 7th : Healthy granulations over the end ofthe bone, and, indeed, everywhere about the wound; discharge, which is from the shoulder, very slight, January 8th : In the afternoon, some diarrhoea; prescribed tr. opii, tr. catechu in equal parts, tAventy drops after each operation on boAvels. January 14th : Whiskey supplies have been out since the 7th; diarrhpea lias been constant; prescribed tannin, catechu, opium, &c, with no effect; losing flesh and getting Aveaker. January 21st: Diarrhaea constant: patient very Aveak; procured Avhiskey to-day. January 26th : During past six days have had good supply of stimulants ; patient very weak; diarrhoea continues; will probably not live till to-morroAV. January 27th : Died at one o'clock r. M. The post-mortem examination revealed the course of the ball. On making an incision from the wound, Avhich 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 AA'hich it was extracted. Wherever any periosteum Avas left, bone was forming rapidly. The hard, firm place in the bottom of the Avound, supposed during the operation to be a spicula from the posterior part of the clavicle, proved to be entirely neAV bony formation. The abscesses around the head of the humerus AA'ere large, and had burrowed back into the shoulder to some extent." The eleventh and last of the series of operations on the clavicle was for necrosis following a simple fracture: Case 11.—Private John Q------. Co. E, 9th NeAV 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 Avas found to be suffering from general emphysema, the result, probably, of a Avound of the apex of the pleura from some of the fragments of the broken bone. He Avas treated for this difficulty for a considerable time and finally entirely recovered. Several spiculae 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, NeAV 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 shoAved 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 Avith and evidently to form a solid piece with that portion of Bequestrum felt through the outer opening. It was thought that the Avhole of that portion of the bone between these two points was dead. There Avas a considerable amount of thickening around it caused by the deposit of involucrum. The Avound discharged slightly. June 1st: The bone was now freely movable in its bed and its sternal end pointed out of the Avound 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, Avith an incon- venience in the motion of the parts, the patient suffered very little and enjoyed a good appetite. On June 21st, 1864, Acting Assistant Surgeon J. K. Merritt removed the sequestrum by slightly enlarging the internal opening. The parts from which this portion of bone Avas removed soon became firmly braced by a neAV bridge of osseous tissue, formed by the involucrum, and really constituted a new clavicle. The motions ofthe arm, though somewhat restrained, Avere 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 gangrene fairly declared itself. On the 10th, a thick, angry-looking slough covered both wounds; the edges of the openings Avere 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 Avere removed and bromine applied directly to the part. By the 16th, the gangrene had extended itself into the track which communicated between the two wounds. The patient complained of a great deal of pain and soreness. Bromine was introduced into the track of the wound, but OAving to the presence of the slough and the difficulty of removing it, the remedy could not be brought in direct contact 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 19th, the parts had entirely healed; there Avas a marked enlargement from deposit of new bone at the seat of exfoliation. The soldier Avas discharged from service October 1st, 1864; the arm was useful and nearly all the normal movements could be made Avith it. The sequestrum is represented 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. 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 FlG 2.->B.—Tubular seques1 rum from necrosis of right clavi- fragments at the hospital at Washington. The excavation on the anterior cle. Spec. 4332, Sect. I, A. M. M. 71 5(i2 WOUNDS AND INJURIES OF THE CHEST. face of the bone was probably caused by the removTal of two or three detached fragments at that time. If there were any small fragments toward the sternal end, as doubtless there Avere, they must have been firmly attached to the periosteum and become incorporated with the involucrum, and helped to form the firm bridge of bone which exists over the subclavian vessels. The Bpecimen was contributed, AAith a history of the case, by Acting Assistant Surgeon G. F. Shrady. Excisions of Portions of the Scapula.—The comparative frequency of fracture of the shoulder-blade in gunshot wounds of the chest has been referred to on page 484 of this Chapter, and examples are there cited of the removal of loose splinters of bone, as part of the ordinary dressing of such injuries. Sometimes, it is necessary to excise undetached portions of bone, to facilitate the extraction of projectiles, 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 part of the scapula, it should be extirpated. The last assertion is justified by the argument of Dr. Stephen Rogers, whose admirable paper* on the subject conclusively establishes the apparent paradox that it is safer to excise the whole than a part of this bone. 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 Cumming, in 1808, in the case of a man with gunshot comminution of the humerus and scapula,' and a similar operation, for the same cause, was successfully practiced by Gsetani Bey, in 1830, on a boy of 14 years. Larrey, in 1838, repeated the operation with success on a subject of the same age. The removal of the entire scapula and preserving the arm is an advance of modern surgery,f which 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 : Case 1.—Private F. E. Bickett, Co. F, 5th Connecticut Volunteers, aged 51 years, was wounded at Chancellorsville, Virginia, May 3d, 1863, by a conoidal ball, which struck the infra-spinatus fossa of the left scapula about midway between its inferior angle and the spine, passed forward, splintered the bone extensively, and finally lodged in the glenoid cavity without injuring the humerus. He was treated in the field hospital of the 1st division, TAvelfth Corps, until the 6th, when he Avas sent to Lincoln Hospital, Washington. An operation, for the removal of the ball, discovered a large number of shattered fragments lying near the joint, which were dissected out from their ligamentous attachment and Avithdrawn. The lower portion of the scapula being noAV entirely separated from the upper, and, not knowing to what extent the inferior portion of the bone had been splintered, it Avas 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 spine and supra-spinous fossa Avere preserved. The smooth head of the humerus was visible through 'the wound. The patient did remarkably Avell. No bad symptoms supervened, and he gradually regained his strength. The incision made Fig. 259.—Portion of left scapula sue- for the removal of the bone filled up without sinuses or discharge of exfoliations. On cessfully removed after a gunshot injury. . __ . . , f _,T , . , , . , Spec. 1090, Sect. I, A. M. M. August 20th, he was furloughed for sixty days. Lpon returning, the wound had entirely * Rogers, S., Case of Excision of the Entire Scapula, to which is added a History of the Operations invoicing a Removal of all or a Considerable Part of this Bone; with the view of establishing the surgical Character and Prognosis of this Class of Operations. In Am. Jour, ofthe Med. S< i., N. S., Vol. LVI, p. 359, 1868. t "Entirely a modern achievement in surgery," said Sir AA'illiam Fergusson (Lectures on the Progress of Surgery,X,or\. (Casualty list.) 5. Private Michaei Donnegan, Co. D, 17th New York Volunteers, aged 25 years. Savage's Station. .June 29th, 1862. Excision of portion of tenth rib. Nearly well September 9th, 1862. Dr. J. A. Keagan, of North Carolina, has published (Am. lour, 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.1 The first indication would present itself when arrow-heads are impacted in the ribs;2 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,3 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.4 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 irom the rib.5 The operations for tumors may present formidable difficulties; but need not be considered here.6 l M. DEMARQUAY (Gaz. Mid. de Paris, T. XXIV, p. 30, 1869). I cite M. Demarquay as the latest author who has treated the subject systemat- ically. Dr. F. H. Hamilton (Principles and Practice of Surgery, 1872, p. 266) proposes another indication : " To exsect a portion of the rib in order to reach and secure the bleeding A'essel" in some cases of haemorrhage from the intercostal artery, which is, I think, inadmissible. 2 See Ripcrt of Surgical Cases, etc., Circular No. 3, S. 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' Anatomie Chirurgicale et de Midecine Opcratoire, Paris), 1855, p. 660. M. Malle observes justly that Heine's osteotome is a preferable instrument for such operations, but this is a very expensive instrument, rarely made except for the armamentaria of public institutions. Medical officers should know that there is one, which they are at liberty to use, in the collection of instruments at this Office. * Duverney (Traite des Maladies des Os), Bottcher (Ausivahl. d. Chir. Verhandes, Berlin, 1795), GOULARD (OZuvres de Chirurgie, Pizenas, 1766), Callisen (Systema. Chirurg. Hod. Hajnim, 17S8) writes on this class of cases. ROUX reports a case in the Examinateur Medical, Vol. I, p. 122. A full collection of enses is made by JAEGER, Handworterbuch der gesammten Chirurgie, Leipsig, 1839, Art. Resectio ossium, B. V., S. 424. t Dr. William A. McDoaa^ell, of Fincastle, Virginia, was one of the first in this country to excise considerable portions of necrosed ribs. He describes in his Dissertation on the Pathology of the Bones (Am. Med. Recorder, Vol. XIII, p. 119), the extraordinary operation he successfully performed June 25th, 1827, for the removal of the greater part of the right sixth and seventh ribs. At that time the operation by Richeuand (the account is translated in the Medical Repository, New York, 1818,Vol. IV, p. 401), and that of ClTTADINI (Annali univ. di Medicina, Milano, Marzo, 1826; but published in the Journal complementaires of the great dictionary in sixty A'olumes, in 1820) were about the only instances of this operation mentioned in the current surgical 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 ajirobe-pointed knife, and the rib by cutting forceps. 6Consult Professor S. D. Gross's System of Surgery, 5th ed., Vol. II, p. 1080. M. DEMARQUAY, Article Cotes, in the Nouveau Dictionnaire de Medicine et de Chirurgie Pratiques, Paris. 1869, T. IX, p. 589, and the amplification of this article in a dissertation entitled R 'section des cdtes in the Gazette Medicate de Paris, 3eme Serie, T. XXIV, pp. 29, 56; Percy's Article Resections, in the Diet, 'des Sci Mid., T. XLVII, p. 550; RlVKKIUS, Observationes Medicnruni Centurice Quatuor, Lugduni, 1763, p. 129; Communicated observation by A. D. OZIA AlMAU, 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 opening into the thorax was produced that would admit the hand. Aimar removed four fingers' breadths from the carious rils, and EXCISIONS OF THE STERNUM. 571 Excisions of Portions of the Sternum.—Trephining of the manubrium and gladiolus, which should be 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 Martiniere laid down rules for trepanning the sternum (Mim. de TAcad, de Chir., 1819, T. IV, p. 488); but Percy tells us (Chirurg. dArmee, p. 123) that Purman was the first who performed the operation, and remarks naively that when a ball is lodged in the duplicative of the mediastinum, " ce seroit effectivement l'unique ressource dans cette conjoncture. Mais il faudroit auparavant etre bien sur qu'elle y fut, et on sait combien a cet cgard 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. p. 486). Dr. Judson's case of ligation of the internal mammary (p. 54S) after gunshot fracture of the manubrium and second rib, illustrated by the interesting specimen, No. 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 Montgomery, which afforded the immortal Harvey the occasion to demonstrate to His Serene Majesty Charles II the movements and the insensibility of the heart.f obtained a sound cicatrix. Demarquay says that Cercseus, in the sixteenth century, was regarded as the author of the operation of resection of carious rihs. I do not find this name among the authors of the sixteenth century. Androuet Cerceau (1576) wrote on architecture, and J. A. Cerceau, the only other of the name known to bibliophiles, was a French Jesuit, who, in the next centuiy, wrote verses "of mediocre quality," according to Voltaire. But M. A. Severinus advocated the excision of carious ribs, in the sixth book of his Synopscos Chirurgite, Amsterdam, 1G64, p. 135, and cites Galen, Celsus, and Paul of iEgina, without misleading Champion, who, in 1815, published a thesis entitled Resections des os caries dans leur continuite (from which M. Demarquay complains that writers have quoted without acknowledgment), and duly cites Galen (Methodus medendi, 1. v. ch. 8), Celsus (de Se Med. 1. viii, c. 2) and Soranus, of Ephesus, in the twelfth chapter of the collection made in the eleventh century by Nicetas, of Constantinople. Paul of J2gina (See Syd. ed. translation, Vol. II, p. 453), after preserving 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. Schexkius, De Vuln. thorac, Obs. medicinalium, Frankfurti, 1665, L. II, p. 297; LeVacher, in the Mercure de France, April, 1858. Richerand's famous case is printed in the Bulletin de la Faculte, T. AT. ROUX, wrote on the subject in 1802, in his treatise De la Resect, on du Retranch. des os malades. Moreau describes examples in his two essays, 1803 and 1815. See also ClTTAMXI, De la resect, des cotes (in Arch. Gen. de Med., 1828, T. XATII, p. 71); ClOT BEY, for two cases (Jour. Heb. 1825); BLA>'DKJ, Necrose d'un cote (Gaz. des H&p., 1840, p. 373); FiORl, Resection de la totalite d'une cote (Gaz. des Hop, 1842, p. 518, from Anuali univ. di Milano); Heyfelder (op. cit., Bceckel's ed. p. 236); LARGHI (Operazioni sotto-periostee 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. Milton 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. AA'arren, George McClellan, and William Gibson. Warren's two cases are printed in the Boston Med. and Surg. Jour., Vol. XAT, p. 201, 1837; George MeClellan's case was published in the Western Jour, of Med. and Phys. Sci.,Yol. IV, p. 479,1831, and Dr. J. H. B. McClellan related its later history in the Med. Examiner, N. S. Vol. AT, p. 75, 1850. * Galen gives the Historia pucri persanati, cui os pectoris excisum erat, in his work de Anatomicis Administrationibus. It may be found in the Latin version commented by Vesalius, Liber VI, Cap. 13, in the Opera omnia, Tomus I, of the Basil edition of 1562, as follows: " Quoniam vero semel curati pueri mentionem feci, nihil mali fuerit omnia, que ipsi eucnerut, percensere. Nam propter historiae utilitatem, etiam si ad prassens opus nihil attineat, no abs re fuerit ea commemorae. Ictus puer ille in pectoris osse in palaestra neglectus primum est, deinde parum probe curatus post menses quatuor pus in parte percussa apparuit hoe auferre cogitans medieus puerum incidit, an, ut putabat, subito ad cicatricem vulnus perduxit postea rursus inflammatio oborta est, mox quoque abscessus iterum sectus puer est, nee amplius cicatrix obduci potuit. Quapropter herus ipsius pluribus medicis convoeatis, inter quos ego quoque eram, deliberare super curatione pueri iussit. Cum autem sideratio quam Greci o-^keAt) appellant, pectoris ossis affectus videretur omnibus, appareret aute & cordis a sinistra ipsius parte motus memo affectum os excidere audebat: quippe arbitrabantur thoracis perforationem necessario futuranr. Ego autem citra vocatam proprie a medicis perforationem adhibita, pollicitus sum me excisurum, de absoluta vero curatione nihil promisi: cum incertum esset, num aliquid ex iis quae pectoris ossi subiacent, fuerit affectu, & quatenus affectu. itaque regione detecta amplius nihil in pectoris n.-sc lesum apparuit, atque quod ab initio statim videbamus : quare etiam magis ad manus operationem venire sum ausus: cum iam fines, quibus arteria?, & venae subhserescunt utrinque illaesi occurrissent. Cum vero affectum os ab eo potissimu loco excidissem, in quo talis pericardii vertex ad nascitur cumque nudum cor appareret (quippe involucru ipsius computruerat), ob hoc quide haud bonam statim spem de puero hab- ebam, attamen in totu brevi teporis spacio persanatus est, quod non accidisset si nemo affectum os abscindere ausus fuisset. nemo aut tentasset nisi in administrationibus anaticomicis praeexercitatus. Alius quidam eodem tempore putrificum vitium ex humorum decubitu in brachio subsecans, insignem arteriain particularum membri ignorantia divisit: subitoque ob sanguinis profluvium conturbatus est, & cum vix laqueo ipsam posset intercipere (erat euim profundior) repente quide ex sanguinis fluore periculum repulit, sed aliaratione hominem jugulavit, gangraena videlicet propter laqueum occupate anteriam maxime, & primu deinde omnia ipsi circundata. Haec igitur ex multis pauca obiter dicta sunt, quae cordatis lectoribns praesentis commentarii utUitatem indicant.'' tThe account is printed, as though lost or estrayed, as La Martiniere observes, at page 208, Ex.TAI ofthe Exercitationes de Generatione Animalium, Lugduni, ed. Nov., :ip\id Kerkhem, 1737. The following is the translation of AVillis, (Syd. Soc, ed. 1847, p. 382): "A young nobleman, eldest son ofthe Viscount Montgomery, when a child, had a severe fall, attended, with fracture of the ribs of the left side. The consequence of this was a suppurating abscess, which went on discharging abundantly for a long time, from an immense gap in his side; this I had from himself and other credible persons who were witnesses. Between the 18th and 19th years of his age, this young nobleman, having traveled through France 572 WOUNDS AND INJURIES OF THE CHEST. Operations on the sternum during the war appear to have been limited to the removal of broken fragments at the primary dressing of gunshot fractures involving this part, and the extraction of small necrosed pieces. Fractures, on account of the spongy texture of the bone, and the support it receives from its strong fascia propria, were usually unattended with much comminution. A number of examples have been cited of the more important cases that came under treatment.* The two following abstracts refer to interesting specimens in the Museum : Case.—Private John M., Co. F, 34th NeAv York Volunteers, receiAred a perforating gunshot Avound of the chest at Fair Oaks, Virginia, May 31, 1862. The missile entered at the junction of the third and fourth ribs with the costal cartilage on the left side and escaped at a corresponding spot on the right side. He Avas admitted, on June 4th, to the Balfour Hospital at Portsmouth, Virginia. There was haemoptysis, cough, and spasmodic pain, AA'ith dyspncea upon any emotion. He died June 28, 1864. At the necropsy, the posterior periosteum Avas found to be uninjured, although the sternum was fractured. A slight adhesion Avas found on the right side. The pathological preparation from this case is specimen No. 4938, section I, A. M. M., consisting of tAvo portions of the sternum, and exhibiting a fracture of the gladiolus. It was contributed, with notes, by Assistant Surgeon AVilliam Thomson, U. S. A. Case.—Private John McC, Co. B, 55th New York Volunteers, aged 26 years, was admitted to the Balfour Hospital at Portsmouth, Virginia, June 4, 1862. with a gunshot-perforating Avound of the chest received at Fair Oaks on May 31st. The ball enteredthe posterior fold of the left axilla and escaped at the junction of the right third rib with the sternum. The patient had the usual symptoms of traumatic pleuro-pneumonia. He died June 25, 1862. At the necropsy, it Avas discovered that scarcely a A'estige of the left lung remained. The left pleural cavity contained pus. An ecchymosis Avas found upon the arch of aorta. Specimen No. 4931, Sect. I, A. M. M., is the upper half of the sternum and exhibits a gunshot fracture of the second piece of the gladiolus most conspicuous on the posterior or inner surface. The articulation between the manuhrium and first piece of the gladiolus is obliterated by ossification. The fracture is attended by disjunction of the second and third pieces; the third suture still exists. The preparation was contributed with a memorandum hy Assistant Surgeon William Thomson, U. S. A., who remarks that the interest of the case resides mainly in the long continuance of life (three weeks), Avith such an injury. The mortality of gunshot fractures of the sternum, that came under treatment, was not very great. Of fifty-one cases, only eighteen, or 35.3 per cent., terminated fatally. This coincides with the conclusions of Dr. Oscar Heyfelder (op. cit., p. 241), who has collected seventeen instances of partial excision of the sternum, with only one fatal result :f and Italy, came to London, having at this time a A-ery large open cavity in his side, through which the lungs, as it was believed, could both he seen and touched. When this circumstance was told as something miraculous to His Serene Majesty King Charles, he straightway sent me to wait on the young man, that I might ascertain the true state of the case. And what did I find ? A young man, well grown, of good complexion, and apparently possessed of an excellent constitution, so that I thought the whole story must be a fable. Having saluted him according to custom, however, and informed hint of the king's expressed desire that I should wait upon him, he immediately showed me everything, and laid open his left side for my inspection, by remoA'ing a plate which he wore there by way of defence against accidental blows and other external injuries. I found a large open space in the chest, into which I could readily introduce three of my fingers and my thumb ; which done, I straightway perceived a certain protuberant fleshy part, affected with an alternating extrusiA-e and intrusive movement; this part I touched gently. Amazed with the nOA-elty of such a state, I examined everything again and again, and, when I had satisfied myself, I saw that it was a ease of old and extensive ulcer, beyond the reach of art, but brought by a miracle to a kind of cure, the interior being invested with a membrane and the edges protected with a tough skin. But the fleshy part (which I at first sight took for a mass of granulations, and others had always regarded as a portion ofthe lung)—from its pulsating motions and the rhythm they observed with the pulse when the fingers of one of my hands were applied to it, those of the other to the artery at the wrist, as well as from their discordance with the respiratory moAements—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 young man was in the habit daily of cleansing the cavity from its accumulated sordes by means of injection of tepid Avater; after Avhich 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 perfect safety. Instead of a A'erbal answer, therefore, I carried the young man himself to the king, that his majesty might with his own eyes behold this wonderful case : that, in a man alive and well, he might, without detriment to the individual, obsen'e the moA'ement of the heart, and with his proper hand even"touch the ventricles as they contracted. And his most excellent majesty, as well as myself, acknowledged that the heart was without the sense of touch ; for the youth never knew when we touched his heart, except by the sight or the sensation he had through the external integument. AVe 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 systole of the heart took place at the moment the diastole or pulse in the wrist was perceived; to conclude, the heart struck the walls of the chest, and became prominent at the time it hounded upward and underwent contraction on itself." * See pages 486, 487, 488, 504, 523, 526, 535, 548. t M. Hippolyte Larrey, in his lectures on surgery at ATal-de-Grace, ascribes the frequent occurrence of necrosis of the sternum to the pressure of the soldier's cross-belts. Such an effect has not been observed frequently in the United States service. M. LinOli has resected the xiphoid appendage (Annali univ. di medicina diMilano, 1851) for obstinate vomiting. It has been affirmed by Percy that the xiphoid cartilage will sometimes recede hcfore a ball and then spring back barring the openiDg, as observed by Guillemeau (QSuvres de Chirurgie, Rouen, 1649) in the case of M. de Maleoonie. 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 Buyer did, or the chain saw, as employed by Dr. J. F. Heyfelder. Moreau, Blandin, Jaeger, and Kuchler removed diseased costal cartilages in their operations for partial excisions of the sternum. See JJEGER, Handivorterbuch der gesammten Chirurgie, B. A', S. 425, Leipsig, 1839; SKIELDERUI', On the Operation of Trepanning the Sternum, translated from the Transactions of the Koyal Society of Copenhagen, 1813, in Am. Med. Repository X. S., 1820, Vol. A", p. 273 ; Febgusson', Syst. of Pract. Surgery, 5th ed., 1870, p. 620; Honox, Operation of the Trephine for the Removal of a Portion of Carious Sternum, Am. Jour. Med. Set., Vol. X, p. 45, 1829; and among older authors, COLOSSIUS, Deperforatione ossis pectoralis, Tubingen, 1775; BOttciieu, Abhandlungen v. d. Kranhheil d. Kitochem, T. I. 8. Ill, Dessau, 1781 ; Bkandes, De Pectoris Paracentesi, Goettingen, 1792; J. L. PETIT, Tiaitide vial, chir., already cited, 1771, T. I, p. 76. THORACENTESIS. 573 Thoracentesis.—This operation was occasionally resorted to during the war to relieve the effects of effusions resulting from acute and chronic pleurisy; and, more frequently, on account of effusions consequent on traumatic pleuro-pneumonia, or the lodgement 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, 3d battalion, 12th United States Infantry, aged 22 years, was admitted to the Post Hospital, AA'ashington, May 30th, 1866, 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 fluid. The patient's appetite was good ; he slept soundly, and was able to Avalk about, and felt but little incoiiA'enience. Assistant S lrgeon AVilliam Thomson, U. S. A., performed paracentesis thoracis Avith a silver trocar above the ninth rib, near the inferior angle of the scapula, through valvular opening. Twenty-one ounces of albuminous serum Avere removed, after which the AA'ound Avas hermetically closed. The operation was repeated July 16th, August 7th, and September 22d, giving but transitory relief. He was returned to duty October 16th, 1866. Not a pensioner. Case 2.—PriA-ate Martin Carbit, Co. B, 18th United States Infantry, aged 23 years, Avas admitted to hospital at Camp Dennison, June 24th, 1864, suffering from empyema of left side. The symptoms present Avere an entire absence of the respiratory murmur ofthe affected side, Avith 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 normal circumference of the other. There Avas also a small opening between the second and third costal cartilages at their junction with the sternum. On August 26th, the patient Avas very weak and life was fast ebbing aAvay. His appetite Avas poor, and he suffered from diarrhoea, fever, and great dyspncea. Acting Assistant Surgeon A. Buckingham introduced a canula between the sixth and seA'enth ribs; about one quart of thick pus of a very offensive odor flowed away. The operation was repeated on August 23th and 30th and on September 1st, 3d, and 5th, the same quantity being drawn off each time, the pus becoming thinner. Stimulants and tonics. Avith good, nourishing diet, Avere .administered. The side collapsed considerably, and the patient's strength improved rapidly. He Avas discharged from service September 6th, 1864. Not a pensioner. Case 3.—Private John H. Miller, Co. L, 17th Illinois Cavalry, aged 20 years, Avas admitted to Marine Hospital, Chicago, Illinois, April 4th, 1S64, with incipient phthisis and pleurisy, with effusion. Great dyspnoea and cyanosis occurred On June 29th, Acting Assistant Surgeon Ralph N. Isham performed thoracocentesis. July 4th, patient 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 pysemic 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, Avhich passed directly through the right elboAv-joint. On September 26th, Surgeon AA'illiam A'arian, TJ. 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, Avith nourishing diet, Avere administered. In February, 1864, inflam- mation of the lungs supervened, Avith formation of abscesses, for which paracentesis thoracis was performed by Dr. Moore, of Decatur, Illinois. The patient Avas discharged from service March 23d, 1865, on surgeon's certificate of disability. Examining Surgeon Isa B. Curtis, Decatur, Illinois, August 14th, 1866, reports: "Gunshot Avound through arm near elboAV-joint. There has been resection at the joint. Joint Avas perfectly anchylosed, and the wound still discharging at both orifices. Flexal at right angle. Limb much emaciated and useless. General health poor, result of said wound, OAving to the constant drain on the constitution. He Avas still a pensioner in March, 1872." Case 5.—Private Seth T. Reynolds, Co. G, 4th Indiana Cavalry, aged 22 years, AA'as admitted to Hospital No. 1, Nashville, September 3d, 1864, with a gunshot fracture of the three middle toes of the right foot and the metatarsal bone of the little toe of the left foot, received, accidentally, at Nashville on the same day. Acting Assistant Surgeon M. L. Herr, admin- istered chloroform and removed the three toes of the riglit foot near the metatarsal phalangeal 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 the sixth and seventh ribs, one fourth the distance from the spinal column to the sternum. Twenty ounces of pus were removed. Thr patient improved rapidly under the administration of tonics, stimulants, and nutritious diet, and, on December 21st, was transferred to Crittenden Hospital, Louisville; on June 10th, 1865, to Brown Hospital, whence he was returned to duty, probably to be mustered out, June 14ih, 1865. Surgeon B. B. Breed, U. S. V., reports the case. Three of the eight cases, in which tapping was resorted to on account of the results of idiopathic pleurisy, terminated fatally: Case 6.—Private John Robinson, Co. G., 112th Pennsylvania Volunteers, aged 20 years, Avas admitted to Convalescent Hospital, Philadelphia, February 24th, 1864, suffering from pleurisy of the right side, with effusion. By March 12th, the right 571 WOUNDS AND INJURIES OF THE CHEST. thorax had become perfectly flat on percussion. No respiratory murmur could be heard. The superficial veins were distended and could be seen crossing over the surface. The intercostal surfaces were also distended. The patient Avas in a sinking condition from Avant of due aeration ofthe blood. Pulse 132 ; respiration 48 per minute. Acting Assistant Surgeon A. D. Hall pcrtiirmcd paracentesis thoracis, with bistoury and trocar betAveen the sixth and seventh ribs, anteriorly, at the angle of the thorax. TAventy-four ounces of clear straw-colored serum were evacuated, Avhen the floAV was stopped, as the patient appeared exhausted. The dyspncea Avas much relieved, but the patient was so utterly prostrated that he continued to sink. The treatment, AA'hich had at first been especially directed to the chest, Avas at a later period changed to supporting and stimulating. Death resulted March 13th, 1864. At the necropsy the right chest Avas found to contain twenty-four ounces of bloody serum. "The right lung Avas compressed against the spine. The Avhole caAdty Avas lined Avith thick, false membranes, and soft bridles of the same traversed the cavity in every direction. The upper lobe was consolidated. The left lung was merely hypostatically congested—floating in Avater. 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 perfectly healthy. Case 7.—Private William 0. 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 Avith a sero-purulent fluid, displacing the heart to the right side. Acting Assistant Surgeon H. McElderry performed paracentesis thoracis betAveen the eighth and ninth ribs, on the left side; about tAvo gallons of fluid were eA'acuated. 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 dyspncea. Acting Assistant Surgeon E. G. Waters performed paracentesis thoracis between the eighth and ninth .ribs, on the right side ; about 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. Klanbower, Co. K, 1st Florida Regiment, was Avounded at Mission Ridge, Tennessee, November 25th, 1863, by a musket 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 articulation on the same side. He was taken prisoner and conveyed to Hospital No. 2, Chattanooga, December 8th. Anterior AA'ound discharged daily; dullness over right lung in its whole extent; bulging of chest Avell marked. Percussion over left lung more resonant than natural. Upon forcibly distending the lung, about one pint of unhealthy pus Avas discharged from the anterior wound. Surgeon A. McMahon, 64th Ohio Volunteers, performed thora- centesis at the loAver angle of the scapula and upper border of seventh rib, drawing off at least sixteen ounces of sero-purulent matter, extremely fetid, presenting somewhat the appearance of dirty soap-suds. Wound closed Avith scraped lint. Anterior and posterior Avounds closed Avith lint, firmly covered Avith adhesive plaster. The patient felt relieved after the operation; tlie difficulty of breathing Avas not so great, but he was troubled Avith a short, dry, irritable cough. Stimulants were ordered freely. Death occurred on December llth, 1863. Case 10.—Private George W. Sawyer, Co A, 1st Michigan Sharp-shooters, Avas Avounded at the Wilderness, Virginia, May 5th, 1864, by a conoidal ball, which entered a little beloAV and to the riglit of the riglit 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, Alexandria. Pleurisy 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, and, on June 25th, the patient was transferred to Harper Hospital, Detroit, Michigan, whence he Avas discharged from service July 21st, 1865. Pension Examiner J. W. Falley reports, September 1st, 1865, " the Avound of entrance is still discharging. He is able to walk about the house." SaAvyer died July 30th, 1866. Case 11.—Private Owen Morrison, Co. I, 1st Ohio Volunteers, aged 22 years, received a gunshot Avound of the neck and right shoulder by a conoidal ball at Resaca, Georgia, May 14th, 1864. He was treated in the field, and, on May 27th, Avas transferred to Hospital No. 1, Nashville, Tennessee. By June 17th, the patient was exhausted by coughing and labored respira- tion, 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 Avas highly inflamed. Acting Assistant Surgeon H. C May performed paracentesis thoracis of the right side of the chest, betAveen the sixth and seventh ribs, five inches from the sternum. Ninety-three ounces of sero-purulent fluid Avere drawn off. The removal of the fluid gave temporary relief. Air reentered the collapsed lung. Tonics, stimulants, and nutritious diet were administered. The patient died June 17th, 1304, from exhaustion. * The subject of thoracocentesis in the effusions of acute pleurisy has recently (April, 1&72) been discussed at the Academy of Medicine of Paris, at great length. Professor Behier, in a memoir in which he claimed that the popularization of tracheotomy in croup and thoracentesis in pleurisy were the two greatest of Trousseau's great titles to the grateful homage ot the profession, supported the views advocated in tlie Clinique Mielicale de V Hotel-Dieu, by sixteen carefully observed cases, which he thought demonstrated the innocuity of '' capillary thoracocentesis" with an aspirate r providing against the admission of air. Many of the academicians joined in the exhaustive and somewhat acrimonious debate that followed, among them a few that had participated in the similar discus-ions of 1835 and H?ii5, among- them MM, Guerin, Stdillot, Ri.-het. ('lni-saignae, Roger and Herard. THORACENTESIS. 575 Case 12.—Captain Prosper Dalien, Co. C, 208th Pennsylvania Volunteers, aged 26 years, was wounded at Petersburg, March 25th, 1865, by a conoidal ball, AA'hich entered beneath the inferior angle of the left scapula, passed through the pleura, and emerged at the anterior superior border of the left axillary space. He was treated in the field hospital of the Ninth Corps, until April 24th, AA'hen he Avas transferred to Armory Square Hospital. Washington. When admitted, there was considerable dyspncea, AA'ith excessiA'e pain, which was increased by coughing. At each forcible expiration the air was expelled from the wound ofthe back. Stimulants and anodynes were given. Whenever the patient moved he complained of a gurgling sensation. On percussion in the recumbent and upright position, it was decided that there was a large quantity of pus in the thoracic cavity. The cavity Avas opened by Assistant Surgeon Charles A. Leale, U. S. V., and twelve ounces of pure pus withdrawn, by means of a'Flint's evacuator. Air was forced from the thoracic cavity through the wound in the arm. Morphine given to allay pain. On June 2d, haemorrhage occurred from the cavity near the axillary space, and the patient died on the same day. Case 13.—Private John C. Burk, Co. B, 5th United States Cavalry, aged 28 years, Avas wounded at Manassas Gap, July 21st, 1863, by a ball, which entered the left side of the body better than half way betAveen sternum and side, between sixth and seventh ribs, passing backwards and upAvards, emerging just beloAV the outer and inferior angle of the left scapula, injuring the left lung. There was considerable haemorrhage at time of injury. He was admitted into Lincoln Hospital, Washington, D. C, on July 30th, 1863. when vesicular murmur Avas heard over upper portion of lung; dull over lower; but over region of wound, loud crackling; air rushing in and out during respiration; pulse, 84; tongue somewhat flabby and furred; bowels, costive; no passage for nine days. On August 21st, after consultation, paracentesis thoracis Avas performed by Assistant Surgeon II. Allen, between the sixth and seventh ribs; no pus escaped. Patient improved until September 8th, after which he grew worse, suffering from pain in chest, and failing rapidly; continually calling for Avater, but refusing food and medicine. He died on September 11, 1863. Post mortem nineteen hours after death; rigidity Avell marked; not much emaciated; parts in situ ; right lung barely visible; left lung bound anteriorly to costal pleura, a little behind the junction of the cartilages in the ribs, extending from the clavicle to the fourth rib. Behind and beloAV it, was a collection of pus measuring thirty-six fluid ounces and six drachms. The pleura evervAvhere was covered with a thick layer of lymph ; a small sac was found between the internal portion of the lung and the pericardium, filled Avith a straAV colored limpid serum. Position of heart someAvhat deviated, the apex being in the median line on a level Avith the fifth rib, the left side of the heart being parallel Avith the median line, the right side being thrown much beyond it, encroaching considerably on the right thoracic cavity. The left lobe of the liver extended three inches to the left of the median line; the free margin of the right lobe extended down within an inch of the Umbilicus. The fundus of the stomach was seen beneath the left lobe. Intestines, normal; a feAV fibrinous threads were present; omentum not visible; oesophagus of dark purple color; mucous membrane firm; trachea purplish; contained a small quantity of viscid mucus. Bronchial glands enlarged and blackened 1st lobe of right lung; pigmentary matter abundant externally, parenchyma of a darkish red color, paler toward the surface; permeated everywhere Avith air, and a large quantity of thin frothy matter exuded on pressure. On the second lobe was a conspicuous depressed puckered spot on its anterior surface, which, upon examination proved to be calcareous deposit. Third lobe intensely congested, being of a deep dark reddish color; veins filled with clotted blood, and the same character of bronchial secretion as seen in the first lobe. Left lung much collapsed, being a little over an inch in thickness; much compressed; of a dull mahogany color, and not permeated with air, except the anterior median portion. Right lung weighed nineteen ounces; left lung weighed twenty-tAvo ounces. Heart measured three and a quarter inches in Avidth and four inches long; right auricle contained a small quantity of venous blood, which Avas entangled in soft clots in the meshes of the tricuspid valve, particularly at the base, and a firm fibrinous clot ran through the auricle into the ventricle, thence up into the pulmonary artery, the valves of which were healthy. The left side of the heart contained no clot; a small quantity of blackish fluid was seen at the base of the ventricle; the organ Avas perfectly healthy, and Aveighed ten and a half ounces. Pericardial fluid, twenty-six drachms, of a turbid yellowish color, turbid with lymph. Liver measured twelve by ten inches, and four and a half inches thick; weighed ninety-five and a half ounces; bile, one drachm; of a dark sienna brown color, very viscid, semi opaque; liver perfectly healthy. Spleen, six inches long by three and a half inches Avide; of a darkish mahogany color externally and internally; Aveight, twelve ounces. Eight kidney, five inches long by three wide; of a dark purple color throughout; pyramidal bodies of a lighter color than the cortical, especially at their apices. Left kidney, five and a half inches long by two and a half Avide ; similar in appearance to the opposite kidney; right weighed seven and three-quarter ounces; left, eight and a quarter ounces. Pancreas weighed four and a quarter ounces, ten inches long by two and a quarter inches across head. Brain, membranes healthy; quantity of fluid in the ventricles inappreciable; organ, firm and healthy; weight, forty-eight ounces. Intestines, perfectly healthy. The ball entered in the back two inches below the spine of the scapula, and four inches from the vertebras, making its exit eight and a half inches beloAV the coracoid process betAveen the seventh and eighth ribs of the left side. The case is reported by the operator. Assistant Surgeon H. Allen, U. S. A, The following case of perforation of both lungs by a pistol ball, presented the compli- cations of hsemothorax, emphysema, and tromatopncea, and is interesting as one of the few instances, if not the only one, reported during the war, of lumbar ecchymosis as a sign of chest wounds :* Case 14.—Corporal Samuel A. C------, Co. E, 1st United States Cavalry, aged 20 years, was AA-ounded in a cavalry charge near Culpeper, Virginia, August 1st, 1863; the missile, a revolver ball, entered the back, left side, about two and a * There has been a general disbelief among the military surgeons with whom I haA'e conversed or corresponded, in regard to the diagnostic value of this sign of wound of the thorax, and having never observed the phenomenon in question, I haA'e shared in this incredulity. Cha*issier and Malgaigne contested the possibility ofthe transudation of blood through the pleura during life; but admitted the existence of the lumbar ecchymosis described by Valentin, and ascribed it to the infiltration of blood into the cellular tissue through the external wound. M. Legouest, in the last edition of his Chirurgie d'Armic, page 352, says : " Ce symptome, que nous avons eu l'occasion de constater, est sans importance, et son apparition, toujours tardive, s'ajoute rien au diagnostic suffissamment 61ucid6 par le reunion d'un certain nombre des symptomcs que nous avons exposes." I had concurred in the 57i.:.l. at Bolivar IIeights,Maryland, September 17th, 1862, by a soldier, in the rear rank, Avho neglected to remove his tompion. The missile penetrated the chest from the back and fractured the eleventh rib. The wounded man was carried to the hosp ' P the 1st division of the Eighth Corps. His breathing Avas oppressed almost to suffocation; his pulse Aveak and fluttering; the blood ooze-1 from the posterior wound in a florid tracl-. but not profusely; there was frothy hjemo- Fig. 2P3—Posterior view of sections of the right tenth, eleventh and twelfth ribs, tue eleventh comminuted by a tompion. Spec. 617, Sect. I, A. M. M. ptysis with frequent painful efforts at coughing. A broad chest bandage, decubitus on the right side, and an opiate, made his condition more tolerable toward night, and, on the following day, he was placed in a hospital railway car and sent to Baltimore a distance of eighty miles, and thence, a hundred miles farther, by rail, to Philadelphia. On the 26th, he was admitted to South Street Hospital, Philadelphia, in a state of great prostration, with the symptoms of traumatic pleuro-pneumonia and hepatitis. There was extreme irritability of stomach, frequent cough and dyspncea. Tim lower right chest was flat on percussion; there was a sanious purulent discharge from the wound. The patient died on October 15tb, 1862. At the autopsy, the evidences of extensive inflammation of the right pleural cavity and of peritoneal inflammation in the vicinity of the liver, were very apparent. Spec. No. 616, Sect. I, A. M. M., shows the loAver lobe of the right lung and part of the liver, Avith a portion of the diaphragm intervening, to which both viscc ra are firmly adherent. The lung Avas wounded by the metallic portion of the tompion, which was imbedded in it. The preparation is imperfectly represented in the accompanying wood-cut (Fio. 284), reduced to one-fourth size, from a draAving of the dissection made at the Museum. In the inferior portion the button of the tompion, represented of natural size in Fio. 282, is seen impacted in the lung tissue, which is in a state of grey hepatization. The cut orifices of large bronchial tubes and arterial and venous trunks appear in the left upper portion; and, to the right, an attempt is made to delineate the thickened pleura and diaphragm, to which the lung adhered firmly, and the convex surface of the liver, which partly adhered to the diaphragm. Spec. No. 617, of the same section, represented in FiG. 283, shoAvs portions of the last three ribs of the right side, with the eleventh completely fractured. The fragments are partially united by neAV bone, Avhich entangles some necrosed portions. Both preparations were-contributed, with a history of the case after the patient's admission to South Street Hospital, by Acting Assistant Surgeon II. Hart. The other notes are taken from the field reports. The following is one of the best illustrations that the Museum possesses of the method that Mature sometimes pursues in order to render a foreign body unirritating, by encysting it. A conoidal ball had lodged in the lower lobe of the left lung. Its passage through 1 Dr. Uobinson (Diary of the Crimean War, page 376) gives a cmicus instance of wound by a tompicn. See also Spec. 24(i, Sect. I, A. M. M. Fig. QS1.—Section ofthe lower lobe ofthe r'n'ht lui'tr, with the button and wire of a tumpion imbedded in it, a portion ofthe diaphragm and of the liA'er appear at the upper right hand of the preparation. Spec. Gib", Sect. I,A. M. :.I. BALLS AND FOREIGN BODIES LODGED. 587 an intercostal space and through the lung substance had. been attended by the least possible amount of laceration and bleeding; yet it'had struck and fractured the sternum, and, when reflected, had injured the pericardium sufficiently to light up inflammation. Most of the track healed kindly; the constitutional symptoms were slight at first, and were due to the pericardial rather than the pulmonary lesion. Tlie ball rested a quarter of an inch beneath the pleura. The track leading to it was cicatrized. A well-marked zone, with a radius of about one inch, surrounded the ball. On the immediate confines of this zone, the lung tissue was normal in appearance, and, under the microscope, the only alteration noticeable was slight enlargement of the capillary net-work about the air-cells. Within the line, clearly defined in the specimen hardened in alcohol, the tissues had undergone cheesy metamorphosis, the progressive stages being met in approaching the ball, in the immediate vicinity of which were chalky deposits: Case 15.—Corporal W. S- -, Co. H, l.">lst New York Volunteers, aged 26 years, Avas admitted to the 3d division hospital, Alexandria, December 4th, 1863, Avith a gunshot penetrating wound of the left chest, received at Locust Grove Virginia. November 27th. A conical ball entered two inches below the coracoid process, passed inAvard and doAvnward and lodged in the posterior portion of the lower lobe of the left lung. When admitted, there was slight constitutional disturbance, diminished respiration of apex of left lung, slight cough, and Avbite frothy expectorations. Sedatives, anodynes, and stimulants Avere administered, with nourishing diet. On the next day, the patient Avas able to Avalk about the Avard and seemed quite comfortable. Nothing occurred to attract particular attention until January 3d, when the expectoration Avas noticed to be very offensive; respiration scarcely perceptible in the left lung; pulse very weak. January 8th, 1864, breathing labored, complete dulness of left side extending to right of sternum. He grad- ually sank, and died on January 10th, 1864. Necropsy: Left pleural cavity filled with serum; lung compressed in small space. Pericardium Avas much distended AA'ith fluid, amounting to twelve ounces, and the second rib comminuted. The ball had struck the sternum at the articulation of the second rib, which was denuded and rough. The whole surface of the pericardium Avas covered with coagulated lymph having the appearance of tripe. The ball AA'as found in the posterior portion of the lower lobe of the right lung; the liver was enlarged and soft. A preparation of a portion of the left lung, with the missile lodged just beneath its surface, is represented in the Avood-cut (Fig. 285). The lung has been laid open to display the lodgement of the ball. Even the rings on the base fio. 285.—Conoidal ball encysted of the projectile are imprinted on the cheesy tissue. The specimen Avas contributed, with near tj10 free e, 5th Wisconsin Volunteers, aged 21 years, Avas Avounded at Chancellorsville, May 3d, 1863, by a conoidal ball, which entered between the sixth and seventh ribs, an inch outAvard of the mammillary line, grazing and fracturing the seventh rib. He Avas treated in the field hospital, and, on May 8th, was transferred to Douglas Hospital, Washington. When admitted, the patient was suffering from very severe dyspnoea, accompanied by an incessant, painful, and annoying cough ; respiration was very frequent, forced, and superficial. He stated that he had spat bfood after the injury, but not the least tinge of blood Avas observable in the thick frothy mucous expectoration. An abundant effusion in the left thoracic cavity easily accounted for the dyspncea. Purgatives, diaphoretics, and stimulants Avere administered and counter- irritants applied over the left side of the chest, with Avater dressings to the wound. He died May 10th, 1863. At the post-mortem examination, sixteen hours after death, old adhesions Avere found in the riglit lung and fresh ones in the left. The effusion of sero-sanguinolent fluid in the left cavity Avas the immediate cause of death. Paracentesis thoracis Avould have proved of but little avail, as the diaphragm Avas 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 Avoided it freely and Avithout pain in spite of the extensive injury to the left kidney. The case is reported by Acting Assistant 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 Avood-cut (Fig. 290). FiG. 290.—Ball weighing 510 grains slightly contused after passing through' the thorax. Spec. 293, (Sect. I, A. M. AI. Case 20.—PriA-ate J. A. S- Fis. 291—A conoi- dal ball removed from the mediastinum after death. AVeight, 466 grains. ec.273o, Sect. I, A. M. M. -, Co. C, 145th Pennsylvania Volunteers, aged 19 years, Avas AA'ounded at Gettysburg. Pennsylvania, July 2d, 1863, by a conoidal ball, Avhich perforated the left scapula just below the spine, and passing forward to the right, splintered the sternal end cf the first rib. He Avas conveyed to the hospital of the 1st diA'ision, 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 \A-as found compressed upon itself in the anterior mediastinum, opposite the first intercostal space. The apex of the left lung Avas engorged and the left pleura contained about iavo quarts of sero-sanguinous fluid. Miliary cysts filled with pus Avere seen at the apex ofthe right lung. The specimen is represented in the adjoining AA'ood-cut (Fig. 291). The history was contributed by Acting Assistant Surgeon R. II. Stirling. Case 21.—An unknown soldier, wounded at the battle of Gettysburg, was brought into one ofthe field hospitals, in an insensible state, with a AA-ound 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, Avhen he died, aud, at the autopsy, the missile, a misshapen conoidal, with bony spiculae imbedded in it, Avas found in the posterior mediastinum, behind the arch of the aorta. The projectile is represented by the Avood-cut (Fig. 292). It was contributed to the Museum by the curator, Surgeon J. H. Brinton, U. S. V. 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 parieties ; in one instance, after being encysted for fourteen months : Case 22.—Private Hugh Meehan, Co. A, 63d New York Volunteers, Avas wounded at Gettysburg, July 2d, 1863, by a ball Avhich entered the right side, betAveen the second and third ribs, passed around to the inner border of the scapula and lodged, injuring ihe edge of the bone to some extent. He was sent from the field hospital ofthe 1st diA'ision, Second Corps, to Patterson Park Hospital, Baltimore, Avhere the ballAvas extracted on July 31st, 1663, through a counter incision. The wound healed kindly, and Meehan Avas returned to duty December 11, 1863. The operator, Acting Assistant Surgeon A. T. Pick, presented the missile, represented in the Avood-cut (Fig. 293), to the Museum. Fir.. 292.—Misshapen conoidal ball lodged in mediastinum after trav- ersing neck. Spec. 1439, Sect. I, A. II. M. FIG. 293.—Ball studded with par- ticles of bone from scapula. W sight, 483 grains. Spec. 1422, Sect. I, A. M. AI. FIG. 294.—Conoidal ball laterally flattened, with the apex blunted by im- pact on tlie scapula. Spec. 3174, Sect. I, A. M. M. Casi: 23.—Private Joseph Fouracre, Co. B, 1st DelaAvare Volunteers, Avas wounded at Antietam, September 17th, 1862, by a ball, Avhich struck the scapula and buried itself in the muscles. Its position Avas detected, and it was extracted on September 24th, the date of the patient's admission to McKim's Hospital, Baltimore. There Avere some exfoliations from the scapula, and the wound healed tardily, but ultimately cicatrized firmly^ and the patient Avas returned to duty on June 16th, 1863. The projectile, repre- sented by the Avood-cut (Fig. 294), Avas sent to the Museum by the operator, Surgeon Lavington Quick,U. S. V. Case 24.—Assistant Surgeon J. B. Brinton, U. S. A., contributed the specimen figured in the accom- panying Avood-cut (Fig. 295) to the Museum, Avithout further information than that it was cut out from the Fig. 295.—Omoidal supra-scapular fossa, Avhere it lay partly impacted in the spine of the scapula, in the case of a soldier of the impact with spine of Army of the Potomac, Avounded before IVuTsburg. This Avound healed Avithout ill consequences. s^i't l A M° Ai431' 590 WOUNDS AND INJURIES OF THE CHEST. Cask 25.—Private H. Millineth, Co. E, 9th NeAV York Zouaves, was Avounded at Roanoke Island, February 8th, 1862, by a round musket ball, Avhich entered beneath the anterior convexity of the clavicle and buried itself in the soft tissues. The Avound healed Avithout trouble, the ball becoming encysted. Millineth entered Armory Square Hospital, at Washington, a year afterAvard, with typhoid fever. When convalescent, the ball was detected in the supra scapular fossa, and was excised, April 28th, 1863. The man Avas discharged, AA-ell, 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). FIO. 296.—Round ball extracted from supra scapular fossa, fourteen months after injury. S/iec. 4488, Sect. I, A. Ai. M. Case 26.—Private Julius Wilt, Co. A, 43th New York Volunteers, aged 22 years, was Avounded at Gettys'iurg, July 1st, 1853, by a minie ball, Avhich 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, Avhere, on the 12th, the missile was cut out. He had also a ragged wound beloAV the right nipple, which appeared to implicate only the soft textures. The treatment consisted of tonics, Avith simple dressings to the wound. The wound of the back soon cicatrized; that of the chest continued to dis- charge. The patient became Aveak and prostrate, but improved under the administration of stimulants and tonics. On November 7th he was transferred to Newton University Hospital, Baltimore, at which time the wound of exit had not healed. On March 2d, 1884, 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 Avhich Aveighed one and one-fourth ounces. The presence of this missile had not been suspected for a long time. The Avound soon aftenvard healed, and he waB transferred to De Camp Hospital, New York Harbor, Avhence he Avas returned to duty on September 27th, 1864. The fragment of shell Avas 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). Fig. 297.—Fragment of shell removed from the right side, eight months after injury. Spec. 4503, Sect. I, A. AI. AI. Eighty-eight abstracts of cases attended by the lodgement of balls or other foreign bodies will be found recorded between page 473 and page 582, or the beginning of this sub-section. In over one-third of the cases, or thirty-three, 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 lodgement 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 Kabell, were believed to be examples of wounds of the lung tissue. 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. Cask 27.—Private Francis Cook, Co. K, 2d Michigan Volunteers, was AA-ounded at Bailey's Cross Roads, Virginia, Septem- ber 4th, 1861, by a conoidal ball, which penetrated the lungs. Surgeon W7illiam O'Meagher, 37th Ncav 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 Avound through the lungs, and when discovered by his comrades, who had hastened to the spot, Avasfound faint from profuse haemorrhage, and lying on the Avounded side. By them he Avas 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. Oh examination, his clothes behind. Avere found saturated with blood, AA'hile several large clots were removed from the immediate vicinity of the wound. As he Avas extremely prostrated, some stimulants Avere gradually administered until reaction took place, and, in the meantime, I Avas searching for the exit of the bullet, which had entered the left side posteriorly, fracturing the tenth rib and making a large irregular Avound. On introducing my finger for about tAvo 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 tOAvard the opposite side in a transverse direction ; emphysema appeared to some extent in the vicinity. I did not attempt a further exploration, 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 AA-ounded side. On searching for the exit ofthe ball, the only indication of its presence was a patch of emphysema on the opposite side, someAvhat higher up than the aperture^but the ball itself could not be felt, so I resolved to Avait aAA'hile in order to alloAV the patient to recover someAvhat, hoping that, in the meantime, the respiratory efforts, increased by a pretty tight bandagej would force the ball outward and thus render it palpable. Accordingly, BALLS AND FOREIGN' BODIES LODGED. 591 in about four hours, he began to experience severe pain in this part, and on remoA-ing the bandage, at the same time directing him to take a full breath, Avhich he did Avith ease and evident relief, I was exceedingly gratified to find the ball presenting itself in the sixth intercostal space. On cutting down I found it firmly imbedded in the costal pleura, and after a little delay, occasioned by a desire not to make a large opening, removed it Avith a common forceps, and immediately closed the Avound Avith interrupted sutures. The bandage was again applied, and a full anodyne administered, after Avhich 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 rifle- bullet, irregular and rough at the edges, as if it Avere so designed to produce greater mischief. He continued very comfortable for two days, taking light nourishment and appearing quite cheerful and intelligent, occasonally only being attacked with dyspnoea, which, hoAvever, was never sufficient to cause any apprehension. Obedient to directions, he lay perfectly still, Avithout talking, except in ansAA'er to a necessary question as to his condition. His bed Avas a canvas field-stretcher, with poles inserted into the folded canvas, Avhich Avas 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 sate, easy, and efficacious means of transportation, far superior, 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, Avhere he died on the fifth day. 1 am indebted to Dr. H. Laurence Sheldon, the surgeon in charge, for the following record of the autopsy: ' Left side of chest filled Avith bloody serum ; t lung compressed, and' a space betAveen anterior parietes and surface of lung filled Avith air. Lymph covered the visceral and parietal plurse, and clots of blood Avere on the most dependent portion of the cavity. The ball struck the tenth rib, fracturing it three inches from its articulation Avith vertebra?, passed through the loAver lobe of left lung, where there was intense inflammation in its track, with numerous spiculae of bone carried tAvo inches into substance of lung from the fractured rib, thence through body of tenth vertebra, through diaphragm and upper surface of liver, a distance of two inches ; again through diaphragm, and Avas removed externally betAveen sixth and seventh ribs. There Avas a patch of pneumonia on the right lower lobe. Half a gallon of serum and blood Avas taken from both pleural cavities.' I should have mentioned as rather remarkable, that for three days, though he had considerable dyspncea, and pain referred to in both places, he had neither cough nor expectoration until the fourth day, leading some to suppose that both lungs were not seriously Avounded, as I had at first reported, the ball rather making a circuit outside the lung. But I think it almost impossible that the right loAver lobe could escape when the ball passed twice through the diaphragm and upper surface of the liver, being finally removed from the sixth intercostal space; besides, ' there was a patch of pneumonia on the right loAver lobe, and half a gallon of serum taken from loth 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 fracture 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 parieties 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 *Lari:ey, D. J., Mem. de Chir. Mil., Paris, 1817, T. IV, p. 261 ; Lohmeyer, Die Schussionnden und ihre Behandlung, Gottinpen, 1859, p. 124 ; RUST, J. N., Handbuch, der Chirurgie, Berlin, 1836, Band 17, S. 622; Bauoens, Clinique des plaies des d'armes & feu, Paris, 1836, p. 242; Fabuicius Hildaxus, Observationes Ckirurgicse, Cent. I, Obs. 46; Stromeyer, Maximen der Kriegsheilkunst, Hannover, 1861, p. 432; THOMASSIN, Jr., Disser- tation sur Vextraction des corps etrangers des plaies, et specialemcnt de celles faitespar armes dfeu, Strasb., 1788. 592 WOUNDS AND INJURIES OF THE CHEST. at extraction. M. Demme, on the other hand (Militdr-chirurgische Studien, Zweite Abth., S. 138, Wiirzburg, 1864), says : " Entirely unfounded is the fear of a careful examination for the seat of lodgement 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. PirogofT1 (Grundzilge der allgemeinen Kriegschirurgie, Leipzig, 1864, p. 531) 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. 491) 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,2 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 sondee, c'est la plus grave" heresie que Ton puisse commettre en chirurgie, et l'instrument dit sonde de poitrine, que Ton trouve dans les trousses des chirurgiens, devrait bien etre banni, au moins pour ces sortes de lesions." To this, M. Legouest replies, at page 357, of the last edition of his Traite de Chirurgie d'Armee: "Les faits sont en complet disaccord avec ce precepte: le seul inconvenient auquel on s'expose en sondant une plaie de poitrine par coup de feu que Ton suppose renfermer un corps stranger, est de ne pas trouver ce que Ton cherche. En effet, ou bien le poumon fibre d'adherences s'est retracte vers sa racine et echappe a l'instrument explo- rateur qui parcourt sans obstacle la cavite pleurale; ou bien le poumon est adherent a la plevre costale et sa blessure reste en rapport avec la plaie exterieure. Dans ce dernier cas, une sonde de poitrine ou une sonde de gros calibre de gomme elastique peut Gtre introduite dans le trajet escharifie 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 entraines par le projectile. Si Ton etait assez heureux pour rencontrer le corps stranger dans le poumon, il faudrait, comme le conseille Ledran, dilater suffisamment la plaie exturieur pour aller le saisir avec des pinces et l'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; 1 He also adverts (I. c. S. 549) to the remarkable operation by Dr. Cooper, of San Francisco : "Of desperate operations successfully performed for injuries ofthe chest, few are worthy of imitation. Nearly all concern the remoAal of foreign bodies from the cavity of the chest. A few of these adventurous operations resulted successfully. One ofthe most desperate comes to us agaiu from America. It is a ca6e related by Dr. E. S. Cooper (of Pan Francisco), in 1857. " See Coor-EU, E. S., Report of an operation for Removing a foreign body from beneath the Heart, fl'iiblished by the San Francisco Medico-Chirurgical Association as an additional pap r to its Transactions for the year 1857). Dr. AV. F. Atlee (Am. Jour, of Med. Sci., N. S., Vol. XXXV, p. 229) remarks of this operation that "it is extraordinary even for California, that land of enormities of every description." -Dltlytiiln, Lecons orales de clinique chirurgicale, T. VI, p. 382. BALLS AND FOREIGN BODIES LODGED. 593 but when the 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 Manual1 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 lodgement 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,'-2 or be deflected to distant parts,3 or it may be impacted in a rib,4 or wedged in an intercostal space,5 or lodged in the sternum6 or spine,7 or against the clavicle8 or scapula;9 or it may fracture the rib and push the costal pleura before it and not penetrate the cavity;10 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 four other specimens, the histories of which are briefly as follows: Fig. 298 represents a missile which struck Corporal S. M. Elder, Co. K. 10th Penn- sylvania Volunteers, at Fredericksburg, December 13th, 1862, in the third right intercostal space, and Avas extracted, Jan- nary 19th, 1863, by Surgeon O. A. Judson, U. S. V., near the lower angle ofthe scap- ula. Elder recoAered and was pensioned. Fig. 299, represents apost-mortem specimen found in the body of Lieut. H. H. AV----, Co. D, 6th Maine, wounded at Rappahan- nock Station, November 7th. 1863, the ball fracturing the sternum 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. Con,- over, IT. S. V., having entered December 13th, 1862, in the third left intercostal space anteriorly in the case of Private J. Porret, Co. B, 105th Pennsylvania, wounded at Fredericksburg, who subsequently recov- ered and was discharged. Fig. 301 represents a projectile 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.—Compiler. l A Manual of Military Surgery, prepared for the use of the Confederate States Army, by order of the Surgeon General, Richmond, 1863, p. CO. 2Seepage473. 3 Besides the examples given, see Hennen (I: c, p. 392), Guthrie (I. c, p. 464). 4Page569. 5Page568. 6Page474. ^Chapter IV, p. 460. « Page 475. 9Page 476. i°See a remarkable case related by D. J. LARREY (Jour. G6n. deMed., T. LXXII). 75 Table XXII. List of Specimens contained in the Army Medical Museum of Balls or Foreign Bodies removed from the Walls or Cavity of the Chest during Life. Cn No. n i! miser of Specimen. 1 4400 o 4558 3 378 4 178 5 1579 4 C 4479 7 1211 8 2294 9 4530 10 1561 11 4509 12 4538 13 4503 14 4657 15 4297 16 4536 17 4399 18 1587 19 1422 20 4573 21 563 22 4427 4KW 24 25 26 1443 3240 446G Name of Patient. McMurtreo. Kearney__ Berry..... F^-----... Howard.. McCalechu B-----... Fisher. Baxter... Unknown. Wilt...... Elder____ Soldier of 4th N.Y. Cav. Leavitt. M------ De La Fontaine. Lawrence....... Terry.......... Ford........... AVhite ......... Skillet.......... Stante......... Nature of Missile. Conoidal ball.. Conoidal ball.. Elongated ball. Two fragments of conoidal ball. Elongated smooth-bore ball Round ball............... Conoidal ball split in two. Conoidal ball............ Conoidal ball............. Conoidal ball. Iron ball...... Grape shot.... Fragment of base of shell... Conoidal ball.............. Fragment of carbine ball... Spherical ball....... Heavy conoidal ball. Conoidal ball.............. Conoidal ball.............. Cup portion of conoidal ball Conoidal ball.............. Conoidal ball.............. Elongated rifle ball........ Elongated ball............ Split conoidal ball......... Conoidal ball............. Date of Injury. Dec. 13,1862 July 1,1862 Dec. 12,1862 Aug. 30,1862 July 2,1863 Aug. 28,1862 May 3,1863 May 6,1864 July 1,1863 Nov. 5,1864 July 2,1863 Juno 29,1862 July 1,1863 Dec. 13,1862 June 13,1862 May 3,1863 TJec. 13,1862 June 15,1864 July 2,1863 Sept. 17,1862 Nov. 7,1863 July 1,1863 Sept. 17,1862 May 31,1862 May 3,1863 June 17; 1862 Date of Extraction. Dec. 20,1862 Spring, 1864 Dec. 12,1862 Sept. 3, 5, '62 July 22,1863 Sept. 15,1862 May 14,1863 May 17,1864 July .4,1863 Aug. 18,1865 May 3,1864 Same day--- Mar. 2,1864 Jan. 19,1863 June 13,1862 July 15,1863 Dec. 21,1862 June 20,1864 July 31,1863 Sept. 24,1862 Nov. 10, 1803 Oct. 10,1863 Jan. —,1863 June 9,1862 Oct. 10,1863 Aug. 1,1862 Whence Extracted. Parietes, over shoulder-blade..... Lower portion of body of sternum. Parietes subclavicular region..... Parietes ; fractured scapula....... Parietes near inferior angle of left scapula. From beneath integument......... From substance of infraspinatus mus From spine of scapula............. Walls of chest.................... From behind tenth rib, left side. From under pectoral muscle--- Left axilla..................... Parietes near umbilicus............. Near inferior angle of scapula....... Parietes near middle 3d of claA'icle.. Between ribs and scapula below spine Below superior angle left scapula, near spine. Over third rib, near left axilla ...'... Inner border of scapula............. Over sixth rib, to left of sternum___ Parietes, near right nipple.......... Under intercostal muscles........... Beneath spine of scapula........... Near inferior angle of scapula....... Right supraspinous fossa............ Near spine of eighth dorsal vertebra. Termination of Case. Feb. 5,1863 Discharged ... Discharged--- tSept. 25,1862 {Aug. 14,1865 {Dec. 1,1862 tMay 25,1863 {Sept. 14,1865 *Aug. 12,1863 tAug. 20,1865 *Sept. 28,1864 Unknown...... Discharged... Discharged... Unknown..... RecoA-ered.. Discharged. tJuly 12,1864 Recovered---- JOct. 27,1862 (Nov. 16,1863 tSept. 7,1864 RecoA-ered..... *Oct. 6,1862 Recovered..... RecoAered . ... Fig. 207, p. 473. Fig. 208, p. 474. Fig. 210, p. 474. Fig. 213, p. 476. Fig. 214, p. 480 Fig. 230, p. 489 Fig. 260, p. 563. Fig. 262, p. 563 Fig. 266, p. 567. Fig. 271, p. 568 Fig. 297, p. 590 Cavity not penetrated. CaA'ity not penetrated. Cavity not penetrated. Fractured scapula. Cavity penetrated; lodged near scapula. Cavity penetrated. Excision of portion of scapula. Excision of portion of scapula. RemoA'al of a piece of rib; caA'ity not penetrated. Lung injured. Fracture of rib. Cavity not penetrated. Second and third ribs fractured ; cavity not penetrated. Cavity not penetrated. Lung perforated. Lung perforated. Cavity not penetrated. Cavity perforated. ................ CaA'ity penetrated. ................ Cavity not penetrated. ................ Extra thoracic. Fig. 278, p. 583 Cavity penetrated. ...............I Cavity penetrated ; rib fractured. CaA'ity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. 3 o w CD > o M a M GO O *j >-3 w M O W M 29 30 31 32 33 34 35 36 37 38 39 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 4491 4551 4513 1598 4488- 4534 4532 4528 4524 4487 4526 1131 1448 4734 3953 4421 4508 4505 404 1494 1395 1820 3192 4575 5968 5956 1678 4868 5964 4455 I.eigliton.... Phelps....... Sterling..... Saxon ...... Millenet..... Barrett...... Bogart....... Litoh....... Kern........ Walter...... Dasenbouck . Gcnthard___ Grothonn--- Spencer -. Morrison. Smith.... Robinson. Quint...... Flansburg.. Lee........ Johnson--- Foss..... Creamer... Cramer___ Matthews .. Apple..... Holmes___ Conoidal ball....... Conoidal ball....... Fragment of shell... Spherical ball....... Round ball......... Spherical ball....... Conoidal ball....... Conoidal ball....... Conoidal ball....... Conoidal ball....... Portion of bullet--- Elongated ritio bali. Conoidal ball...... Pistol ball...... Elongated ball. Elongated rifle ball........ Elongated smooth-bore bul- let. Millrion........ McNamara...... Private 5th Infantry. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball. Conoidal ball............. Fragment of brass button. Carbine ball.............. Nov. 7,1863 Aug. 9,1862 April 30, 1863 May 3,1863 Feb. 8,1862 July 1,1863 July 3,1863 Dee. 13,1862 July 1,1863 Aug. 30,1862 9uly 1,1863 July 3,1863 June 9,1863 May 3,1867 Aug. 9,1862 July 2,1863 July 3,1863 Dec. 13,1862 Aug. 30,1862 May 3,1863 Nov. 7,1863 Nov. 7,1863 Sept. 12,1863 Nov. 27,1863 July 1,1862 May 20,1863 Jan. 15,1865 Aug. 1,1863 Conoidal ball... Conoidal ball... Iron arrow-head. June 17,1864 -------,1860 Nov. 10,1863 Aug. 15,1862 April 13,1864 May 14,1863 April 28, 1863 July —,1863 July —,1863 Deo. —, 1862 July 24,1863 Sept. 5,1862 July 3,1863 July 28, 1863 June —, 1863 Same day i)0 18,1862 July 22,1863 Sept, 27,1863 Dec. 20, 1862 May 24,1863 Nov. —,1863 Nov. —,1863 Oct. 31,1863 Dec. 7,1863 Aug. 11,1862 Same day Jan. 9,1872 Aug. 2,1863 Left ot'spino of third dorsal vertebra Infraspiiiousfossa................... Near spine of left scapula.......... Below middlo third of clavicle...... Under scapula.................... Near spinal column............... Over seventh rib, near spine....... Inferior angle of scapula............ Centre of axillary space........... Over border of scapula............ Over middle of clavicle............ Under pectoralis major muscle...... Near shoulder joint............... Recovered . Re Thoracic parietes—glanced from costal cartilage. Below middle of spine of scapula... Dorsal region............ Between scapula and ribs Near inferior angle of scapula. Clavicle..................... Lower angle of scapula....... Inferior angle of scapula...... Lower angle of scapula....... External border scapula...... Over fifth rib................ Dec. 22,1871 3 months after Duty. Above posterior inferior angle of scapula. Behind and a little below the axilla. Parietes above right nipple......... Parietes below inferior angle of the left scapula* Border of left scapula ... Axilla.................. Base of spine of scapula. lleeovered .... *Oct. 29,1863 Recovered...'.. Duty.......... Recovered..... *Dec. 1,1863 "May 3,1864 ............'... Discharged---1.............. "Aug. 17,1863 Fig. 27, p. 92. ;May 12,1864 |............... Died......... See p. 545.--- Recovered. Recovered. Recovered. Recovered.. Discharged. Duty....... Died....... Recovered.. Duty....... Recovered.. Discharged. Discharged___ Discharged___ Died.......... Discharged. Discharged. Fig. 276, p. 582. Fig. 277, p. 582. Fig. 279, p. 583. 'avity not penetrated. lavity not penetrated. Javity not penetrated. !avity not penetrated. 'avity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not opened. Cavity not opened ; ligation of subolavian artery. CaA'ity not opened. Excision head of humerus; cavity not opened. Cavity not opened. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. Cavity not penetrated. CaA'ity not penetrated. Cavity not penetrated. CaA'ity not penetrated. Rib fractured ; cavity not penetrated. Lung wounded. Lung wounded. Lung wounded. Lung wounded. Lung perforated. t Died. { Discharged. CO 596 WOUNDS AND INJURIES OF THE CHEST. 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 parallel 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:* Cask.—Henry Miltenberger, Co. K, 12th Ohio Cavalry, aged 20 years, was injured, June 9th, 186-1. at Mount Sterling, Kentucky. In a report in the Medical and Surgical Reporter, Vol. XVI, p. 404, Dr. A. Geiger of Dayton, Ohio, says: " He was struck, at Saltville, Va., April 7th, 1864, by a minie ball in the left side; the ball entered at the loAver 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 cainp, 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 suffocation. 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 pipe, 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 unAvell 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 three 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 puB. Considerable hsemorrhage followed the expectoration of the ball, but the relief he experienced Avas 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 Avorking at his trade, and he is of the opinion hoav that all will soon be right with him. It might be idle to speculate as to Avhere 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 ofthe 'vis medieatrix natural,' 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 Avith 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 National 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 Avas suffering from intense dyspncea and had to be constantly propped up in bw. The symptoms were those of pneumonia. During the treatment, he expectorated a ball in connection with bloody mucus and pus, and soon aftenvard 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 circumsrances of the case, especially the marked relief which the discharge of the ball brought, after about four days of intense suffering from dyspncea, 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 applicant 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 Mount Sterling,—returned to duty June 23d, 1864," signed by Acting Assistant Surgeon Eobert Peter; "admitted to regimental hospital, July 19th, 1864, with diarrhoea; sent to general hospital, July 24th, 1864," signed by Surgeon G. \V. Brooks; admitted to Lexington general hospital with "inguinal hernia in right iliac region, by a kick from ahorse; furloughed September 18th, readmitted October 16th, transferred October 17th, reported at Camp Dennison, Ohio, October 26th, 1864," signed by Acting Assistant Surgeon Eobert Peter; " admitted to Camp Dennison, October 26th, 1864, Avith inguinal hernia; furloughed for tAventy days, February 22d, 1865; readmitted March 18th, • * Delil'S, of Erlangen (Amxnitates Medicse circa casus medico-practicos haud vulgares, Lipsiae, 1747, Vol. V, p. 154), speaks of a soldier coughing up a ball long after the reception of the injury. Reveille-PARISE, Deux observations sur des corps ctrangers qui ont sijourni dans la poitrine d. la suite des plaies penetrantes de cette partie; in Arch. Gen. de Mid., Mai, 1825, T. VIII, 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, tweh-e days afterwards, a piece of blue cloth and a small sequestrum- A year subsequently, he expectorated a larger sequestrum, and then recovered his health completely and resumed his military duties. He afterwards married and begot two children. In 1825, he enjoyed good health. Baron PERCY (I. c. p. 125) tells of his friend M. the Marquis of Bavfljy, who enj03'ed good health, though shot in the chest ten years before, and having expectorafed many patches, and even pieces of tow used as wadding. Professor Gltuas (Practical Treatise on Foreign Bodies in the Air-passage?, 1854, p. 58) recalls the instance recorded by FABRICIUS HiLDANl's (op. om. p. 41, 1682. already cited in note to p. 591), that of TULPIUS (Obscrvat. Medic. Lib. II, obs. 15, Amsterdam, 1652), and that of Pigray (Epitome des Preceptet de medecine et chirurgie, Rouen, 1G42), of necrosed fragments of bone and pieces of tents coughed up three, four, and six months after injury. In his System, 5th ed., Vol. II, p. 406, Professor GROSS cites other cases, and among them, two "of the spontaneous expulsion of bullets in the act of coughing." Dr. F. H. Hamilton (Prin. and Pract. of Surg., 1872, p. 112), misleads his readers by referring for the above case to the New York Medical Record, Jam 15, 1867, which contains no allusion to it. BALLS AND FOREIGN BODIES LODGED. 597 and returned to duty March 21st, 1865,^' signed by Surgeon C. McDermont, U. S. V. This is all the evidence presented by the official files of the Surgeon General's Office; but, in his second application, filed at the Pension Bureau, Miltenberger adds the folloAving testimony: "Wallace K. Hughes, M. D., Berlin Centre, Mahoning County, Ohio, under oath, declares that he was the surgeon of the 12th Ohio Cavalry, and that he treated Miltenberger Avhile in the service aforesaid. He attended Miltenberger during the time between June 9th, 1864, and June llth, 1864, and March, 1865, to November, 1H65. At the battle of Mount Sterling, Kentucky, June 9th, 1864, at about nine o'clock A. M., Miltenberger Avas Avounded by a minie ball in the left lung, the ball lodging. He was sent to hospitals and did not again return until in March, 1865, and I treated him from March, 1865, to muster-out of regiment, November 14th, 1865, for said Avound. Ball remained in his lung up to date of his discharge and had produced phthisis pulmonalis." The official army register of the Volunteer force of the United States Army, published by the Adjutant General, Washington, August (list, 1865, states, Part V, p. 19, that Surgeon G. W. Brooks, 12th Ohio Cavalry, resigned August ?th, 18(i5, and that Assistant Surgeon Wallace K. Hughes, 12th Ohio Volunteers, was promoted Surgeon, September 20th, 1865. The affidavit of Dr. Hughes is not in accord Avith the certificates of Drs. Brooks, Peters, and McDermont, or the report of Dr. Geiger. The applicant informed Dr. Geiger that he Avas wounded at Saltville, Virginia, April 7th, 1864, and Dr. Hughes states that this particular wound Avas received at Mount Sterling, June 9th, 1864. The applicant alleges that he expectorated the ball in February, 1866; he told Dr. Geiger that it Avas ejected on March 26th, 1867. Erastus Moderwell, late Major l'2th Ohio Cavalry, testifies to knowing Miltenberger intimately, and to the wound of the lung as above stated, and that the soldier Avas under his immediate command. Major ModerAvell was, himself, pensioned for a very curious injury. He was reported by his regimental surgeon, Dr. George W. Brooks, as having received "a severe gunshot fleslwound of the abdomen, at Mount Sterling. Kentucky, June 9th, 1864." His name does not appear on the registers of any general hospital. He avc.s furloughed for eight months, and then served Avith his regiment till its muster-out in November, 18G5. In his application for pension, Dr. W. K. Hughes certifies that "the ball entered on a line Avith, and five inches to the left of, the umbilicus and passed directly through, coming out near the spine." Examining Surgeon W. C. Brown, of Geneseo, Illinois, reports, July 25th, 1666, "that the ball entered parallel to the umbilicus four or five inches to the left and made its exit near the spine on the same side. The result of this injury is partial paralysis of the left leg." The same surgeon reports, November 21st, 1871, that "a small portion of the transverse process of spine Avas taken aAvay by the ball." Examining Surgeon S. C. Plummer, Rock Island, January 1st. 1872, reports that the " ball entered two and a half inches above and one inch in front of anterior superior process of left ilium, ranging backward and upward, nipping the transverse process of the third lumbar vertebra and escaped about one inch to the left of the spinous process. The left leg is partially paralyzed, and, in changeable and damp Aveather, becomes so painful as to require the use of opiates." This pensioner was last paid, March 4th, 1872 ; his pension increased to the maximum (or 8'2o per month) from November 7th, 1871. The Pittsburg Evening Chronicle publishes this as an interesting case of Avound penetrating the abdomen, and announces that the ball carried in Avith it a gold pen, which afterward worked its way out at the neck! The next abstract was read at a meeting of the Association of Army and Navy- Surgeons, at Richmond, at the conclusion of a valuable report on Gunshot Wounds of the Chest, by Surgeon W. G. Thom, P. A. 0. S. The particulars were communicated to the reporter by Surgeons W. Selden and W. J. Moore, P. A. C. S. The case was printed in the Confederate States Medical and Surgical lournal for April, 1864:* Case.—"Mr. R. D. Q., 22 years old, of scrofulous temperament, in January, 1840, was leaning on his gun, the muzzle in contact with his left side, when it exploded, tearing a hole in the chest of three or four inches in diameter, carrying with the load of shot fragments of the third, fourth, and fifth ribs, and the whole of a very large, heavy English gold patent-lever Avatch except the ring to which the chain was attached, which, singular to say, Avas found in the lining of his Avaistcoat on the rio-ht side. Dr. Selden found the patient apparently about to expire, and, from the impending suffocation upon the ingress of air Avithin so large an opening, he could make no exploration ofthe Avound. Closing the Avound Avith a large compress and bandage, opium and stimulants were freely administered. Reaction took place, and, in a fortnight, sufficient adhesions were established to permit exposure of the cavity of the wound and to recognize and remove the metal face of the watch from some six inches at the bottom of the Avound. For several Aveeks fragments of the watch continued to present themselves and were extracted, some from upon the diaphragm, others below the clavicle. The lung collapsing, Avas not torn to pieces, though.wounded in several points. Both the heart, covered by the pericardium, and the aorta were exposed to view and to touch. Suppuration was enormous; haemorrhages frequent. The collapsed lung became bound down by adhesions. The whole side of the thorax sank. Sustained by every article of nutritious food calculated to supply an inordinate appetite, the patient's recovery was slow, until the Avound, progressively reduced, could only admit a female catheter. The supervention of the tintement mitallique during the progress of the case offered the enviable opportunity of viewing the cause of its production. Drs. Andrews and Higgins (whose patient Mr. D. was), were perfectly assured that the bursting of the bubble on the surface of the pus 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 the chest by a gig-shaft, with recovery of thirteen years' duration, and by an iron-pointed try-sail yard, in the person of a sailor, who survh'ed many years, are preserved, with the instruments of penetration, in the Hunterian Museum (see Dr. Earle's account, Am. Jour. Med. Sci. N. S., Vol. II, p. 117). Mr. South gives a good account of them in his Notes to Chelius. Dr. Houston, of AA'hceling (Am. Jour. Med. Sci. N. S., Vol. IX, p. 342), records a case in which a piece of coarse linen, two inches and a half in length by two in width when unrolled, the patch of a ball that had perforated the lower lobe of tho 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 bronchial tubes. The specimen was presented to the Wistar Museum. Surgeon J. J. B. Wright's account of the case of General Shields, whose right chest was perforated by a canister shot at Cerro Gordo, April li?, 1847, may serve the junior medical officers as a model clinical history. It is printed in Dr. P. H. Hamilton's Practical Treatise on Military Surgery, New York, 1861, p. 157. ✓ 5(,)S WOUNDS AND INJURIES OF THE CHEST. ejected by expectoration with sputa. Mr. D. possesses, now, every part of the watch except the hands, a considerable portion of the small works having been expectorated. The openings into the lung were of sufficient size to allow a current of air to escape, and, if directed against the flame of a candle to extinguish it. Mr. D's health 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 pouched 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 ball, but may indicate the lodgement of two balls. Of balls 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 fistulse, 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 discretion, of persevering efforts to dete.ct 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 proposition 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.f The section maybe concluded with the following summary of operations on the chest: Table XXIII. Numerical Statement of Four Hundred and Ninety-four Operations in Cases of Injuries or Diseases of the Chest. OPERATION. Ligation of the Subclavian................. Ligation of the Internal Mammary.......... Ligation of the Suprascapular............... Ligation of the Intercostal................. Ligation of the Axillary................... Ligation of Branches of the Axillary........ Excision of portions of the Clavicle......... Excisions of portions of the Scapula........ Excisions of portions of the Ribs........... Removal of portions of Sternum, Ribs, etc... Thoracentesis............................ Extraction of Balls and other Foreign Bodies Cases. 25 2 1 8 13 2 11 4 4 84 24 316 20 2 6 13 1 7 1 1 24 15 108 Discharged.' Duty. 4 2 3 42 7 119 18 2 81 Result Unknown, Aggregate. 494 198 185 103 * Else he may be subjected to the mortification experienced by the surgeon mentioned by Dr. Fraser, 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 BAGIEU, Examen de Plusieurs Parties de la Chirurgie, Paris, 1756, p. 25). t Since the achievements of Dr. Billroth and others in the 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 what the French term la haute chirurgie. RECAPITULATION AND GENERAL OBSERVATIONS. 599 WOUNDS AND LNJUKIES 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 LLundred and Seven Cases of Wounds and Lnjuries of the Chest reported during the War. CHARACTER OF AVOUND. Sabre Wounds.................................... Bayonet Wounds.................................. Incised Wounds.................................. Punctured Wounds................................ Contusions.....................-.................. Simple and Compound Fractures of Ribs, not gunshot. Gunshot Flesh Wounds............................. Gunshot Penetrating Wounds....................... Totals............................................ 20,607 9 . 29 27 " 6 225 47 11,549 8,715 1 9 8. 4 5 4 113 5,260 5,404 Discharged. 4 6 5 1 15 9 1,790 1,939 Duty. 4 12 14 1 205 25 8,988 1,204 3,769 10,453 Undeter- mined. 11.1 2 33.3 29.6 66.6 2.2 9 10.5 658 1.0 312 62.5 981 Ratio of Mortality, 27.5 It might be supposed that, with so large a body of facts determined with reasonable accuracy, and the total number of wounded being known approximatively, 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 common, 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 roughly stated that the proportion of wounds of the chest to the whole number 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 be augmented to about two hundred and seventy thousand (270,000) cases of wounded men reported by name. 600 WOUNDS AND INJURIES OF THE CHEST. For the 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 a^iv^atc 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 (9.33 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 Campaigns during the last year of the Rebellion, 1864-65. Battles, Action, or Series of Engagements. Wounds of Thoracic Parietf.s. Pentrating Wounds of Chest. Missile. 0 w a 2 o ►J H O H o a p-5 Names or Dates. Cases. Deaths. Cases. Deaths. Large projec-tiles, cannon shot, shell, and bomb frag* ments, grape, and canister. Small projec-tiles, musket, carbine, rifle, pistol balls, and small mis-siles from shrapnel and canister. *Army of the Potomac from May 4th to August 31st. 1864...... Armies of the Cumberland, Tennessee, and Ohio during the Campaign to Atlanta from May 4th to September 8th, 1864. Armies of the Cumberland, Tennessee, and Ohio, and Cavalry, General Hood's invasion of Tennessee, from October 25th to December 31st, 1864................................... 1,613 818 132 56 43 43 475 126 303 361 6 28 2 1 1 1,025 968 86 52 53 38 460 80 193 248 366 408 16 2J3 13 3 107 22 38 75 220 100 19 1 21 14 86 16 38 30 2,392 1,618 195 105 70 61 808 189 451 530 38,944 23,308 3,610 1,533 1,075 2,111 16,120 2,196 7,542 9,101 6.77 7.66 6.03 7.04 8.93 3.83 5.80 9.38 6.57 6.69 General Sherman's Campaign in 1865 through the Carolinas... Armies of the James and Ohio, etc., from Fort Fisher to Golds-boro', N. C, 1865........................................ Army of the West Mississippi during the siege^of Mobile, from March 26th to April 9th, 1865............................ Army of the James during General Grant's Campaign against Petersburg from May 4th, 1864, to April 9th, 1865......... 5 3 Engagements in the Shenandoah Valley, May 4th to August 20th, 1864......................................... Campaign in the Shenandoah Valley, Aug. 2IsttoDec. 30th, 1864 *Army ofthe Potomac from Sept. 1st, 1864, to April 9th, 1865___ 3,970 54 3,203 1,070 545 6,419 105, 540 6.79 M. Scrive, from extensive data,f derived from the French returns from the pitched battles in the Crimea and from the trenches before Sevastopol, estimates the relative frequency of chest wounds in the total of wounded as one in twelve in siege operations, and one in twenty icropen field fighting. * Incomplete. tScr.iVF., Relation Medico-chirurgicale de la Campagne d'Orient, Paris, 1857, p. 443. The author gives the relative frequency of wounds, according to their seat in the principal divisions of the body as, in sieges: For the head, 1 in 3.4; the neck, 1 in 46; for the chest, 1 in 12; for the abdomen, 1 in 15; the upper extremities. 1 in 6.2; the lower extremities, 1 in 4.3. In open field actions: For the head, 1 in 10; the neck, 1 in 112; the chest, 1 in 20; the abdomen, I in 40; the upper extremities, 1 in 4.3 ; the lower extremities, 1 in 3.5. 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.1 M. Chenu gives the relative frequency, of chest wounds to the total number of wounded in the French Army in the Crimea2 as one in twelve and one-sixth, and in the Italian war of 1859,3 as one in thirteen and eight-tenths. Dr. Stromeyer4 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,5 in the Danish War of 1855, he treated twelve hundred and ten cases, and the proportion of chest wounds was nearly one in twelve. Demme6 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,7 of Breslau, had under his charge in the Silesian campaign of the Six-Weeks War, two hundred and twelve wouncled, of whom eighteen, or one in twelve, had chest wounds. Professor H. Fischer8 treated, at the siege of Metz, eight hundred and seventy-five wounded, the proportion of chest wounds being about one in twelve. Dr. Bernhard Beck9 reports, after the action at Tauberbischofsheim, fifty-seven wounded, with a proportion of chest wounds of about one in ten. The same distinguished surgeon10 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. Serrier11 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. MacCormac12 has carefully classified these injuries. i The total number of British 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 ofthe chest. During the second period, from April 1, 185.'), 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 7,081 determined cases, of which 420 were chest wounds. Hence 579 + 2,619 + 7,081 = 10,279, or the aggregate of determined cases of wounds, and 54 + 153 + 420 = 627, the total of chest wounds, and 10,279 -v- 627 = 16.3, the proportion of chest wounds to the aggregate. JM. Chenu (op. cit., pp.627, 636) gives the total killed and wounded ofthe French Army in th£ Crimea as 50,826. Deducting 10,240 killed, there remain 40,586 wounded. In 31,306, the seat of injury was reported, and 2,818 were returned as wounds ofthe chest, or 1 iu 12 1-6. 3 In the Italian War of 1859, M. Chenu (op. cit., T. II, pp. 474, 851) states the French losses from the enemy's fire at 17,054, including 2,536 killed outright. Ofthe remaining 14,518 wounded, 1,052 received wounds ofthe chest, or 1 in 13.8. 4 Stromeyer, L. Erfahrungen uber Schusswunden im Jahre 18C6, Hannover, 1867, S. 18. Of 1,394 cases of gunshot wounds 110, or 1 in 12.6, were of the chest. 6 DERSELBE. Maximen der Kriegsheilkunst, Hannover, 1855, S. 585. " Of 1,210 wounded near Idstedt, 97 had injuries of the thorax," or 1 in 12.4. 6 Demme. Militar-chirurgische Studien, Wiirzburg, 1861, Erste Abth., S. 19. Of 8,500 wounded Austrians, 680 were struck in the chest, or 1 in 12.5; of 8,595 French and Sardinian wounded, 595 had chest wounds, or 1 in 14.4. 1 Maas, H. Kriegschirurgische Beitrage, Breslau, 1870, S. 72. At the hospital at Nachod, in central Silesia, Professor Maas treated 212 wounded Prussians, among whom, 18, or 1 in 11.7, had been struck in the chest. 8 Fischer, H. Kriegschirurgische Erfahrungen, Erlangen, 1872, Theil I., S. 28. At the hospitals of Forbach, Styringen, Neuenkirchen, and Ottweiler, under Professor Fischer's charge, of a total of 875 cases of wounds, 76, or 1 in 11.5, were of the chest. 9 BECK, B. Kriegschirurgische Erfahrungen, Freiburg i. B. 1867, p. 26. Of 57 cases, the chest was injured in 6, or 1 in 9.5. 10 DERSELBE. Chirurgie der Schussverletzungen, Freiburg, i. B., 1772, Erste Halfte, S. 160. Dr. Beck was generalarzt of the fourteenth German corps, the Bavarian army corps of General Werder, in the late Fanco-German war. He reports an aggregate of 4,344 wounded, of which 361 had chest wounds, or 1 in 12.03. n SERRIER. Traite de la Nature, des Complications, et du Traitement des Plaies d'Armes el Ecu, Paris, 1844, p. 30. U 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 hospitals at Sedan, placed, on August 31, 1870, the day before the great battle, the barracks at Asfeld, a hospital of 384 beds, in charge of the 16 surgeons of the Anglo-American Ambulance. Mr. MacCormac reports that they received 610 wounded, of whom 54 had received wounds of the chest, or 1 in 11.29. '76 602 WOUNDS AND INJURIES OF THE CHEST. Thus a comparison of the returns of the War of the Rebellion with those from the Crimea,* the Danish, Italian, Bohemian, and Franco-German wars, presents a remarkable uniformity in the comparative frequency of wounds according to their seat. Of information regarding the seat of injury in those killed in battle, we possess but little, and that little is, for the most part, in the shape of general observations, insuscep- tible of reduction to numerical estimates. Dr. Fraser remarks that "if it were not for the financial objection, a special staff of medical men might well be employed during circumstances similar to that in which the army was placed before Sebastopol, or in any standing camp before an enemy, to ascertain the kinds of wounds which 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 whose 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 observation of Surgeon *I take the liberty of quoting entire Dr. Fraser's tables of the chest wounds in the British army 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 acknowledgment, and usually with slight, but not advantageous, alterations. I agree with Dr. Fraser and Dr. Neudorfer (Handbuch der Kriegs- chirurgie, Leipzig, 1867, S. 553) that the 153 chest wounds 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 Wounds of the Chest. Total Number of all Wounds, 12,094, in the Crimean War. WOUNDS. TO total number wounded. Percentage of all chest wounds to total number wounded. Percentage of actual lung wound to total number wounded. Mortality of all chest wounds to total number wounded. Mortality of actual lung wound to total number wounded. TO total strength. Percentage of all chest wounds.................„.. Percentage of actual lung wounds.............___ Mortality of all chest wounds....................., Mortality of actual lung wound................... Cases. 474* 474 164 135 130 0.54 0.17 0.14 0.13 Mortality of all chest wounds... Mortality of actual lung wound. Cases. 474 164 Deaths. 135 130 Per Cent. 28.50 79.26 *To this number ought properly to be added 153, being the number of chest wounds received during tlie first period of the war, of which 32 are reported to have died, making a grand total of 627; but, as the data for the first period of the war is uncertain, the number has not been admitted into the calculation. Table Y. Showing the Number of Chest Wounds on the occasions named, and from, the Authorities quoted, with the Percentage of Deaths to Wounded. ACTIONS, Etc. The Director-General's Records prior to Crimean War. Crimea................................. Sympheropol (Russians).................. Toulouse................................ Quebec................................ Carlist War.............................. Paris, 1830............................... Paris, 1848............................... Paris, 1850............................... Battle of Kilet........................... Battle of Idstedt......................... Battle of Canton.......................... M. Meniere.............................. M. Legouest............................ Guy's Hospital Reports................... Danish War; Report of Chief-Surgeon Schytz. Total wounded, 227. Dr. Kidd................................ Aggregate. Wound. Died. Per Cent. 39 27 70.00 474 135 28.50 200 197 98.05 106 50 50.00 26 2 7.07 29 27 100.00 20* 10 50.00 9 4 44.00 11 5 45.50 21 11 50.00 97 17 17.00 4 4 100.00 20 20 100.00 6 3 50.00 72t 9 12.50 10 2 20.00 36 24 66.00 1,180 547 * De Lamballe and Baudens. t Of this number, the lung was really wounded in two cases only.1 RELATIVE FREQUENCY OF CHEST WOUNDS. 603 J. A. Lidell, U. S. V., has already been recorded.1 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 hemorrhage, 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 1863-5,2 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 reports3 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. i Surgical Report in CIRCULAR No. 6, S.G.O., 1865, p. 29, and Lidell, On the Wounds of Blood-vessels, etc., already cited, New York, 1870, p. 12. 2 Mouat, J., Special Report on Wounds and Injuries received in Battle in the New Zealand War 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 ofthe chest, or about 1 in 12. 31 venture to quote entire Dr. Loeffler's invaluable table, from his General-Bericht uber den Gesundheitsdienst im Feldzuge gegen Danemark, 1864, Berlin, 1867, Erster Theil, S. 46 : INJURED REGION. PRUSSIANS. DANES. -a a a •*"£ "■a " a M 0 o -, e= a © -a ■a CD 13 0 0 O Died of Wounds. ■a a a ■a •a* "o ■a a 0 o "3 o H Fatal. a '!§ •a* S ■a s •a w cwa '•3 § o „ fs fa a 3 m '1g ■a s •a '•B 3 Head.......................................... 468 48 254 147 99 610 729 196 8 117 44 7 2 13 272 40 137 103 92 608 716 13 3 20 31 3 2 7 12 1 37 25 24 51 83 25 4 57 59 27 53 90 £21 12 174 103 34 55 103 120 26 113 89 80 317 458 8 15 31 6 6 14 2 61 26 26 62 140 22 2 76 57 32 62 146 Chest.......................................... 2355 387 1968 82 233 315 702 1203 66 331 397 604 WOUNDS AND INJURIES OF THE CHEST. Mortality of Wounds of the Chest.—Great diversity of opinion has existed and still exists as to the comparative fatality of chest wounds. With the data now 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. E. Klebs1 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 wounds 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 Pensions2 reports seventy-six thousand four hundred and sixty-nine pensioners on the rolls on account of injuries 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,3 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 ofthe chest. Dr. George Williamson4 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. Regarding 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,5 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 91.6.6 In the British Army in the Crimea,7 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. 1 Klebs. Beitrage zur Palhologischen Anatomic der 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. 2 Baker, J. H. Report of the Commissioner of Pensions to the Secretary of the Interior, for the year ended June 30, 1871, pp. 6, 20. Hon. J. H. Baker states 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 are 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 Hannover. Die Ddnischen Invaliden, Berlin, 1870, S. 8. The proportion of invalids wounded in the chest is as 1 in 26. 4 WILLIAMSON. Military Surgery, London, 1863, p. 237. Two of the nineteen died shortly after arrival. See Specimens 3637, 3638, and 3669 in the Netley Collection, and Plate n, p. 86, of Dr. Williamson's work. The proportion of those surviving chest wounds temporarily was as I in 31.7. 5 In the New Zealand War, Inspector-General Mouat (op. cit., Vol. vii, p. 485) reports thirty-eight cases of gunshot wounds ofthe chest. Eleven were wounds ofthe muscles, one of the bones, three penetrated the chest without 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. Mouat'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 Maori prisoners), six resulted fatally. «M. Chenu (op. cit, p. 187). From the total of 2,818 classified as chest wounds, are 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 164 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 per cent., were penetrating. i MATTH ew (op. cit., Vol. II, p. 313) tabulates only the 474 cases of the second period, with 135 deaths. I have added the 153 cases with 32 deaths of the first period. The mortality of chest wounds in the Russian army in the Crimea has not, as I am aware, been officially reported. Dr. Pirogoflf expresses his regret (Grundzuge der Allgemcinen Kriegschirurgie, Leipsig, 1864, S. 535) that he cannot furnish any statistical data, and quotes from Demme and Stromeyer. It is stated by Mouat that, at Sympheropol, the Russians had 200 patients with gunshot wounds of the chest, of whom 197 died. The Sardinian army had but few wounded in the Crimea, 193 in all; of whom 10 were killed and 16 died of wounds, according to the table of Dr. Comisetti, president ofthe Health Board ofthe Sardinian Army. The effective force ofthe army was 21,000. MORTALITY OF CHEST WOUNDS. 605 In the Italian War of 1859, Demme1 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 hospital, 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 French2 was much less, amounting to only 46.48 per cent, even for the pene- trating gunshot wounds alone. In the first Schleswig-PIolstein war,3 after the battle of Idstedt, Dr. Stromeyer lost but 17.6 per cent of patients in the Hannoverian army with gunshot wounds of the chest. In the Danish AVar of 1861,4 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. Maas5 reports twelve gunshot wounds of the lung, with only four fatal cases, or 33.3 per cent. Dr. Stromeyer,6 at Langensalza, had but sixteen recoveries in forty-seven penetrating gunshot wounds of the chest, a death rate of 65.9. Dr. Biefel,7at 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 War, numerous partial returns have already been received. At Mannheim and Weissenburg, Professor Theodor Billroth8* lost but nine of thirty patients with penetrating gunshot wounds of the chest. At Metz, Dr. H. Fischer9 reports the proportion of fatal gunshot wounds of the chest at 55.8 per cent. After Sedan, Mr. MacCormac reports10 the mortality of penetrating gunshot wounds of the chest at the Anglo-American Ambulance at Asfeld, as 54.8.' At the field hospital at Floing, Generalstabsarzt Stromeyer11 had fourteen cases of penetrating chest wounds, seven of whom were likely (September 26th, 1870) to recover. i Demme. Allgemeine Chirurgie der Kriegswunden, Wiirzburg, 1864, 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 hi3 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. Loefiler justly complains. They abound in the second edition, of 1853, for which reason, I quote usually from the edition of 1861. 2 M. Chenu (op. cit. T. II, p. 474) tabulates one thousand fifty-two chest wounds; deducting thirty-seven sabre, bayonet, and lance wounds, and two hundred and four miscellaneous injuries, 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. 3 July 20th, 1850. Dr. Stromeyer had seventeen deaths in ninefy-seven patients with chest wounds, in a total of twelve hundred and ten wounded. Maximen der Kriegsheilkunst, S. 385. 4L(EFFLER (loc 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 thirty-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. Lceffler gives us the assurance, which, in his case, is unnecessary, that the larger mortality among the prisoners was not due to any difference in the treatment received by the prisoners. Professor Billroth justly extols the statistics of Dr. Lceffler, 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. 5 Maas. Kriegschirurgische Beitrage, S. 72. 6 STROMEYER. Erfahrungen uber Schusswunden, S. 42. 1 Biefel. Im Reserve Lazareth. Kriegschirurgische Aphorismen, von 1866, in Langenbeck's Archiv fur Klinische chirurgie, B. XI, S. 369. SBILLROTH (Chirurgische Briefe aus den Kriegs-Lazarethen in Weissenburg und Mannheim, 1870, Berlin, 1872, S. 192) reports that of thirty cases of penetrating wounds of the chest, nine, or 30 per cent., died, a result so much more favorable, as several 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 the injury, was attacked by typhus and died in consequence. 9FISCHER, H. (Kriegschirurgische Erfahrungen, Erster Theil, vor Metz, Erlangen, 1872, S. 116) says: "Seventy-eight gunshot wonnds of the thorax were treated, and of these, thirty-four, or 43.5 per cent., were perforating. * * Of the seventy-eight cases of gunshot wounds 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: "Really 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 from that usually employed." If Dr. Fischer deducts the three cases of amputation and one of typhus 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. lo MACCORMAC (op. cit., p. 126). Of fifty-four wounds ofthe chest treated, thirty-one were regarded as penetrating, of which seventeen terminated fatally. 11 IBID., p. 122. There were at this Feld-Lazareth one hundred and twenty-one patients—sixty-four Germans, fifty-seven French. 606 WOUNDS AND INJUKIES OF THE CHEST. 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. But the Endresultat 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 prisoners as well as of Union soldiers : Table XXVI. Numerical Statement of Eight Thousand Seven Hundred and Fifteen Cases of Penetrating Gunshot Wounds of the Chest reported on the Returns daring the War. CHARACTER OF WOUND. Discharged. Duty. Undeter- mined. Ratio of Mortality, Missile entered and passed out, traversing the cavity ofthe thorax. Missile entered the thoracic cavity and was believed to have lodged within it.......................................... Missile stated to have penetrated the cavity of the chest without specification as to lodgement or exit........................ Missile entered and wounded lung without specification as to lodgement or exit........................................ Cases described as severe gunshot penetrating wounds of the side, chest, or thorax, without further indication............. Missile impacted between the ribs, but external to the pleural cavity.................................................. Missile fracturing and depressing ribs but not itself entering the thoracic cavity........................................... Missile perforating chest and wounding both lungs.............. Missile penetrating and wounding diaphragm.................. Missile penetrating both chest and abdomen.................... With wounds of the intercostal and internal mammary arteries__ With wound of the pericardium.............................. With wound of the heart.................................... With wound of the innominata............................... With wound of the vena cava'............................... With wound of the oesophagus............................... Aggregate........................................ 2,782 484 1,780 1,683 1,304 1 446 58 8 121 21 10 12 3 1 1 1,011 243 1,348 1,192 1,214 1 68 47 8 89 17 6 11 3 1 1 1,352 189 65 110 403 48 299 266 16 4 68 115 90 176 7 186 2 16 2 31 4 4 1 36.5 50.6 78.7 76.0 100. 100. 15.8 83.9 100. 74.2 80.9 60.0 91.6 100. 100. 100. 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 convalesence, and their ultimate fate is unknown. The mortality rate for the determined cases of penetrating 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. LoefHer (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 thousand 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 full.1 Surgeon C. Terry2 reports, from the battle of Chickamauga, six cases of penetrating gunshot wounds of the chest, with four recoveries; and Surgeon D. C. O'Keefe3 publishes five cases with only one fatal result. Examples of recovery after injuries of this nature are also cited by Surgeons Selden, Thom, Bead, Baruch, Michel, and Browne.4 All of them are included in my estimates. 1 Among the Confederate writers. Dr. E. Warren (op. cit., p. 370) observes that "wounds ofthe lung are far from being so fatal as might be supposed in advance. Numerous cases have come under my own observation, during the present war, 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 haemorrhage or collapse, a favorable prognosis may be formed in a majority of such cases." The writer does not indicate the degree of fatality which might be erroneously "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. Chisholm (op. cit., p. 310) says : " Wounds ofthe 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." He then relates some remarkable examples of recovery, ami 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. Chisholm 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, gives a list of seventy-four cases of gunshot wounds perforating the chest and transfixing the lungs, as reported by Confederate army 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 he ascertained, bloodletting had been resorted 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 60, of the April, 1864, number of the Confederate States Medical and Surgical Journal, it is found that, after a preliminary 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 gunshot 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 died, as Dr. Chisholm interprets. But the contradiction destroys the statistical value of the report. Were it otherwise, Dr. Chisholm's assumption, that the mortality of 25 (27.21) 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 unexpected from a surgeon usually careful and accurate in his statements. 1 do not yield to Dr. Chisholm in deprecating the employment in chest wounds of the depleting measures of former years, still advocated by Professors Gross and Erichsen and Stromeyer; but to maintain that expectancy or any mode of treatment can reduce the mortality of lung wounds fifty per cent, is to advance a proposition too egregiously improbable to be discussed. One may hope that it was through inadvertence, and not to sustain his argument, that Dr. Chisholm, in quoting Dr. Thorn'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 of Medicine and Surgery, the New Orleans Journal of Medicine, the Atlanta Medical and Surgical Journal, and the Southern Medical and Surgical Journal, vainly searched for additional information on this subject. > Confederate States Medical and Surgical Journal, Vol. I, p. 75. 3Ibid, p. 25. *Ibid., Vol. I. 608 WOUNDS AND INJURIES OF THE CHEST. Three hundred and ninety-five abstracts of gunshot wounds are cited in the preceding pages of this section. It is obvious that they were selected without the slightest reference to the question of mortality, yet they corroborate in a remarkable manner the conclusions of Table XXVI. Abstracting eighty-five cases of non-penetrating wounds, with a mortality of 25.8 per cent., there remain three hundred and ten cases of penetrating wounds, with one hundred and ninety-two deaths, a mortality of 61.9 per cent.; or, separating the Union and Confederate cases, there are twenty-seven in the latter and fifteen deaths ; two hundred and eighty-three of the former, with one hundred and seventy- seven deaths, a mortality rate of 55.5 and 62.5 per cent., respectively. I would propose to substitute for the table commonly quoted (Table V, cited from Dr. Fraser, p. 602, ante) the following, in which such extreme statements as those regard- ing the battle of Quebec, the street-fighting in Paris, and the losses of the Eussians at Sympheropol are excluded : Table XXVII. Showing the Number of Penetrating Wounds of the Chest on the Occasions named, and from the Authorities quoted, with the Ratio of the Mortality. ACTION, &C. Wounds. Died. Eatio of Mortality. New Zealand War (Mouat).................... French in Crimea (Chenu)..........-.......... British in Crimea (Matthew)___................ French in Italy (Chenu)....................... Austrians and Italians (Demme)................ Hannoverians in Schleswig-Holstein (Stromeyer) Prussians in Danish War of 1864 (Lceffler)...... Danes in Danish War of 1864 (Lceffler)......... Prussians in Six-Weeks War (Maas)............ Prussians at Langensalza (Stromeyer).......... Prussians at Landeshut (Biefel)................ Germans in Franco-Prussian War (Billroth)...... Germans near Metz (Fischer).................. French at Sedan (MacCormac).................. Aggregate........................... 23 491 164 256 159 97 137 113 12 47 15 30 34 31 15 450 130 119 97 17 57 76 4 31 8 9 19 17 60.8 91.6 79.2 46.48 61.0 17.6 41.6 67.2 33.3 65.9 53.3 30.0 55.8 54.8 1,609 1,049 65.2 These figures establish that the ordinary percentage of deaths in large series of cases commonly classified as penetrating wounds of the chest1 is above sixty per cent".; that surgeons erroneously indulge the belief that they save a majority of their patients under these circumstances ; and that the more rigorously the diagnoses are scrutinized and the final results traced, the higher the proportion of mortality rises. Dr. Matthew, in his 11 share the conviction of XEL'DORFER (Handbuch de Kriegschirurgie, B. I, H. II, S. 554) that the percentage of mortality of actual lung woundg is much higher. In commenting on the British, French, and American statistics on this subject, Neudorfer says : " Diese hier angeftihrten Mortalitats- ziffern sind aber alle viel zu klein ; in der Wirklichkeit ist die Sterblichkeitsziffer viel grosser, weil viele von denen, welche ala genesen, oder deren Sohicksal als unbekannt angefiihrt ist, nachtraglich gestorben sind." MORTALITY OF CHEST WOUNDS. 609 Surgical History of the Crimean War, in the summary on gunshot wounds of the chest (the whole article, as Mr. Blenkins justly observes, being " replete with masterly observations"), remarks that " it seems very doubtful if every case in which the ball was lodged within the pleural chest lining did not terminate in death, arid the instances where recoveries are returned (two men and one officer) may be open to great doubt as to whether the ball had actually penetrated.'' Dr. Fraser believes " that in the human subject, as well as in animals, an actual wound of the substance of the lung is always, sooner or later, mortal, not from the effect of inflammatory action, but, in recent cases, from the sudden cessation of proper aeration in either the whole, or portions of one or two lungs; or sudden hsemorrhage." The opinions of Dr. Macleod, which have had undue weight, in this country, because of the accessibility of his Notes, are not to be weighed in comparison with those of Drs. Matthew and Fraser; for his observations on this subject were but few, and those published do not sustain his conclusions, which are conformed to the opinions then in vogue. The figures that I have given respecting the mortality of penetrating chest wounds conflict with those offered by Assistant Surgeons Smart (p. 510,—150 cases, 49 deaths, or 32.6 per cent.) and Billings (Appendix, p. 200,—858 cases at Gettysburg, with 295 deaths, or 3-1 per cent.) only in appearance. It was impossible for those officers to trace the cases to their terminations. It is seen in Table XXV, that I found the mortality, in the f eld and primary hospitals, of all the penetrating wounds of the chest returned in the Union army for the last year of the war, to be 33.4 per cent., or nearly the proportions given by them. I cannot better explain the difference between the early and remote statistical results on this subject-, than by referring to the very carefully studied report of Surgeon J. T. Woods, 99th Ohio Volunteers, of fifty-five cases of supposed penetrating wounds of the chest that he observed after the battle of Chickamauga. The fifty-five patients had all been wounded by conoidal musket balls on September 19th and 20th, 1863, and made prisoners. They were paroled and sent to the Chattanooga hospitals after ten days' detention-. Hence, the series includes only those who had escaped the dangers of early hsemorrhages. Dr. Woods made his report early in January, 1864, having had the survivors under his care nearly three months. It was believed that the lung was wounded in all of these cases, and, with few exceptions, they were perforations. Dr. Woods classified them according to their precise seat as follows: So there were twenty-nine apparent re- coveries in a series of cases selected from those who had survived penetrating gunshot wounds of the chest for ten days, or a mortality rate of 47.2 per cent. But, on tracing the twenty- nine survivors to the base hospitals, it is found that one was discovered to have only a non- penetrating fracture of the sternum, and that seven died, several of them within three weeks after leaving Chattanooga. Hence, the table must be amended to fifty-four cases, with thirty-three deaths, or a mortality of 61.6 per cent. 77 Penetbatinq Chest Wounds by Conoidal Musket Ball. Cases. Deathi. Right Lung.....< t. Not ascertained -.. j Lower lobe....... t Not ascertained ... 6 5 3. 5 12 9 7 6 2 4 0 0 5 3 4 3 5 2 Total .................... 55 26 G10 WOUNDS AND INJURIES OF THE CHEST. 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.1 Other 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,2 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.3 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.4 1 The ancients were less sanguine than the moderns in this matter. Galen (Lib. V, cap. 26) pronounces deep wounds of the lungs fatal. John Tagault says (Institutionum chirurgicarum Libri Quinque, ed. Uffenbachii, Francofurti, 1610, Lib. II, c. iii, p. 736) : " Vulnera autem quse pulmonibus incidunt, ideo curatu sunt diffleillima, imo magna ex parte insanabilia; quoniam promptissime phlegmonem excitant." ElCHAKD WISEMAN (Severall Chirurgical Treatises, (London, 1676, Book VI, c. viii, p. 434 and p. 436) writes "almost all those wounds made by gunshot are mortal," and "many instances may be given of gunshots in the breast, but few do recover that are shot in the lungs. Plenck says (Instit. 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, London, 1824, 4t0), many readers do not pause to reflect that the preparation 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. THOJI (i!oc. 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 marvellous 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 Garratt, of Massachusetts (Boston Med. and Surg. Journal, Vol. LVII, p. 488), who, on a voyage to Liverpool, encountered 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/nan to London, where he was recognized by Professors Partridge and Fergusson, and appointed janitor ofthe Museum ofthe London Hospital. 3 Thus Dr. F. H. 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 past five years (Circular No. 3, S. G. O., 1871, A Report on Surgical Cases treated in the Army, etc., p. 29), three (CASES LXXVH, LXXXI, 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. 4 Thus Surgeon Middleton Michel, P. A. C S., adduces (Confederate States Medical and Surgical Journal, p. 102\ in his dissertationon "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 punctured 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 llth 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 for 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 Baruch, 3d South Carolina battalion, I examined several whose chests had 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 haemorrhage of any account from the wound had been remarked. The men were seate'd up in their tents on the fourth day, eating, and the cordform 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 the cases mentioned are the same cited by Surgeon Baruch, 3d South Carolina battalion, at page 133 of the same Journal. These cases (Finkler and Percival) are noted on page 470 of this chapter, the reference to Dr. Baruch's paper being inadvertently omitted. Dr. Baruch is positive that the right lung was interested in Finkler's case, though the haemoptysis was the only symptom of lung wound, and auscultation gave negative results. He is less confident in Percival's 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 infuriated 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 dyspnoea, 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 during 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 displaced by the patients lying on the left side." If the reader cannot thread his way through the labyrinth of breastworks '' ten lines deep," nor determine 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 difficult. 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 haemorrhage, emphysema, and pneumothorax, hemothorax, 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 hsemorrhage and h£emothorax, pleurisy, hydrothorax and empyema, pneumonia, abscess of the lung, carditis and pericarditis, erysipelas, gangrene, tetanus, pysemia, secondary emphysema, fistula, and contraction of the side of the chest. Haemorrhage.—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 nofreadily 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 implicat'ed.* * In such cases, if. the vessels were largely opened, immediately mortal hsemorrhage 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 hsemorrhage 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 Percival (whose heart was providentially displaced into the posterior mediastinum) were two of the sufferers, although he might not agree with Dr. Michel that the cases furnished an analogy for the healing 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 treatment of these cases induces me," writes Dr. Baruoh "to consider bayonet wounds as very simple injuries." * * " 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 60 were it generally known that bayonet wounds are almost harmless when compared with the ploughed tracks which the terrible minie bores through the tissues." * * " A bayonet wound almost invariably heals by first intention under auspicious circumstances." * * " Why is it that soldiers have such a wholesome dread of the bayonet!" Hennen tells us (op. cit. p. 374) that "bayonet's passing along or through the muscles covering the chest and its vicinity, demand a peculiarity of attention, solely from the danger of inflammation spreading to the pleura, or the lungs and heart, or of troublesome abscesses forming. In this view, the very slightest are interesting, and sometimes highly dangerous, particularly in persons disposed to pulmonic affections." * I have followed M. Legouest in including these lesions with wounds of the chest, a classification which, I think, presents many advantages.__ Compiler. r 612 WOUNDS AND INJURIES OF THE CHEST. distinguish the bleed mg from the subscapular and circumflex branches from that of the main vessel, the degree of hsemorrhage and the cessation of the radial pulse 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.1 Simultaneous lesion of the axillary artery and vein gave rise to aneurismal varix in three cases of incised wounds recorded by D. J. Larrey.2 This condition may result likewise after gunshot wounds* as was observed by Dupuytren and reported by Berard.3 A case of successful ligation of the subclavian for aneurism reported by Dr. Josiah 0. Nott,4 in 1841, is also cited as arterio-venous in its character. Dr. J. P. C. Wederstrand,t5 also reports an aneurismal varix following a gunshot wound of the subclavian vein and artery, which the patient survived seven years, when he died from an intercurrent disease. M. Legouest6 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, haemorrhage was a prominent feature in one hundred' and one.7 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^pf compression by a pouch stuffed with lint should be borne in mind. Some examples have been given with a view to prove that haemorrhages 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,8 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 l All the cases anterior to his time are cited by MORGAGNI, De Sedibus et Causis Morborum, Epis. V, § 21 sqq. See MAGENDIE, Sur I'Entrie accidentelle de VAir dans les Vcines, sur la mort subite qui en est Veffet, in the Journal de Physiologic Experimental^, T. 1,1821, pp. 190-199; LEROY (d'fitiolles) Notes sur les Effets de I'Introduction de VAir dans le Veins, Arch. Gen. de Me-d., 1823, T. HI, p. 410, Juillet, 1824, p. 430; SAUCEROTTE, Des Effetsproduits seu VEconomic animate par la Presence de VAir atmospherique dans Vappareil circulatoire, These de Strasbourg, 1828; DELPECH, Memorial des Hospitaux du Midi, November, 1830; Laxgenbeck, Beitrage zur chirurgischen Pathologic der Venen, Archives, Berlin, 1861, Erster Band, S. 1; WATTMANX, Sicheres Heilverfahrcn bei Lufteinfritt in die Venen, Wien, 1843. 2 Larrey, D. J., Clinique Chirurgicale, T. HI, p. 139, and Bulletin de la FaculU de Medecine, T. Ill, p. 27. 3Dictionnaire de Medecine (en XXX) Paris, 1833, T. IV, p. 510. 4XOTT, J. C, Am. Jour, of Med. Sci., X. S., Vol. H, p. Ill, and Annales de la Chirurgie Franchise, et fitrangere, T. IV, p. 120, and London Medical Gazette, October 22, 1841, p. 158. 5 Wederstraxdt, New Orleans Medical News and Hospital Gazette, 1854. <-LEGOUEST, Chirurgie d'Armie, 2d ed. p. 323. 7 In the twenty -three cases of penetrating gunshot wound of the lung that came under treatment in the New Zealand War (Mouat'8 report, already cited, p. 15), six terminated fatally from primary, and three from intermediary, haemorrhage. 8 BILLROTH, Chirurgische Briefe u. s. w. S. 122. Brofessor Billroth tied the subclavian three times and assisted at two other ligations for bleeding from the main trunk. One of the patients is believed to have ultimately recovered. I may here 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 the summer of 1872, and found the man in tolerable health, though a small tumor with an aneurismal thrill, had reappeared. COMPLICATIONS OF INJURIES OF THE CHEST. 613 subject might be profitably reviewed.1 I can here 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 without leaving any trace of wound in the walls of that organ, viz., by gradual absorption of the wall of pulmonary 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 case2 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 Lamotte3 and Larrey.4 Hsemorrhage from wounds of the smaller pulmonary vessels, and from laceration of the lung tissue will be considered under the head of haemothorax. 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: CASE.-Private William H. Mansfield, Co. D, 13th New York Cavalry, aged 21 years, was wounded while attempting to pass the line at Piedmont, October 19th, 1864, by a conoidal ball, 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 emphysema supervened in the tissues about where the missile lodged. He was conveyed to the field hospital, where the ball was excised by Assistant Surgeon J. T. Burdick, 13th New York Cavalry. Cold compresses were applied, with continuous pressure to the back. Morphia and tincture of veratrum viride were freely administered. Quiet was enjoined, and the patient instructed to lay upon his left side. He recovered, with partial atrophy of upper lobe of left lung. Discharged from service in June, 1865. Not a pensioner. The infrequency of this complication in the Confederate service is noticed by Surgeons Chisolm and Jeffery.5 Dr. Williamson6 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.7 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 be specified. Such was the influence exerted by the observations of Sauvages, Littre, Boyer, and Larrey,8 that the celebrated Hennen wrote (op. cit., 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 symptom, and by no means a frequent one. 1 Consult the authorities cited in the note to p. 527 and refer to the preparation of Professor Theile, in the museum of pathological anatomy at Berne, in which a laceration of the arch of the aorta was not fatal for several months after the accident; also the recent case at Carlsruhe, which Professor Billroth alludes to (op. cit, S. 113) and Dr. SOCIN describes (Kriegschirurgische Erfahrungen, u. s. w., Leipzig, 1872, S. 48 : " Lecrepe, wounded at Worth, August 6th, 1870, transferred to Carlsruhe. * * Copious haemorrhage on the sixteenth day; death." Dr. Klebs Beitrage zur path. Anat. der Schusswunden, Leipzig, 1872, S. 126, gives the notes of the autopsy made August 20th, 1870, and remarks on the slight primary bleeding. - CAEVALLO, p. 534, and Circular No. 3, S. G. O., 1871, p. 33, and Specimen 5929, Section I, Army Medical Museum. 3 LAMOTTE. Traite complet de Chirurgie, Paris, 1781, T. II, p. 69. 4 Larrey. Clinique Chirurgicale, T. II, p. 291. 5CIIISOLM. (A Manual of Military Surgery, 3d ed. p. 319): "It is a sign which our extensive experience shows to be rarely present." JEFFERY, K. W., Surgeon C.S.N. (Confederate States Med. and Surg. Jour., vol. I, p. 39), describes a gunshot wound of the lung attended with emphysema, in a seaman of the C. S. Steamer Isondiga, and remarks, in 1864: " Since the beginning of the war, this is the second case of wounded lurg in which, if my memory serves me aright, I kave seen emphysema, and in which there was no expectoration of blood." So, also, the authors of the Confederate Manual observes of emphysema: " It is not common after gunshot wounds, but occasionally happens.'' 6 WILLIAMSON. Military Surgery, p. 76: "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." 7 Mouat. British Stat San. and Med. Rep., 1865, Vol. VII, p. 487. In the twenty-three detailed reports of penetrating chest wounds in the New Zealand war, the presence of emphysema is noted in six, of which five had a favorable termination. 8BOISSIEK, vulgo De SAUVAGES, Nosologia methodica sistens morborum classes, Amsterdam, 1763. LlTTRE, Mim. etc VAcad. des Sciences, 1713 p. 4 et sqq. BOYER, TraiU des Maladies chirurgicales, Paris, 1846, T. V, p. 613. Boyer states that the humors of the eye even contain air-bubbles in some cases. LARREY, D. J., Clinique Chirurgicale, T. II, p. 88. This great surgeon tails into the error of stating that " la plupart des plaies penetrants de la poitrine sont suivies d'un emphysema plus ou moins considerable." He gives an excellent plate of a generalized traumatic emphysema (op. cit., Atlas, T. II, pi. 4), which has been often copied. 614 WOUNDS AND INJUEIES OF THE CHEST. It will be understood that traumatic emphysema is exclusively considered here. The inflation of the pulmonary air vesicles, termed emphysema by the physician, a condition sometimes resulting in the production of bullae on the surface* of the lungs, und rupture and pneumo-thorax, is occasionally observed in military surgery, in laceration of the lung by concussion, but is quite distinct from the condition under consideration. The older authors were in error not only regarding the frequency- of emphysema in penetrating wounds of the chest, but in relation to its importance as a sign of lung wound. It is of so little importance in this respect, that I treat of it here instead of with the symptoms in the subsection on diagnosis. Yet great faith has been placed in this sign. Lamotte and JFerrein1 put it down as a certain sign of lung wound. But Dr. Fraser's analysis of modern observations2 proves that emphysema may follow penetrating wounds of the chest with or without injury to the lung, complicated or not with fracture of the ribs. In fifty-one cases of penetrating gunshot wounds of the chest studied by this author (op. cit., p. 66), emphysema was present in seven. Four of these were fatal cases, and the lung was found wounded in three of them. Hennen (op. cit., p. 380) says of emphysema: " The plain fact is that it does not occur in one case in fifty," and Neudorfer (op. cit., p. 377) remarks that " according to observations made in the wars of the last twenty years, it appears to follow injuries of the chest in only one out of two hundred cases, and that cases of its extension over the entire surface have not occurred at all." John Bell3 and C. Mayer4 remark upon the greater'frequency of emphysema in stabs than in gunshot wounds. This is probably due to the want of parallelism, in stabs, of the tegumentary and intercostal orifices. But*Baudens5 and Dr. Stromeyer6 offer another explanation of the rarity of emphysema in gunshot wounds: "That the ball passing into the substance of the lung bruises it and causes an immediate extravasation of blood in the lung substance, so that no air can pass from the air-vesicles or small tubes into the pleural cavity." And Baudens conceives that the bronchial tubes possess a resiliency analagous to that of the arteries. The treatment of emphysema is very simple. If the wound is oblique, the external and internal orifices are to be made parallel by an incision through the skin and muscular tissue, as inculcated by Larrey (loc. cit., p. 888). The movements of the chest are to be confined by a bandage, and, if the extension of the crackling tumor is oppressive, the air is to be liberated, as advised and practiced by Wiseman7 and William Hunter8 and more modern authors,9 by puncture or incision. i LAMOTTE, op. cit., 2f5me ed., T. Ill, Des Playes de la poitrine; FERRIEN, Ant. Siemens de Chirurgie pratique, Paris, 1771. - The British Director-General's Report, p. 63, says : " The wound was soon followed by emphysema, * * showed unmistakeably that the lung had been injured." The same opinion is held in the Lancet, February 14th, 1852; and in the Medical Times, December 17th, 1853, the proof of lung wound given is "emphysema and dyspnoea ;" and in the same journal, on April 6th, 1841, emphysema is again adduced as a sign of lung wound ; and on April 27th, 1850, in the same journal, a case is related in which emphysema was present, but no other symptom of lung wound. Preparations of ca.-es in which emphysema existed when the lung was wounded are to be found in the museums of St. George's and Guy's Hospitals. 3 John Bell. Discourses on the Nature and Cure of Wounds, 1795, Part II, p. 11. ♦ C.MAYER. Tractatus de Vulneribus pectoris penetrantibus, Petropolis, 1823, p.'28. 5 Baudens. Clinique des Plaies d'Armes d, Feu, Paris, 1836, p. 260. 6 STROMEYER. Maximen der Kriegsheilkunst, Hannover, 1855, S. 602. ? Wiseman (Severall Chirurgicall Treatises, Folio, London, 1676, Book V, p. 368). " A footman was wounded into the left side: He cought bloud and discharged much by the Wound. * * Some few days after, a Tumour arising about a wound, I gave him a visit and felt the swelled Parts crackle under my fingers. Concluding it Wind got out from the cavity within the Thorax, I made an Incision into the Swelling about an inch long, by which the Wind was discharged." SHUNTER, WILLIAM. Medical Observations and Inquiries, Vol. II, p. 17, with characteristic elegance and correctness, describes this condition and the proper remedy. ■Lohmeyer, C F. (Die Schusswunden, u. s. w., S., 133). " Trifling degrees of emphysema generally disappear after the application of a soft compressive bandage, which at the same time fixes the ribs that may have been fractured, as it principally enforces the respiration by motions of the diaphragm. But when the emphysema over the larger portion of the body extends, the air may be liberated by puncture or incision of the skin, or its farther extension into the cellular tissues may be prevented by enlarging the wound, that the air filling the pleural cavity be forced directly outward during expiration." COMPLICATIONS OF INJURIES OF THE CHEST. 615 M. Gosselin1 maintains that contusions of the chest, attended by lacerations of the lung substance with integrity of the visceral pleura, may cause emphysema. Perhaps the case2 in Guy's Hospital, cited by Dr. Fraser (p. 66) as a proof that " emphysema, taken by itself, is not a certain sign of lung wound," was of this character.3 Fractures.—The gravity of penetrating wounds of the chest was much augmented by the existence of fracture, especially if the lesion of bone was at the point of entrance. It was formerly believed, and is still maintained by rTeudorfer,4 that all gunshot perforations of the chest are attended by fracture; but many instances have been adduced in this work, in which balls have entered and emerged through intercostal spaces, or broken the ribs only in exit. .Unquestionably the size of missiles is here an important element, and its influence is apparent in the mortality rate of chest wounds. Dwelling upon this point, Dr. Socin, in his recent work,5 maintains that his statistics disprove Dr. Neudorfer's state- ment that " the intercostal spaces are too small to allow even the Prussian Langblei to slip through," and asserts that it is indubitable that the small chassepot missile may pass through most of the intercostal spaces without interesting the bones, and contends that "with the late improved arms, perforating gunshot wounds of the chest are not rare," and that " this, no doubt, is one of the causes of the more favorable results lately obtained," In the reports of the eight thousand seven hundred and fifteen penetrating wounds accounted for in Table XXVI, page 606, the presence of fracture of the ribs, in cases in which the missile was believed not to have entered the thoracic cavity, is mentioned in four hundred and forty-six cases. In cases attended by penetration, it is referred to in only five hundred and five cases, of which two hundred and four were fatal, although it existed, in all probability, in the majority. The complication of chest wounds by fractures of the sternum is recorded in fifty-one cases, by fractures of the vertebrse in ninety-two cases, by fractures of the clavicle in one hundred and thirty-six cases, and by fractures of the scapula in three hundred and seventy-five cases. This, however, is a very imperfect summary. It includes only the. cases in which the lesion named is directly specified in the 1 Gosselln (Recherches sur les Dechirures du Poumon sans Fractures des Cotes correspondantes, M6m. de la Soc. de Chir. de Paris, 1847, T. I, p. 234. 2 See a case in Guy's Hospital Reports, Second Series, Vol III, seventh case in Table II, p. 147: a " contused wound on the right side, opposite the eighthxib, from a fall on a spike; no fracture; emphysema of nearly the whole side ofthe chest; no symptoms whatever. ' Creuzenfeld (Bibliotheca Chirurgica, Vindibonae, 1781, p. 665) compiles, mainly from WALTHER and HALLER, three quarto pages of reference, to writers on empneumatosis or emphysema. Among those interesting to the military surgeon are the observations of Smetius (Miscell. Med., Franc, 1611, Lib. P7), " de enormi emphj'semate ex pectoris vulnere, quod die quinto evanuit;" Bartholixus (Hist. Anat. Cent., Hafnise, 1654, Cent. V, Obs. 12), "emphysema ex pulmonis vulnere;" a case reported by Peter Estanne (in Eiviere's Obs. Med.), "de emphysemate a vulnere pectoris;" WORM (Epist Posth., Hafhias, 1651), "A vulnere pectoris emphysema;" REIES (Elysius jucundarum quseslionum campus, Bruxell, 1661), "emphysema a pectoris vulnere;" PAULUS DE SORBAIT (Examen Chirurgorum), "de emphysemate in pectoris vulnere;" Littre (Comment. Acad. Sci., Anno 1713), "de emphysemate;" Petit (TraiU des Mai. Chir., 1790, T. I, p. 124), "des plaies de poitrine;" AsTRUC (Traite des Tumeurs et des Ulceres, Paris, 1759); SCHULZE, De Emphysemate, Thesis, Halae, 1733 (in Haller's Disp. Chir., Vol. II, p. 567) ; Hewson, On Emphysema and Wounds of the Lung, in Path. Obs. and Enq., London, 1767, Vol. Ill, p. 372; William Hunter (Med. Obs. and Inq., Vol. II, p. 17). Sir Andrew Halliday (Observations on Emphysema, London, 1807) has collected most of the observations and experiments of his predecessors and added much valuable material of his own. Consult also the articles by BRESCHET, MURAT, Begin, and Jacquemet, in the French Dictionaries, and LASSUS (Path. Chir., T. U, p. 331) ; ABERNETHY (Surgical and Physiological Works, London, 1830, Vol. II, p. 171); John Bell (Discourses on Wounds, Part II, p. 11); RlCDTEB (Anfangsgriinde der Wundarzneykunst, B. I, S. 451).; and, among later writers, DUPUYTREN (Clin. Chir., T.I, p. 110); MALGAIGNE (Du Traitement des grands Empliysemes traumatiques, in Bull, de Therap., T. XXII, p. 352) ; DOLBEAU (De VEmphysime traumatique, These d'aggrega- tion, 1660). 4NEUDfJRFER (Handbuchder Kriegschirurgie, Leipsig, 1867, S.581): "Alle perforirenden Schussverletzungen der Brust sind mit Knochen- oder Knorpelverletzungen combinirt. Der Intercostalraum ist auch beim Erwachsenen zu klein, um ein Projectil glatt durch schlupfen zu lassen." s SOCTN, A., Kriegschirurgische Erfahrangen gesammelt, in Carlsruhe, 1870 und 1871, Leipzieg, 1872, S. 84. The Langblei, or missile of the Prussian needle-gun, is an ovoid solid slug. The specimen in the Museum (No. 4737, Sect. I) weighs 514 grains and has a calibre .56 of an inch. The chassep&t missile weighs 380 grains and has a calibre of .43 of au inch. The heavy Russian ball used in the Crimea, and many of the conoidal balls of large the chassep&t and needle-gun. calibre employed in the War of the Rebellion almost invariably inflicted fractures in striking the chest. (After MacCormac.) 75 616 WOUNDS AND INJURIES OF THE CHEST. report, omitting those where its existence could readily be inferred. Moreover tlie numerous cases, in which, for example, the clavicle, scapula, and ribs were fractured simul- taneously, are entered but once, under the head of the injury which was regarded as the most severe. The special gunshot fractures of the clavicle, scapula, sternum, and ribs, and the operations which they sometimes involve, have been fully illustrated in preceding portions of this chapter, and those of the vertebrae, in Chapter IV. The general conclusion that formal primary excisions of the bones of the trunk for injury are very rarely required, has been corroborated by the recorded experience of military surgeons abroad, during more recent wars. Though exceptional or hypothetical cases might be presented, in which partial or complete excisions of the clavicle or scapula might be justifiably practiced, the reparative powers of nature are known to furnish excellent results in grave injuries of these bones, and it is generally agreed that the removal of "primary sequestrae," or entirely detached fragments, should be commonly the. limit of operative interference. Where extended necrosis occurs, judicious surgical intervention may be of great benefit.1 In compound fractures of the ribs, it is commonly recommended that the splintered extremities should be resected or smoothed off, especially if the splinters are directed inwards. But this is a theoretical rather than a practical precept. Dr. Fischer (op. cit., p. 116) states that in his extended experience he has had occasion but once to have resource to this expedient. Unless bound down by the pleuritic adhesions, the lung usually recedes far enough from the projecting splinters to avoid laceration. If necrosis supervenes, the rib becomes so separated from the soft parts that partial excisions are facilitated. Dr. PirogofF warmly inveighs against early interference in these cases. Professor Gross,3 however, has "met with shot wounds of the chest where the ribs were so much shattered as to require removal with the cutting pliers." But he adds " the instances demanding such a procedure must be uncommon." A number of examples of gunshot fractures of the sternum have been detailed. These injuries are interesting from the frequency with which they are complicated by lesions of the internal mammary or of the pericardium and great vessels, or by the lodge- ment of balls, and because of consecutive necrosis and abscesses in the mediastinum.4 i Besides the operations on the scapula referred to in the text and note at p. 557, the reader may refer to the cases of Drs. E. M. Bartlett (St Louis Med. and Surg. Jour., 1854, Vol. XII, p. 64), and T. M. Owens, of Arkansas (New Orleans Med. and Surg. Jour., Vol. XI, p. 164,1854); Wutzer's case, in Ortbach's dissertation, Bonn, 1835; a successful case recorded by Esmarch in a dissertation published at Kiel, in 1859 ; and cases by Mazzoni and Biagini, in the Gazette Med. de Paris, 1854, and Bulletin de Therap., T. VI; Syme (Fracture of the body ofthe Scapula, Edin. Med. and Surg. Jour., April, 1831) ; SMILEY (Twenty cases of Gunshot Wounds, Boston Med. and Surg. Jour., 1863, Vol. LXVIII, p. 412) reports a case of gunshot fracture of spine ofthe scapula, with extraction of fragments. For operations on the clavicle refer to Dawson, W. W. (Excision of the Entire Clavicle, Boston Med. and Surg. Jour., Vol. DZ, p. 95, 1868-69) ; TRYON, J. R. (Exsection of Right Clavicle, Am. Jour. Med. Sci., Vol. XLIX, p. 357, 1865); Irvine (Excision and Regeneration of the Entire Clavicle, London Lancet, 18S7, Vol. I, p. 206). 2 PiROGOFF (Grundzuge der Allgemcinen Kriegschirurgie, S. 537) : " Stromeyer und Demme sprechen sogar von der Rippenresection ; welche in dem holstein'schen und italienischen Kriege—im letzten, wie es scheint, selbst frtihzeitig—bei comminutiven Rippenbriichen vorgenommen worden war. Gott sei Dank, dass uns das noch fehlte I" 3 GROSS, A., System of Surgery, Vol. II, p. 446, 1872. Consult also DlSDIER, De Costarum Fractura, Paris, 1764, T. IX, p. 686; VEKDUC, Pathologic de Chirurgie, Paris, 1703, p. 395; MALGAIGNE, Recherches sur les Variet&i et la Traitement des fractures de Cotes, in Arch. Gen. de Med. 1^38 ; GURLT, E., Handbuch der Lehre von den Knochcnbruchen, Hamm, 1864, Zweiter Theil, S. 191; DlEFFENBACH, J. F., Die Operative Chirurgie: Leipzig, 1848, Zweiter Band, S. 400. ■i La Marteniere (Sur VOperation du Trepan au Sternum, in Mem. de 1'Academic Royale de Chirurgie, T. IV., p. 545), to whom I have not sufficiently expressed my obligations on the notes to p. 572, gives an excellent account, with cases, and a handsome plate, of the injuries and diseaseg of this bone, and the operations practiced on it. Consult also the learned Freind'S (The History of Physick; from the Time of Galen to the beginning of the Sixteenth Century, London, 1726) account of the descriptions by Avenzoar and Salius Diversus of abscesses of the mediastinum. Most of the older surgeons refer very deferentially to the opinions of Realdus COLUMBUS on perforations of the sternum, in his work De re anatomica; but Pare desired that he should have treated more fully of diagnosis. (Purmanx, M. G. (Lorbeer-Krantz oder wundartzney, Franckfurth und Leipzig, 1692, p. 480) treats at length of the subject, and practiced the operation of trepanning the sternum. Among the moderns, consult Sabatieb, Memoire sur Us Fractures du Sternum, in Mem. de l'Institute, an VII, T. II, p. 115 ; Richerand, Lecon du citoyen Boyer sur les Maladies des Os, 1803, T. I, p. 99; DUBOS, Maladies du Sternum, These de Paris, 1835. Ashhlt.st. On Fracture of the Sternum, Am. Jour. Med. Sci., X. S. Vol. XLIV, p. 406. COMPLICATIONS OF INJURIES OF THE CHEST. 617 Hernia of the Lung.—This complication has been fully considered in the subsection beginning on page 514. I have only to add that it has been very rarely observed in the late wars in Europe'; descriptions of only two cases having been found recorded by recent writers. These cases were observed by Dr. H. Beaunis,1 at Juranville, in an ambulance of the Army of the Loire. Lodgement of Foreign Bodies.—A hundred and ninety-four examples have been adduced to illustrate the numerous varieties of lodgement of missiles, fragments of clothing and equipment, and other foreign bodies, and it is hoped that sufficient evidence lias been accumulated on this point to guide the practitioner to the safe middle path between rash interference and timid and harmful non-interference. The instances in which foreign bodies remain sacculated and innocuous within the tissues for lengthened periods, have been shown to be very rare in comparison with those in which serious mischief and danger ultimately arose. The peace of mind which the extraction of the foreign substance invariably induces in the patient is, in itself, a strong reason for using every judicious means for their removal. It has been seen that foreign bodies may be buried either in the soft parts, bones, or viscera, of the thorax, or be loosely in the pleural, pericardial, or mediastinal spaces. No attempts to remove them from the two latter situ- ations were reported. The judicious cautions of systematic writers on the use of the probe have received due attention, and it has been shown that they do not always apply to old cases, or all recent cases, and that careful exploration with the finger or gum catheter may sometimes be more judicious than abstention, and the circumstances justifying interference have been fully illustrated. Examples of the expectoration of balls in coughing, and of their escape through the thoracic walls and intestinal canal have been cited. A general survey of the long series of cases, while leading to the inference that foreign bodies sooner or later produce grave accidents, favors a belief in the possibility of recovery with lodgement.* The other primary complications of penetrating wounds of the chest may be most conveniently considered with those that are consecutive. Of these the most important are the visceral inflammations: Traumatic Pleurisy.—This, according to the received doctrines, attended, in a greater or less degree, all of the cases of penetrating wounds of the chest; but the instances in which it is referred to as the most prominent complication number only ninety-four, fifty-two 'Beaunis. Impressions de Campagne. In Gazette M6dicale de Paris, 36me Serie, T. XXVI, No. 52, p. 593, December 30, 1871. "We had seventeen cases of penetrating gunshot wounds of the chest, out of which there were four deaths in the first fortnight. There were two cases of hernia of the lung. One of these men died a few days after the reception of the wound ; in the other, I ligated the protruding portion of the lung, which was of the size of an egg; and the fourth day after, the day of our departure, no serious symptoms had supervened. In neither of these cases was there any tendency towards the spontaneous redustion of the tumor." * See MaNEC, case of an iron blade lodged in the lung substance for fifteen years (Bulletin de la Sociili Anatomique, Paris, 1829, p. 51); Berchon 's (Gazette Medicate, 1861, pp. 20!), 225, 1241) rectification of the history of the convict at Rochefort, cited by many authors, in whose chest, between the first and fourth ribs, was found the fragment of a knife-blade 83 millimetres (3£ inches) in length, which had wounded the lung and lay in an indurated canal, formed at its expense, according to GaILLER (Presse Midicale, T. I, p. 51). NlSLE (Arch. gin. de Mid., 1831, T. XXV, p. 253) gives the case of a man wounded in 1814, who died of a cerebral disorder in 1830, and, at the autopsy, the ball was found in a cavity of the size of an egg, in the lower lobe of the right lung. MOORE, of Plymouth (London Lancet, January 9th, 1847), gives a case in which a ball lodged near the surface of the lung for fifty years. M. Hippolyte Larrey (Relation Chirurgicale des Gvinements du Juillet, 1830) cites two cases of ball lodgement. Surgeon Arnot, of the Grampus (Medico-Cltirurgical Transactions, Vol. XIII, 1827, p. 281), reports a case of a piece of hoop-iron removed from a cyst in the left lung, opposite 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 inflammation of the lung in 1826. Leash (Catalogue of the Museum of the Royal College of Surgeons) reports the history of Henry Barrot, 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 in 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 the finger protected by a thimble, within reach of the forceps, must not he 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 Wisoonsin, aged 20, wounded at Antietam, September 17th, 1862; admitted to General Hospital at Frederick, September 24th; died October 28th, 1862. 78 618 WOUNDS AND INJURIES OF THE CTTEST. of which were Chickamauga: fatal. Surgeon J. T. "Woods observes, of the chest wounds he treated at ••I have been astonished at the non-occurrence of pleuritis, the wounds being ragged, injuring twice both thoracic and pulmonary pleural with spicula* of ribs sometimes thrown inward, to irritate the parts and aid in exciting this result; but, in tliese cases, the symptoms of pleuritis were botli infrequent and mild." Mr. Erichsen says2 "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 pleurae, 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, wus 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. wounded in the first battle in which his regiment participated, at Gainesville, August 28th, 1862, 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, hut 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 dyspncea, and anxiety, and a quick small pulse. Occasional stimulants, with small anodynes, and cooling drinks, constituted the 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 pulmonalis 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),2 and in specimens 2424, 1142, 1315, and 696, of the Army Medical Museum. Intense local pleuritic exudation is displayed in specimen 515, case of S. B-----, p. 490. ' ERICHSEN", The Science and Art of Surgery, 5th ed., London, 1872, Vol. I, p. 436. 2 Assistant Surgeon A. A. Woodhull, 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 inflammation 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 tissue had undergone a cheesy metamorphosis. COMPLICATIONS OF INJURIES OF THE CHEST. 619 The pleuritic exudations sometimes were observed to plug the wound, as if to repair the injury to the serous membrane, as was observed by Dr. John Thomson1 after Waterloo, and by John Hunter in experiments on animals, from which he deduced that this was the natural process of cure. Traumatic Pneumonia.—This 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 l,r>62 cases wounded after the battle of Antietam, at Hospital Xo. 5, at Frederick, Surgeon Henry 8. Hewit, 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 cases 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 fatal in most. The temporary recoveries have exceeded the proportion 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 aud 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 for 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 passing 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 quadrat us himborum. The treatment pursued in all the cases of lung wound was that of nutrition and stimulation. Hurried respiration was quieted by aconite, aud 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 characteristic 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 organ. 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, 1862, by a minie" ball, which entered at the internal angle of the axilla, passed directly through the upper lobe ofthe 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 sions, the patient was put upon Bennett's plan of treatment and with visible effect each day. On October 25th, some fragments of bone presented themselves near the point of exit and were removed. October 28th : All the symptoms better. The physical siiriis 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 suppurating kindly; patient continued to improve, in fact, walked about the room, l THOMSON (Rep. of Obs. in Mil. Hosp. of Belgium, p. 91): " We saw several cases in which the external wounds having healed during the continuance of pleuritic inflammation, etc." 620 WOUNDS AND INJURIES OF THE CHEST. when, on November ^th, he had a chill, followed by fever, flushed face, and hurried respiration. The wounds looked dry and had suppurated but slightly on that day and the day previous. He continued to grow worse daily and died November 15th. Post mortem revealed the left cavity ofthe chest nearly filled with pus, which was very foetid, and some serum in the pericardium. The lung was entirely collapsed, gray, and presented the appearance of a putrid mass." Case.—Private B. W. Hill, Co. K. 8th Louisiana Volunteers, was admitted to Hospital No. f>, Frederick, Maryland, November 23d, 1862, with a gunshot penetrating wound ofthe chest, received at Antietam, .September 17th. A minie hall entered the right lung between the third and fourth ribs, going directly through the body. The case was progressing favorably on admission. 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 quite solidified above; broncophony, The wound was still suppurating, though slightly. The suppuration had been very profuse, requiring dressing three or four times a day. On November 28th, 1862. he was senv to Kichmond, at which time he felt quite able to travel and was in excellent spirits. Without the occurrence of any unexpected symptom he would recover entirely. Acting Assistant Surgeon A. V. Cherbonnier reports the case. Case.—Private Bernard McCrofern, Co. A, 63d New York Volunteers, aged 41 years, by occupation a hempdresser, was wounded at Antietam, September 17th, 1862, 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 stimulating diet, with marked benefit, the symptoms diminishing in intensity each day until his discharge from the hospital, 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 depressed. His spirits and appetite were excellent, and, as he expressed it, he felt quite 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 : * * "A conoidal 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 sputa; matter for days emerging from sternum, sometimes amounting to four ounces a day; air also escaping 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 kidneys ; 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 vesecular murmur and symptoms of slow incipient phthisis." Eldridge was discharged March 6th, 1863, and pensioned February 21st, isii(>. 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, 99th Ohio Volunteers, makes the following observations on the treatment of traumatic pneumonia in connection with the perforating chest wounds lie reported after the battle of Chickamauga: "The great danger is pneumonia, the treatment of which is not only delicate and difficult, but likely to prove unfortunate. Xo occasion was found for Guthrie's heroic phlebotomy or for active purgations. Xo indication for antimony or the impairing the blood's plasticity presented itself. The only plausible hope for successful treatment lies in early application of remedies, and in this matter lies an error fraught with fatality. The patients are mingled with others in crowds, the air is often impure, and this, with depressed 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 aud humanity, upon the detection of pneumonia in its early stages. The administration of tincture of veratrum virida 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 in the way of the inflammatory process, it leaves no traces of a destructive process of a permanent constitutional character. Great attention 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.'7 COMPLICATIONS OF INJURIES OF THE CHEST. 621 "Pneumonia is an invariable sequence of wound of a lung," says Mr. Erichsen,1 in 1869, "and constitutes one of the great secondary dangers of this injury; the 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." His 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. Ashhurst's concisely embodies the results of his analysis ofthe evidence on this point, Neither statement is based, apparently, on personal pathological investigation. 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 hyperemia3 is induced, and the auscultatory signs are modified. The lung does not play and the ordinary respiratory murmur is not produced. Dr. Fraser (op. cit., p. 691 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.4 It is obvious that in many of the reports of penetrating chest wounds in the War of the Rebellion, 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 pericarditis 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 (op. cit, p. 83), in his report of the one hundred and twenty-nine autopsies of patients dying from the effects of gunshot wounds, at Carlsruhe, in 1870, records twenty post-mortem examinations in cases of shot wounds of the lung, and remarks of i Erichsen. The Science and Art of Surgery, 5th ed., London, 18G9, Vol. I, p. 435. I have italicised the statements to which I particularly demur. 2 Ashhukst. The Principles and Practice of Surgery, Philadelphia, 1872. 3 Professor SCHUH (Wiener Wochenschrift, Jan., 1857) remarks that in shot wounds of the lung, one of the elements necessary to induce pneu- monia, the rough and sudden inflation of air into the- delicate lung structure, is wanting, as a wounded lung is partially, if not altogether, undilatable. * I regret that I 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, selected from the thirty-one post-mortem examinations that I have made, demonstrating, in some instances, the non-existence of inflammation in close proximity to the wound. I shall avail of an opportunity of introducing them hereafter. 622 WOUNDS AND INJURIES OF THE CHEST. 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 present 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.1 Commenting on a series of autopsies of patients dying from wounds of the lung, after the battle of Worth, Dr. Socin2 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 only hepatized 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 completely 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- opement of inflammatory phenomena, have been observed to warrant the conclusion that parenchymatous inflammation of this organ is as infrequently the result of injury as of disease.3 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.4 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 1 Matthew (op. cit., 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 ca.ses hereafter appended, the wound in the lung healed with hardly a trace of the inflammatory process in the substance of the organ." s Socix, A., Kriegschirurgische Erfahrungen u. s. w. Leipzig, 1872, S. 75. ■'• See ROKITANSKI, A Manual of Pathological Anatomy. Translated from the German by C H. Moore. Am. ed., Philadelphia, IS55, Vol. IV. p. 131. * Compare EEvDlT.EIscu, A Textbook of Pathological Histology. Translated from the second German edition, by W. C Kloman, M. D., Phila- delphia, 1872, p. 231. '' In the striated muscles of the trunk and the limbs it is comformable to experience that even the slightest degree of inflammation, for example, even that slight tumefaction which we find accompanying chronic rheumatism, and of which it has not yet been decided whether it essen- tially goes beyond a considerable degree of hyperemia, 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 painfulness. If we attempt to transfer these experiences to the heart it is readily manifest that even the slightest degree of diffuse inflammation must have, as a consequence, the stoppage of tli» heart, and, therefore, the death of the patient, and that only subsequent stages of the inflammatory process, would, in general, be possible in partial affections.'' COMPLICATIONS OF INJURIES OF THE CHEST. 623 and lead to its stoppage. On the other hand, in all of the cases examined, in which balls 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 effusions. The progress of these cases to their fatal termination was usually very rapid.1 From the solid exudations on the serous membranes, in wounds of the chest, we pass to the consideration of the gaseous and liquid effusions 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 previously 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 dyspncea 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 i The following articles, in addition to those cited on p. 534, may be consulted in reference to lesions of the heart and of its sac : COXE, J. R. Some observations on Wounds of the Heart, Am. Jour. Med. Sci., Vol. IV, p. 307, O. S., 1829 ; Davis, T., Foreign Body in the Heart of a Boy, Am., Jour Med Soi Vol XV, p 205, O. S., 1834; Wound of the Heart, Am. Jour. Med. Sci., Vol. XXV, p. 225, O. S., 1839; RICHARDS, G. W., Case of Woundof'the Heart, Boston Med. and Surg. Jour.. Vol. XXXV, p. 336, 1847; TRUGIEN, JOHN W. H., A Case of Wound of the Left Ventricle of the Heart- Patient survived five days; with remarks, Am. Jour. Med. Sci., Vol. XX, p. 99, 1850; Hopkins, R. C, Gunshot Wound of the Heart; Death two weeks after the Accident, Boston Med. and Surg. Jour., Vol. XLVII, p. 534, 1853; Balch, O. B„ A Case of Gunshot Wound; In which a Leaden Ball remained in the Walls of the Heart for Twenty Tears, Boston Med. and Surg. Jour., Vol. LXIV, p. 515, 1861; Roberts, J. B., A Man runs Sixty Yards and lives One Hour after being shot through both Lungs and the Right Auricle of the Heart, Richmond and Louisville Med. Jour., Vol. XII, p 607 1871 • PARADIS, M., Observation de plaie penitrante de poitrine avec lesion du piricarde, in Rec. de Mim. de Mid., de Chir. et de Pharm., Paris, 1836 T. XL, p. 325; TOURXEL, Observation d'une plaie penitrante de la poitrine; avec lesion du coeur, du poumon et de la branche phrinique gauche, in Rec. de Mini, de Mid., etc., Paris, 1836, T. XXXIX, p. 174. 624 WOUNDS AND INJURIES OF THE CHEST. wounds, this complication is noted as troublesome in less than half a dozen.1 Yet there are many recorded instances2 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. Saussier3 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 oth^r liquid effusions, as dyspncea, 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 cegophony. 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. When dyspncea is urgent, paracentesis is the principal and reliable remedy.4 Hemothorax.—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.5 ' 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 (orthopncea) 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 wounded side to the level of the effusion; the intercostal spaces are protuberant, 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 1 Abstracts of three of these cases are printed : Beck, p. 493 ; Lewis, p. 494 ; Eldridge, p. 520. Two recovered ; the third was attended by emphy- sema and empyema, and the patient succumbed from exhaustion, not from suffocation. "- BOYER, Traite des Mai. Chir., T. VII. p. 301; Dupuytrex, Lecons Orales, T. VI, p. 331; GUTHRIE, Comm., p. 439. "> Saussier, Recherches sur la Pneumothorax et les Maladies qui la produisent, Paris, 1841, p. 81. iTARn (Dissertation sur les Collections gazenses qui se forment dans la Poitrine, Paris, 1801) specially studied this morbid phenomenon. L^exnec (Traite de VAuscultation mediate et des Maladies des Poumons et du Coeur, Paris, 1831) treats of this subject with characteristic accuracy. Our immeasurable obligations to him and to AUEXBRUGGElt (Inventum novum ex Percussione Thoracis humani, Vienna, 1761) are never to be forgotten in considering the diagnosis of affections of the chest. 4 Du VERXET, Sur VHydropisie de Poitrine, in Mem. de l'Acad. des Sciences de Paris, 1703, p. 174 ; TEICHMAYER, H, F., Diss, de Hydrope Pectoris, Iena, 1727; MORAXD, Sur une Hydropisie de Poitrine Guerie par Operation, in Mem. de l'Acad. royale de chirurgie, 1759, T. II, p. 545; VOGEL, Diss, de Hydrope pectoris, Gottingen, 1763; GEHLER, Diss, de Hydrothorace, Leipzig, 1790; Otto, Diss, de Hydrothoract, Francfort, a. v., 1800; Maclean, L., An Inquiry into the Nature, Causes, and Cure of Hydrothorax, Sudbury, 1810. 6Consult LlDELl. on Traumatic Hsemorrhage, New York, 1870. COMPLICATIONS OF INJURIES OF THE CHEST. 625 frequent, small, irregular; the face is pallid, the 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- clavian 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 haemorrhage 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 haemorrhage.1 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. Chassaignac2 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,3 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 twTo 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 effusion 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 haemorrhages 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 i LEGOUEST, Chirurgie d'Armit, ed. 1872, p. 353. In this juncture, the majority still advise liberally repeated bleedings, says M. Legouest; but: "Nous repoussons inergiquement les saignies, comme etant plus nuisible qu' utile." 2 Chassaignac, Th6se, 1835, p. 82. 3 Legouest, Chirurgie d'Annie, p. 353, 79 626 WOUNDS AND INJURIES OF THE CHEST. in this chapter, include twenty-one cases of haemothorax, 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. Stromeyer1 cites similar examples. John Hunter's2 admirable account of haemothorax is quoted by Mr. Poland in his article in Holmes's System, which is issued to medical officers. Dr. Chisolm,3 in his excellent Manual, gives a graphic account of a case of primary haemothorax, in which the extrava- sated blood was evacuated by partial inversion of the body. When haemothorax 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 haemothorax.4 The blood effused in the pleural cavity rapidly coagulates in the costo-diaptragmatic 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 i3 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 _,----------------------------------------------.-----------------— 1 Stromeyer, L. (Erfahrungen uber Schusswunden im Jahre 1866, Hannover, 1867, S. 42): " Twice did it happen, that men, who had been considered 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." 2Huxter. Works by Palmer, Vol. Ill, p. 567, and A Treatise on the Blood, Inflammation, and Gunshot Wounds; by the late John Hunter, London, 1794, p. 553. 3 Dr. Chisolm observes (A Manual of Military Surgery, 18C4, 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 armpit 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." 4 Sanson. Des Himorrhagies traumatiques, Paris, 1836, p. 260; Louis, Mem. de l'Acad. de Chirurgie, T. IV, p. 24; Legouest (op. cit, p. 358); Ebichsex (op. cit), VoL I, p. 434 ; Dr. Macleod (op. cit, p. 239) says it appears seldom. Dr. Ashhurst (op. cit, p. 360) places it among the more trustworthy physical signs of haemothorax ; but on the authority of Valentin and Larrey. Callisen, Desgranges, and Chaussier give instances in which it was present without haemothorax existing and absent where there was effusion of blood in the pleural cavity. COMPLICATIONS OF INJURIES OF THE CHEST. 627 preceding pages, and discussed in all its varieties by-authors,1 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, TJ. S. A., transmitted a mechanical contrivance designed for use in the treatment of penetratiug wounds of the chest not involving the lung to such an extent as to cause danger from haemorrhage, 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 (Fio. 304), is thus commented upon by the writer: "It is merely a valve to be applied to tlie chest over the wound, permitting the air, blood, etc., to pass out, but preventing the passage ot air inward. The whole instrument is to be immersed in water, and when perfectly saturated applied to the chest, the centre corresponding to the wound. It is to be retained in position 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 dependent 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 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 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. l FABRICIUS. De empyematis natura et curatione, Rostock, 1626; MARQUART SCHLEGEL, Dissertatio de empyemate, Jena, 1639; BALDUS, Dis- sertatio de empyemate, Leyden, 1646; C'RAMrFER, Dissertatio de empyemate, Leyden, 1647; WEDEL, G. W., Dissertatio de empyemate, Jena, 1686; ECKHOUT, J. VON, Dissertatio de empyemate, Leyden, 1709; BONETUS, Sepulchretum Anatomia Practica, T. Ill, p. 348, Geneva, 1700; Ingram, Practical Cases and Obs. in Surgery, London, 1751; FtlRSTENAU, In Ephem. nat. curios., Vol. IX, p. 329, Obs. 78, 1752; WARNER, Philosophical Transactions Vol. XL, p. I; HERRISSANT, An in empyemate necessaria licet raro prospera paracentesis 1 Paris, 1762; A. MONRO, State of the Facts concerning the first Proposal of performing the Paracentesis of the Thorax, Edinb., 1770; MARCHETTIS, Sylloge Obscrvat. Medico-chirurg. rar. obs. 43, pp. 99, 102, 104, Naples, 1772; BROMFIELD, Surg. Obs. and Cases, VoL I, p. 24, 1773; NlCOLAI, De utilitate et necessitateparacenteseos thoracis, Jenae, 1775- HEMMANN, Med. chir. Aufsatze, Berlin, 1778; FlaJaxi, Collez. d'osservaz., Roma, 1802, oss. 47, p. 145; Gumprecht, De pulmonum abscessu aperiendo Gottingen, 1796; ZAKG, Darstellung blutiger heilkiinstlerischer Operationen, Wien, 1821, Band III, Th. I, S. 132; Pelletan, Mem. sur les epanchem'ens dans la poitrine et Vopiration de Vempylme; in Clin. Chir., T. Ill, p. 236, Paris, 1810; Albrecht, De paracentesi pectoris, Berolini, 1616- JACKSON, S., Case of Effusion into the Chest, in which Paracentesis was performed, Phil. Jour, of Med. and Phys. Sci., 1825, Vol. X, p. .119 ; FAURE, Observation sur la ponction de la poitrine, pratique pour remidier aux divers cas d'epanchement pleuritique, Gaz. Med. de Paris, 1836, p. 759 ; SEDILLOT Ch. De I 'operation de Vempylme, These de Concours pour la Chair de M6d. operatoire, Paris, 1841 ; ROE, Hamilton, On Paracentesis Thoracis as a Curative Measure in Empyema, etc., in Land, mcd.-ch. Transact, 1844, T. XXVII, p. 198; TROUSSEAU, Pleuresie, Paracentese de la poitrine, in Clin. mid. de VHotel-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 ; Shattuck, Empyema, Paracentesis, Spontaneous Opening, Death Boston Med. and Surg. Jour., Vol. 53, 1856, pp. 80 and 81; Bowditch, IL, On Paracentesis Thoracis, Boston Med. and Surg. Jour., Vol. 56, 1657 p 349 • WARREN, J. M. (Paracentesis Thoracis), Surgical Observations, with Cases and Operations, Chap, IV, p. 146; Gairdner, W. T., Question of Thoracentesis and the' mode of its performance, Clin. Med., Edinburgh, 1862, p. 369; BOUDIN, J. C. M., ttudes sur la Thoracentese, Paris, 184H; LANDOUZT H. De la respiration tubaire et amphorique dans la pleurisie et des indications & la Thoracentese, Paris, 1856 ; Velpeau, A. A., Discussion sur la Thoracentese Paris, 1865; Vernay, Indications et Contre-Indications de la Thoracentese, Paris, 1864; BILLROTH, Die Thoracentese, Handbuch der Allffemeinen und SpecielHn'Chirurgie, B. III. Th. V, S. 149 ; Brill, J., De empyemate internis prsecique remediis curando, Diss., Marburgi, 1834; MCDONNELL R. L., Contributions to the Diagnosis of Empyema, Dublin, 1844; ROMBURG, A., Zur chirurgischen Therapie des Empyem, Diss., TUbingen, 1869; Schletter, W. F., Uber die operative Behandlung des Empyems, Leipzig, 1870, Fig. 304.—Dr. A. H. Smith's apparatus for effusions in the pleural cavity: A, leather disk; B, glass tube; O, valve. (Reduced one-half.) Spec. 4732, Sect. I, A. M. M. 62* WOUNDS AND INJURIES OF THE CHE8T. Abscesses in the Lung.—Of true abscesses of the'lung, or vomicae, many examples have been related. These purulent formations were generally induced by the presence of foreign bodies in the lung. In rare instances, circumscribed abscesses broke and dis- charged into the bronchial tubes; more frequently they opened into the pleural cavity. Sometimes, when seated near the surface of the lung, they pointed externally; and, when the integument became discolored, the pleural surfaces were usually found to have formed adhesions, and the pus could be advantageously evacuated by a free incision. This form of abscess was distinguished from that resulting from caries and necrosis of the ribs, sternum, or vertebrse. The Museum possesses several specimens illustrating both varieties, but no drawings in.which they are satisfactorily represented. Metastatic abscesses, or " foci," due as a rule to peripheral thrombosis, was one of the frequent epiphenomena of what was generally designated as pysemia. But this complication was not a common result of wounds of the bony case of the thorax; and, in the few instances that were reported, the pathological specimens were not preserved, nor were the morbid appearances described with precision. I am forced, therefore, to borrow from a case of joint wound an illustration of the condition in question. In Plate XIII, the external appearance of a metastatic focus in the lung is beautifully delineated. The drawing was made under the supervision of my predecessor, Surgeon J. H. Brinton, U. S. V., who also supplied the pathological notes. The clinical history was drawn up by Surgeon E. Bentley, U. S. V. : Case.—Corporal Jesse S------, Co. B, 4th Ohio Volunteers, 3d division, Second Corps, was admitted to the McVeigh Branch of the 3d division general hospital, Alexandria, Virginia, on December 5th, 1863, with a gunshot wound of the knee- joint, received near Mine Kun, Virginia, November 27th. A conical ball struck the knee of the right leg just below the patella, on its inner and anterior aspect, fracturing the inner condyle and opening the joint, passed downward and forward, and was extracted about four inches from the point of entrance. At the time of the patient's admission to the Alexandria hospital, the joint and thigh were very much inflamed and discharged pus copiously, and the man was much prostrated and terribly anxious as to the result of his wound; but after being washed and fed, and otherwise cared for, he appeared much recruited. On December 8th, the operation of excision of the knee-joint was performed by Surgeon Edwin Bentley, U. S. V.; one inch of the femur, and about one inch and a half of the tibia bones being removed. The hsemorrhage was slight, but the condition of the tissues was not very satisfactory. The patient endured the operation well, and .the reaction was good. On the 9th, the patient complained of severe pain on the right side of the chest over the lung, which continued for several days; no pain else- where. On the night of December 10th, he had a severe chill, which was followed by two still more severe attacks on the llth. Stimulants were freely given, with raw eggs well beaten up and beef essence for diet. He continued to have chills till the night of the 13th, when he was seized with a very severe chill, from which he never rallied, and died oil the morning of December 14th, 1863. The post-mortem examination, eighteen hours after death, showed no attempt at reparation, and there was consid- erable sloughing, while upon the inside of the thigh there were numbers of small abscesses. The heart and left lung were healthy, but the right lung was infiltrated with pus, and a single large abscess appeared upon the surface of the inferior lobe. There was no pus nor abscesses found in the liver, but it was very much softened. The stomach, kidney, and intestines were perfectly healthy. The preparations in the case were sent to the Curator of the Army Medical Museum, Surgeon J. H. Brinton, U. S. V., who made the following memorandum of the appearances in the limb: " Whole joint is one suppurating mass; pus extending up and down, far down under gastrocnemius, and up between the muscles of the thigh on the inside; a long abscess in the sheath of the vessels, extending up to the middle of the thigh. Small clot in femoral artery, three inches long and thin; none in femoral vein. Surrounding tissues of vessels in some places hardened, where pus had not reached. Lining membrane of femoral vein dirty gray and softened." Clot in suphena vein. Dr. Brinton added the following notes of the preparation of the lung, represented in Plate XIII, received at the Museum December ICth, 1863: "Apparently a metastatic abscess very circumscribed. When examined, found to be a clot, in different degrees of softening, and red blood corpuscles in every state of change; but no pus. The greenish mass in each [condyle?] was complete circumscribed gangrene ofthe cancellated bony tissue (coinciding with/Virchow's doctrine). See picture painted by M. Staccii." The picture is very accurately copied in the rhromo-lithograph opposite,1 Plate XIII. There appears to be no reason why shot fractures of the ribs should not be followed by metastatic deposits in the lungs, the intercostal veins communicating with the pulmonary ' The preparation of the lung was preserved in the Army Medical Museum and numbered 1910 of the surgical series, but became so much decomposed after exposure by the draughtsman, that it -was discarded, and the number 1910 was assigned to another specimen. There is a partly finished drawing of the femoral vessels by M. Stauch, which has been copied and elaborated by Mr. Fabre, with a view to its reproduction in chromo- lithography. The excised fragments ofthe knee-joint were not preserved. The adjacent portions ofthe diaphyses of the femur and tibia are numbered 1909, Sect. I, A. M. M., and are figured in the Catalogue, p. 336, FIG. 115. See, for a note of the case, the surgical report in Circular No. 6, S. G. O., J 865, p. 59. / ^c f Slilllrl, J. I l,\ i;,,s,„ilu,[ ,-l.roi.K.la! METASTATIC FOCUS IN THE LUNC. COMPLICATIONS 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 contributed on this subject will be fully considered hereafter, in the discussion of thrombosis and embolism in general.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,2 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.3 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. Desgenettes4 communicated a case of the sort to Larrey, and the latter5 mentions a case of an officer with " well characterized phthisis," and in like manner Usher Parsons6 entertained a similar belief, and Hennen,7 though he never observed such an example himself, Was reluctant to discredit the testimony on the subject. None 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.8 1 Consult VlRCHOW, Die Cellular pathologic in ihrer Begriindung auf physiologischeundpathologische Gewebelehre, Vierte Aufiage, Berlin, 1871, S. 234; ROKITANSKI, Lehrbuch der Pathologischen Anatomie, Wien, 1861, Dritter Band, S. 76. 2 See case of Colonel Collis, p. 584, and the less authenticated case of Miltenberger, p. 596. Dr. A. J. C. Skeene (Med. and Surg. Reporter, Phila., 1862, Vol. IX, p. 100) 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 injury. 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, 1862. The sergeant was promoted to a lieutenancy in the 21st Michigan Volunteers, March 3d, 1864, and mustered out Juue 8th, 1865. A fourth case is printed in the Boston Medical and Surgical Journal, 1868, Vol. I, N. S., p. 339, of Private A. N. Rossiter, 49th Massachusetts Volunteers, said to have been wounded at Port Hudson, March 14th, 1863, and suffer- ing subsequently from haemoptysis, and coughing up, five years afterward, a flattened buckshot, after which " he was wholly relieved from his disagreeable symptoms." He is not a pensioner, and the hospital record gives the diagnosis "chronic diarrhoea," without indication of any wound. 3 See cases of Stolpe, p. 515, and of Belt, p. 584. * DESGENETTES told Larrey that in the painting of the death of General Wolf, by Benjamin West, the figure supporting the fallen hero in its arms is the portrait of an officer who received a ball in his chest and was thus cured of well-marked phthisis. 5 LARREY (Memoires de Chirurgie Militaire et Campagnes, 1812, T. Ill, p. 376), on relating this statement of Desgenettes, records two examples of recovery from phthisis, following amputation of the shoulder-joint, as "proofs of the salutary effects 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 ofthe Guard, in whom the symptoms of pulmonary phthisis and those of the sorofulous cachexy, developed in the highest degree, entirely disappeared," 6 PARSONS. New England Journal of Medicine and Surgery, 1S18, p. 209. i HENNEN (Principles of Military Surgery, 3d ed., 1829, p. 400) : "An instance of this kind has never come under my notice ; although I have very respectable living authority to say that a strong predisposition to phthisis was suspended in one case and spasmodic asthma remarkably relieved in another, by penetrating wounds of the thorax." • 81 think the doctrine of the cure of pulmonary consumption through the agency of penetrating wounds of the chest should be regarded as a fable, perpetuated by respectful compliance with authority. It is said of Phalerus, by Pliny (Nalurie Historiarum, Lib. VII, Cap. I, p. 166), deploratus t\ medicis vomicx morbo, the abscess 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 purpose of getting killed; but being only run through the body, the purulent matter escaped, and they all recovered (GUTHRIE). Other commentators hold that the Scythian vulture performed paracentesis in the case of Prometheus. Dr. MACLEOD says (Notes, etc., p. 256): "Veritable phthisis, has, however, as is well known, been cured by the rough medication of a gunshot wound." The reader will find some interesting observations on this subject in Dr. USHER PARSONS'S ■Cases of Gunshot Wounds through the Thorax, with Remarks, printed in the seventh volume of the New England Journal of Medicine and Surgery, 1818, page 209. 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 affection, all which 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 pulmonalis. The haemorrhage was very profuse, but was followed by a speedy recovery both from the wound and phthisical affection. Quere. Do not these facts speak in favor of venesection as a remedy in consumption as recommended by Dr. Gallup?" 630 WOUNDS AND INJURIES OF THE CHEST. Thoracic Fistulai.—Fistulous openings in the walls of the chest were occasionally observed among the troublesome consequences of penetrating wounds of the chest. Of twelve hundred and twenty-three invalids on the pension roll of the United States, for the results of this form of injury, twenty-two are reported with thoracic fistulse. This condition is likely to arise when an a'bscess or empyema having discharged or been punc- tured through the chest wall, the pleura fails to adhere near the orifice, and forms a pouch in which the pus accumulates. Some examples have been given in the preceding pages. (Cases of Young, p. 479, Kuhn, p. 480, Brownlee, p. 488, Henry, p. 490, Tomlinson, p. 502, and Bowman, p. 577.) The following is an instance in which the reducing measures employed did not avert a fatal termination: Case.—Private James Parker, Co. G, 16th New York, aged 24 years, was wounded at Gaines's Hill, Virginia, June 27th, 1*62 ; the ball entered between the eighth and ninth ribs, seven inches from the spine on the right side, and emerged below the head of the tenth rib, one inch from the spine on the same side; the ninth rib was fractured about midway in its course. He was treated in the field and transferred to Ascension Hospital, Washington, on July 4th. On admission, there was no emphysema or other sign of injury to the pleura or lung. Some small spic.ulse of bone, which had worked to the surface posteriorly, were removed, and the chest nearly encircled by adhesive straps. Antimonial and saline mixtures were administered, and low diet ordered. August 1st: Some friction sound at point of fracture, but no effusion and no pneumonia. Tincture of veratrum viride was ordered, and, as the pulse.was 105, calomel was administered, but a better diet was given as his strength was failing. A pulmonary fistula was established on August 2d. Air issued, with a bubbling sound, anteriorly and posteriorly, on coughing or sneezing. By intercepting the air by pressure between the points of wounding and the point of fracture, the fistula and fracture were found to be identical in position. There was no effusion, no pneumonia, no collapse of the lung, and no emphysema, on account, it was supposed, of the free exit afforded by the wound to the air, and it was, therefore, judged that the pleura was adherent about the point of fistula. His weakness increasing, punch, iron, and quinine were ordered freely. The bandage was still continued. August 4th: The sputum is now tinged with blood; pulse, 105; strength poor; fistula still exists. A slight friction sound was still perceptible, but localized at the fistula. Vomiting and diarrhoea have set in. Anodynes and astringents were given, and the nutritious diet continued, with a diaphoretic for the slight pneumonia. Over the subcutaueous fistulous point a compress was applied, and bandaged firmly in hopes of its closing. August 7th: Pneumonic sputum disappeared. Anterior orifice closed entirely ; posterior one cicatrizing; fistula entirely gone. There is now no dulness, no effusion, though the friction sound continues. No cough; pulse, 95. Compress removed. Bandage and nutritious diet continued. Diarrhoea gone. August 15th: The pleurisy is marked, the fracture uniting. There is no effusion or pneumonia, and the patient is gaining strength decidedly. The fistula has not returned, and the posterior orifice has almost healed. His diet is less nourishing, and the antimonial and saline preparations, with morphia and mercury recommended. He was discharged from service on September 20th, 1832. Acting Assistant Surgeon W. W. Keen, jr., reports the case. Under date of October 17th, 1863, Pension Examiner Benjamin J. Moses, reports: " The ball entered the anterior and lower part of the scapula and passed out close to the spine, injuring the right lung and producing the various symptoms of consumption under which he appears to be laboring at present." He died on January 10th, 1851. Professor Gross (op. cit., Vol. II, p. 449) indicates the proper remedy in these cases. A counter-opening must be made into the most depending portion of the sac and ready drainage ensured by a canula or elastic tube. Weak astringent and detergent injections are also indicated in these cases. Sometimes the fistula communicates with the bronchial tubesT and then much caution is requisite in the employment of injections. Dr. Hannover, who has paid much attention to the remote effects of gunshot wounds, refers to cases of thoracic fistula among the Danish invalids.1 M. Chassaignac treats of the subject with his usual minuteness.2 Dr. Neudorfer3 dwells on the necessity of frequent renovation of the air in the cavities of thoracic abscesses. The detection and removal of the irritating cause to which the persistence of the fistula is due, are the objects the surgeon will ever have in view. i Hannover (Die Ddnischen Invaliden aus dem Kriege 1864, in arztlicher Beziehung, Berlin, 1870, S. 17) observes : "Where life is preserved after gunshot wounds of the chest, the degree of invalidity is generally insignificant, and the capacity for labor is little diminished; in several cases, even where the cavity of the chest was penetrated, the ribs fractured, and the lung injured, a complete cure followed in the course of several years, while in others a fatal result ensued, or the patient suffered from a fistula and its consequent mischief. In a yet living patient, the connection between the fistula and the lungs is so large that injections into the fistula pass through the windpipe into the mouth." * Chassaignac. Traite pratique de la Suppuration et du Drainage Chirurgicale, Paris, 1859, T. IT, p. 347. 3 Neudorfer (Handbuch der Kriegschirurgie, Leipsig, 1867, Zweite Halfte, S. 655) observes : "I wish to lay especial stress upon the fact, that the air in the suppurating pleural cavity be constantly renewed and never be closed in, as only then the circumstances are the same as a freely opened abscess. * * * It is a fact that, in the suppurating pleural cavity, confined air is pernicious; it is this that changes healthy pus into putrid matter." COMPLICATIONS OF INJURIES OF THE CHEST. 631 Collapse of the Lung.—Collapse of the lung, partial or complete, unless the organ is already adherent to the- thoracic walls, sooner or later follows upon an opening, larger than the glottis, being made into the pleural cavity.1 This phenomena takes place whether the lung is wounded or not, but more rapidly when it is extensively wounded. The falling away of the lung is not a uniform consequence of a penetrating wound of the chest. If the wound is small, or if it is at a distance from the free margin of either lobe, the expanded lung remains in contact with the costal pleura, and often remains long enough for adventitious adhesions to form. When the lung collapses, unless compressed by liquid effusion, it generally is partially expanded by air passing from the sound lung into the trachea, and thence, on closure of the glottis, into the bronchi of the wounded side. It is inflated in expiration and not in inspiration. The experimental enquiries on this subject, by Hales in his Statical Enquiries, by Hewson, Hoadley, Houston, Van Swieten, Cruveilhier, Halliday, Graefe, and Dr. Fraser,2. must be consulted for anything approaching a full discussion of this interesting subject. In connection with them the following account of recent experiments will be valued: Assistant Surgeon A. H. Smith, in a letter dated Fort Wadsworth, New York, October 15th, 18G7, details some experiments, which were undertaken with a view to determine why certain cases of penetrating wounds of the chest result in collapse of the lung, while in other cases apparently similar the lung remains distended. The lungs were not wounded in these experiments: " The object of the first experiment was to ascertain the manner in which the lung collapses when air is admitted into the pleural cavity. An animal was killed by a blow upon the head, the trachea exposed and secured by a ligature, and the lungs brought into view by raising the sternum. On cutting the ligature it was observed that the lungs did not recede from the thoracic wall, but withdrew themselves from the sternum toward the spinal column, keeping their external surface closely applied to the inner surface of the ribs. This was evidently due to the pressure of the atmosphere, which prevented a separation ofthe two smooth, moist pleural surfaces, while it permitted one to slide upon the other, as maybe observed when two moistened glass plates are pressed together. This observation led to the inquiry: what would be the result if the chest were opened at a point away from the free margin of the lung? It was anticipated that, in this case, the gliding motion above described would not take place, as the air would not have access to that portion of the thoracic cavity which must be the first left vacant by the retraction of the lung, viz : that part occupied by its free margin. But it seemed probable that the lung tissue, contracting at the point where the wound had left a vacancy in the thoracic wall, would draw with it a circle of the lung-substance immediately surrounding and then form a cup-hke depression, the circumference of which would go on increasing (the pleura pulmonalis peeling aslt were, from the pleura costalis) until the entire lung had collapsed. Experiments, however, afforded a different result while they completely justified the anticipation with regard to the non-retraction of the lung. An opening was made in one of the intercostal spaces of a recently killed animal, care being taken to select a point as distant as possible from the margin of the lung and from the division^between the lobes. The pleura costalis being carefully opened, the lung was found to remain closely applied to the wall of the chest, showing no disposition to collapse, except that there was a slight depression, the margin of which corresponded exactly with the margin of the wound in the pleura costalis. That the depression did not extend farther seemed to depend upon the fact that it could not exceed a certain depth without putting upon the stretch the fibres of lung tissue radiating (see Figure 305) from its apex to the surface of the lung at a distance from FlG: 305.—A—Depression in lung opposite wound. the wound, and where the atmospheric adhesion to the chest was unimpaired. <*£™£*^™££ fX^ction^D. The wound before described, which was about midway between the sternum Zs^££S£3&^j&'-S3i£3. ----------------------"------------'. . . . . -t „„„, j v«. difficult to name anv point connected with the mechanism of respiration that 1 This has been denied by speculative writers and ^«^f» ^ * *° ™ gM that the air escaped from a wound in the chest during has not been called in question. BENJAMIN BELL (System of Surgery, 1804.Vol.I p. 2WJ tang J ^ ^ ^ inspiration, and many observers have reportec.that^^ the lune '' has been more frequently spoken about than seen, which is a wormy ™ ^ itis,Ibelieve,owingtocomPressionof ^ * ^-^^ ^^ ^^^TSS*^ transactions, Vol. IX, p. 138; Hoablev, 2 Hewson, Medical Observations and Enquiries 1776, VoL 111, p ^ , Transactions, Vol. IX, p. 139; CRUVEILHIER, Anat. Three Gulstonian Lectures on the Organs of ^J^^AT o£ —< onEmplysema, 1807; FRASER, op. cit, p. ,9. Path. Liv. XXI; GRAEFE, London Lancet, May, 1828; HALLIDAY, vuservu (y.V2 WOUNDS AND INJURIES OF THE CHEST. whenever the anterior wound was kept covered with the finger, but retracting the instant the finger was removed. These observations have since been repeated a sufficient number of times to leave no doubt, that in the dead subject the lung will collapse if the chest be punctured at or very near the free margin of one of tlie lobes, while it will remain distended if the puncture be made elsewhere. In the living animal the results obtained were the same, except that the lung never collapsed entirely when one side only of the chest was opened. A portion of the air in the lung on the sound side evidently passed into the other lung with each expiration-, and thus kept it partially expanded.. The degree of this expansion depended upon the character of the respiration. Thus, when the animal was fully under the influence of an anaesthetic and the respiration not affected by the will, the collapse was more nearly complete, while the moment consciousness began to return and an attempt was made to use the voice, the inflation of the lung with each expiration became very considerable, and when a loud shrill cry was uttered; or, in other words, when the aperture of the glottis was narrowed, and, at the same time, a forcible expiratory effort was made, the lung completely filled out the cavity of the chest, and the edge of one of the lobes was thrust out through the wound. This suggests a method of reinflating the collapsed lung, if thought desirable, in similar cases in the human subject. Nothing more would be necessary than to instruct the patient to take as full an inspiration as possible, the wound being covered with the hand, and then, uncovering the wound and closing the mouth and nostrils, to make a forcible expiratory effort. The collapsed lung would then be partially inflated, and by repeating the manoeuvre a sufficient number of times its complete distension would be effected. Several of the above experiments were made in the presence of Dr. E. F. Weir, late Assistant Surgeon U. S. A., and with his assistance." On May 27th, 1869, Dr. Smith communicated the following report: "Experiment 1st, March 10th, 18G8.—A bullock was killed by cutting the throat; ten minutes afterward, a stopcock was tied firmly in the trachea and closed. An opening was then made in the eighth intercostal space, on the left side, nine inches from the spinal column; air immediately entered the chest, and the ribs visibly expanded; as the trachea was completely closed, it would seem that the retractile force of the lung tissue in the last moments of life overcame the elasticity of the ribs, resulting in a diminution of the cavity of the chest. On passing the finger into the wound, it came directly upon the margin of one of the pulmonary lobes. Experiment 2d.—An opening was made in the seventh intercostal space, on the right side of the same animal, at the same distance from the spine. The result was precisely the same as in experiment 1st. The wound was found to be opposite to the margin of one of the lobes of the lung. On opening the stopcock, both lungs immediately collapsed. Experiment 3d.—One of the smaller lobes was detached from the remainder of the lung, and its costal surface applied to the inner surface of the chest. Seizing it in the middle, between the thumb and finger, and making traction, a considerable resistance was experienced, and the margin drew in toward the centre an inch or more before any separation between the two serous surfaces took place. At the same time, a gliding motion from side to side was easily produced. Experiment 4th, March 16th, 1858.— A large dog was fully chloroformed and a small opening made in about the middle of the ninth intercostal space on the left side. The opening came directly upon the edge of a pulmonary lobe; air entered immediately through the wound and the lung collapsed. The opening was then enlarged to the extent of about three inches, when the lung could be seen nearly collapsed, but apparently inflating a little with each expiration. The animal having regained partial, consciousness, and the wound being closed by drawing the skin over it, a faint vocal sound was audible with each expiration. Uncovering the wound, this sound immediately ceased, but returned each time the opening was closed. A knife being passed through the integument with the intention of dividing the medulla oblongata, loud cries were uttered; the lung was distended, and a portion of it was thrust through the wound. Experiment 5th.—The animal having been killed by a blow upon the head, the trachea was opened and a tube inserted, through which the lung was fully inflated. The tube was then closed. An opening one-third of an inch in length was made on the right side, between the ninth and tenth ribs, one-third of their length from the spine; a continuous surface of lung wae exposed; on opening the tube, the chest, which was over distended, contracted, the lung retaining its contact with the chest, but gliding upwards until the margin of a lobe came opposite to the opening, when immediate collapse took place. The lung was again distended and an opening made one space higher up, and the first wound covered; no marginal line was visible on the lung, yet collapse followed when the tube was opened. On examination, it was found that the lung had not been fully distended; its complete expansion being prevented by air imprisoned in the deeper portion of the cavity of the chest; an elastic catheter was therefore introduced into this space through the wound, thus affording means for the air to escape. The lung was now inflated, the catheter withdrawn, and the little tube in the trachea opened, the first opening in the chest being covered. No collapse took place; the same was the result when an opening was made in the seventh intercostal space. Experiment 6th.—Kaised the sternum, inflated the lungs, and allowed the air to escape; the left lung retracted, keeping its outer surface in contact with the inner surface of the chest. The right lung collapsed irregularly. Experiments 4, 5, 6 were performed in the presence of Dr. S, Traver, Assistant Surgeon U. S. Navy. Experiment 7th, March 24th, 1868.—On the right side of the body of a man who died of acute diarrhoea, a small opening was made two and a half inches below and external to the nipple ; air immediately entered and the lung collapsed. It was found that the liver was greatly enlarged, and that the lung did not extend below the opening. Experiment 8th.—An opening wyas made on the left side of the same subject two and a half inches above and external to the nipple; a continuous surface of lung was exposed to the extent of a circle half an inch in diameter. No collapse took place; but there was a cup-like depression of the exposed portion of the lung; on passing the handle of a scalpel into the wound and lifting up its margin, air entered and the lung subsided. I regret that this subject didnot attract my attention until after the close of the war, which would have afforded abundant opportunities for testing the correctness of my views. One case, however, of which I retain a very distinct recollection, has an important bearing upon this question. A private of the 43d New York Volunteers was wounded by a musket ball while on picket before Yorktown, about April 20th, 1862 ; the ball entered in the second intercostal space on the right side, directly above the nipple, and emerged through the centre of the scapula, appearing not to have injured the ribs either at its entrance or exit. There was no collapse of the lung, as I remember tracing, day by day, the physical sign* of the pneumonia that followed. The recovery was remarkably rapid, and the last of June I met the patient walking in the streets of New York, apparently perfectly well. The situation of the wound in this case was central in regard to the upper lobe of the lung, which goes to support my view; it is possible, however, that there may have been previously existing pleuritic adhesion, but the likelihood'of this is diminished by the fact that the patient was not more than 17 or IP years of age." * * 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 fistula).1 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 Bromfield2 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 hsemorrhage from the incision of the abscess, and a tourniquet was made to compress the brachial artery. The hsemorrhage 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 were 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, the 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 physicists on pneumatics were exciting great popular interest, in cases of secondary pneumothorax, surgeons paid great i Professor GROSS remarks (A System of Surgery, 1862, Vol. II, p. 449), of fistulous thoracic abscesses : " The cure of these affections, which is e-enerallv follo*wed by a remarkable retrocession of the walls of the chest, is sometimes promoted by weak astringent and detergent injections." * BROMFIELD, Chirurgical Observations and Cases, London, 1773, Vol. II, p. 93; Jons Bell. Discourses on Wounels, Tart II, p. 19. 80 f>34 WOUNDS AND INJURIES OF THE CHEST. 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 subject, with his accustomed acumen, in the second volume of his Surgical Observations (p. 171). Wounds of the (Esophagus, 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 Bell1 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 Both 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,2 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, 1863, by a conoidal ball. 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 Philadelphia, admitted to Satterlee Hospital October 27th, and returned to duty May 3d, 1884. He was discharged the service August 25th, 1835. The case is reported by Acting Assistant Surgeon L. Smith. Pension Examiner R . S. Simington, 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 Perryville, Kentucky, October 8th, 1S62. He was treated in hospital at Perryville 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 ' BELL, B. Of Wounds ofthe Thorax, Chapter III, of the 7th edition of his System of Surgery, Edinburgh, 1801. = Hemmann, Med.-chir. Aufsdtze, Berlin, 1778; SCHLICHTING, Traumatologia nova antiqua, Amsterdam, 1748; PvAVATON, Chirurgie d'Armee, ou Traite des Plaies d'armes a feu and Pratique Moderne de la Chirurgie, Paris, 1776; Vant SWIETEN, Commentaria in Hermanni Boerhaave Aphorismus, Paris, 1735; FORESTUS, Observationum Chirurgicarum Op. Omn., Francof., 1610; SCHMICKER, Chirurgische Wahrnehmungen, Berlin, 1774. DIAGNOSIS AND PROGNOSIS. 635 through the left 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 for 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. Wood issued from the wound-of the neck at every expiration, and he could not breathe without great difficulty, except when the wound in neck was closed. March 6th, 1866 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, which was recently instantaneously restored by an attack of vomiting; his nervous system suffers much, whole left side weak and paralyzed. Pension Examiner J. P. Hosack, of Mercer, Penusvlvania, reports, January 18th, 1870, that the weakness of lung, shortness of breath, stifiness of shoulder, weakness of arm, and painful aphonia, is equivalent to total disability. Case.—Private John W. Ell-ins, Co. (i. 12th Louisiana Regiment, aged 19 years, was wounded at Nashville, Tennessee, December 15th, 18ii4, 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, 1Ho5. The wound became gangrenous, and he died March 10th, 1865. Gangrene of the walls of the track of a musket ball through the lower lobe of right lung is observed in Specimen 3348 of the Surgical Section of the Museum.1 Tetanus.—The rarity of tetanus as a complication of chest wounds, an observation for which we are indebted to Dr. Fraser,2 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,3 our Revolutionary authority in military surgery, 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, dyspncea,. 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. Tromatopncea —The passage of air through the external wound was once regarded as conclusive evidence of wound of the lung.4 This is disproved by observation and experiment, Air will pass freely in and out through a small opening in the pleural cavity l Spec 3318 SECT I A. M. M. "A preparation of the lower portion of the right lung, perforated hy a conoidal hall which entered between the sixth and seventh r'ibs^ and is gangrenous. Corporal J. P----, Co. A, 69th Ohio, Petersburg, 2Sth June. Admitted to hospital at Alexandria, July 4th; died July 12th, 1861." .... -u * * A 2 FRU5ER. Treatise upon Penetrating Wounds of the Chest, p. 20. The proportion of cases of tetanus given in the text, one m five hundred and twelve cases does not appear very small. But there were 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 Paris, 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 (Meniere). The reports of the Indian Mutiny refer to one case of tetanus in the small series of chest wounds (Williamson). Of twenty-nine cases of tetanus in the Crimea, but one supervened in chest wounds, a case of trismus in a French soldier (Fraser)^ Larrey does not mention a case. In the Danish War 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. 555) states that in a naval action, in April, 1752, of eighty-eight wounded sixteen had tetanus. Dr. B. BECK (Allgcmeine Militar-arztliche Zeituvg, 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. .,•»»■,•♦„ I Plain, Concise, Practical Remarks, on the Treatment of Wounds and Fractures; To which is added an appendix on Camp and Military Hospitals ; Principally designed for the Use of Young Military and Naval Surgeons in North America; By Jou.v JONES, M. D., Professor of Surgery in King's College, New York; Philadelphia, Third Street; printed and sold by Robert Bell. 8vo. 1776. 4 Hence, the "waste of time and wax-tapers in ascertaining the exit of air through the passage to which Hennen 3d ed.p 37o) alludes Dr. J. Thomson remarks (Report of Observations made in the British Military Hospitals in Belgium after the Battle of I^er^o Edinburgh 816 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 pomt are emoved he moment we observe air coming out of the wound upon coughing." Of nine fatal cases reported by Dr. Fraser eop. cit p. 86) of penetoting hest 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 prL uUn one Jtwelve cases of recovery, it was present in one. It was present in two out of twelve fatal cases, m the British Director General s reports and* one of nine cases of recovery. Dr. Williamson (op. cit. p. 80) mentions that •«twelve perforating gunshot wounds of the chest arrived from India;" * * in four instances, it is mentioned that air passed out of the wounds in the chest. * * -In all these cases, there can be l.ttlr doubt of the lung having been wounded." 6% WOUNDS and injuries of the chest. 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, tromatopncea 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). Tromatopncea 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 : " 1'cspiration through the thoracic opening, exhibitiug 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.,1 attached much importance to this sign. He writes, in the second year of the war : u Of Gunshot AVounds 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 iu 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." Tromatopncea was observed in only eleven of the cases of which abstracts have been ■given in this chapter.2 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. Haimopiysis.—Until recently most writers on military surgery have taught that spitting of blood spon after the reception of a wound of the chest was a certain sign that the lung was wounded.3 This view, though still maintained by some authors,4 is now known to be erroneous. It is desirable, therefore, to arrive at a correct estimate of the diagnostic value of this symptom. i PlXEO. Boston Medical and Surgical Journal, 1862, Vol. LXV, p. 373. i Cases of Osborne, p. 483 ; L---, p. 485; Edkin, 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 tromatopncea 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." 3 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 emphysema 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." Sciimickeu (Chirurgische Wahrnehmungen, Berlin. 1774, Zweiter Theil, p. 20) speaks ofthe spitting of blood as evidence of wound ofthe lung. IlECKER, A.F. (Kurzer Abriss der Chirurgia Medica, Berlin, 1808, 8. 793), is of the same opinion. Ballingall (Outlines of Military Surgery, Edinburgh, 1855. 5th ed., 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." Guthrie (Commentaries, etc., Cth ed., pp. 453,467,474,475) is evidently of opinion that haemoptysis, with the passage of air by the wound, is proof of injury ofthe lung. THOMSON, as h&s been seen (p. 635), regarded tromatopncea as pathognomonic, and haemoptysis as a sign of nearly equal certainty. (Rep. of Obs. in Mil. Hosp. in Belgium, p. 80.) " That the lungs have been wounded may be inferred with nearly equal certainty." LAWRENCE (London Lancet, 1830, Lectures, Vol. I, p. 55.")) 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, 18."5, S. 6C0) says that in shot wounds the lung is always contused, " wie d:es sieh auch aus dem Blutcpeien ergiebt, welches bei diessen Wunden niemals fehlt." l Dr. MACLEOD still reiterates (Notes on the Surgery ofthe War in the Crimea, p. 236) the routine statement "blood by the mouth and blood and sir by the wound are unequivocal proofs that the lungs have been injured." Assistant Surgeon T. K. BiRNIE, 1st Royals {London Lancet, 1856, p. f »■-1, reports two cases of recovery from supposed lung wound, the diagnosis being based on the presence of haemoptysis; HANCOCK (London Lancet, 1 H56, p. 686) mentions several cases of recovery after chest wounds in which wound ofthe lung was "evidenced by expectoration of blood." Matthew (Surg. Hist. Crimea, A'ol. II, pp. 315) mentions two cases in which haemoptysis took place, " rendering it highly probable that the lung had been injured.'' DIAGNOSIS AND PROGNOSIS. 637 Mr. Lawson and Dr. Schwartz1 believe that haemoptysis 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 symptorn 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. Hennen2 recognized that bloody sputa was not indicative necessarily of lung wound. Mr. Blenkins3 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,4also, states that haemoptysis is not a pathognomonic symptom of penetration, it may be only the casual complication of some superficial injury." Professor Gross5 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,6 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. Chisolm7 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. Rest 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 haemoptysis is of doubtful value as a sign of lung wound, except in conjunction with other symptoms. i Lawson, in Druitt's Vade Mecum, 10th ed., 1870, p. 484. Schwartz (Beitrage zur Lehre vonden Schusswunden, Schleswig, 1854, S. 112): "In severe wounds of the lung, a great quantity of partly dark, partly light-colored blood will issue from the mouth and the opening of the wound.'1 'Hennen (Principles of Military Surgery, London, 1829, 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. The bloody sputa, however, were only secondary, and neither so active nor alarming as those which pour at once from the lung when wounded."' 3 Blenkins. Addition to article Gunshot Wounds in the eighth edition of Cooper's Dictionary, Vol. I, p. 8£6. 4 Apri .v. The Ambulance Surgeon. English translation by Messrs. Nunn and Edwards. Edinburgh, 1852, p. 173. ' GROSS. A System of Surgery, Philadelphia, 1872, p. 447. ^ASHHURST. The Principles and Practice of Surgery, Philadelphia, 1871. p. 307. " CHISOLM. A Manual of Military Surgery, Columbia, 1864, p. 318. ooci WOUNDS AND INJURIES OF THE CHEST. Dyspnoea.—This is admitted to be a very uncertain sign of wound of the lung or even of penetration of the pleural cavity. It may be present when the lung is uninjured, or absent when it is seriously wounded. It may be due altogether to moral causes, and constitute one of the chief elements of the condition termed shock by some surgeons.1 It is then transitory. It is most intense when the walls of the thorax expand freely on inspiration, while obstructions in the bronchial tubes prevent the air from inflating the vesicles and hinders the lung from following the movements of the chest wall. When the air enters and passes out freely through a wound, there is no dyspncea unless from compression of the sound lung by effusion, or from hindrance of the movements of the lung by old adhesions or through some obscure lesion of the nerves; for when the lung lias collapsed and the pressure of air admitted through the glottis and the wound is equal, the collapsed lung offers no opposition. . Of fifty-one cases of penetrating shot wounds of the che.st, analyzed by Dr. Frazer, dyspncea was present in thirteen only, as follows: in three of nine fatal cases in which the lung was wounded, in three of nine fatal cases in which the lung was uninjured, in two of twelve cases of recovery, in four of twelve fatal cases from Dr. Matthew's report, in one of nine cases of recovery from the same report. In two hundred and fifty-two cases of which abstracts are given in this chapter in which the symptoms were carefully noted, dyspnoea was present in fifty—eighteen of recovery and thirty-two fatal.2 Nervous Anxiety.—Great agitation, nervous anxiety, and general prostration some- times follow the reception of wounds of the chest3 The alarm and apprehension accompanying this depression overcome the fortitude of men of the steadiest self-control and most devoted courage.4 In analyzing this condition, the surgeon will endeavor to discriminate between the symtoms due to impeded respiration, those arising from faintness i Of the effect of venesection in relieving dyspncea, as practiced in some instances, in the Franco-Prussian war of 1870-71, Dr. H. Fischer (Kriegschirurgische Erfahrungen, Erlangen, 1872, S. 126) remarks: "In cases of severe dyspncea and cyanosis we practiced venesections. If not made too copiously the desired effect is reached ; momentary relief of breathing and less oppressed circulation of blood, without depriving the patient of more blood than he needs for the approaching tedious suppuration. * * * In several cases we observed excellent results, * * * in other cases the effect of the venesection was very transient. In one instance we made repeated venesection, with only a very rapidly passing relief." » VlDAL (Traite de Pathologic Externe et de Midecine Opiratoire, Seme ed., 1860, T. IV, p. 66) remarks that slight punctures of the chest may induce dyspncea, cough, and nervous anxiety: " Les piqures les plus l§geres de la poitrine peuvent donner lieu aussi a une serie de pbenomSnes qui semblent accuser ordinairement les lesions les plus graves de l'economie ; ainsi: refroidissement de la peau, resserrement du pouls, suffocation, syncope meme, toux, enfin la plupart des symptomes de la lesion d'un organe profond, d'une h6morrhagie interne; et cependant ni organe, ni vaisseau un peu considerable n'ont 6t6 lesfis. On observe ces ph6nom6nes surtout dans les blessures recues en duel. Quel que soit le courage des champions, au moment rlu combat, le sang ne circule pas normalement et l'innervation n'est pas regulidre, on n'est pas sans Amotion; s'il se joint &. cet 6tat moral une plaie 41a poitrine, le blesse en concoit les plus vives inquietudes, et si la peur ne l'a pas encore pris, il est voisin d'en etre possf3d§. On concoit a,lors la production des pMnomdnes que je viens d'indiquer, et l'effet salutaire, sur des hommes peu 6clair6s, des succions qu'on faisait autrefois, accompagnees de paroles plus ou moins mysterieuses : le tout formait une pratique qui s'adressait au moral de l'individu, lequel 6tait bientdt radicalement gu6ri quand le danger n'etait pas physique. Ces ph6nomenes nerveux peuvent aussi s'expliquer par la lesion des nerfs qui animent les parois de la poitrine. Or on sait qu'il en est de respirateurs, comme le dit Ch. Bell: eh bien, la lesion de ces nerfs peut donner lieu a une toux, une suffocation, qui simulent singulierement une lesion des poumons ou un epanchement pleuretique." a Professor GROSS (System, Vol. II, p. 445) says: "Death from mere shock is by no means uncommon in wounds and injuries of the chest; cases of the kind are frequently met with both in civil and military practice, and their occurrence has occasionally been noticed where, upon dissection, no serious lesion has been detected to account for so untoward a result." 4 It is within the observation of most medical men, that the behaviour of men, when death is imminent, though partly governed by the measure of fortitude and courage they possess, is largely affected not only by physical but by mental and moral causes, and especially by their convictions 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 futiye felicity. Skeptics may contemplate the approach of dissolution with serene indifference, or with remorseful 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 noted. (Observations by Chenu, Perier, Brinton.) It is probable that these differences depend very much upon the structure implicated, and are modified as the mortal wound affects the nervous, circulatory, or respiratory system. (See Sir Benjamin Collins Brodie'S Psychological Inquiries. Being a Series of Essays intended to Illustrate the Mutual Relations of the Physical Organization and the Mental Faculties; in the edition of his works collected end arranged by Mr. Charles Hawkins, London, 1865, Vol. I, p. 117.) DIAGNOSIS AND PROGNOSIS. 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, ante) 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.1 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 tromatopncea, various friction sounds,2 absence or diminution of the respiratory murmur, and modifications in resonance, the surgeon will listen in vain for uniform sounds characteristic of particular lesions.3 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 l See Hfvnens case LXdT(o». cit, P. 395), Lieut. Colonel H----, wounded at Waterloo, under the centre of the left clavicle: " I was very curioultleJt^sLeorthe arteryf itlay a'wfully pulsating in situ, which uncovered arteries are not always observed to do." See also Professor Billroth's cases already referred to, and a number cited in this work. ....*. c a' r a x. t t .Though refusing to accept Joberfs and Bouillaud's bruits de frottement as distinctive and pathognomonic indicates of wounds of the heart, would by no leans depreciate, in the slightest degree, the value of physical exploration in such cases. One cannot but read with a touching interest the recLt'ctures of Professor Piorry on the utility of percussion in the diagnosis of chest wounds. Though desolated by the afflictions of his country ne eTrln p ofessor says that he wiles to impart to the young surgeons whatever aid a physician can offer, and has, therefore, pnnted this series of dtco^rorpSsLJsm,anart, which, in the perfection to which Profess Piorry has carried it, wdl perhaps ^nsh with ^ discourses on p ess - ^ ^ ^ L ^ sa>, that in wounds of the lung : "On auscultating the chest immediate! v after the" on of the injury, and before there is time for the supervention of any consequences, a loud rough crepitation will be distinctly audible aTandlro\tl Z seat of inju£." The surgeon does not have an opportunity of examining the wound before there is tune for the effusion of blood At i^S^T*. can famine, he may or may not hear loud rough crepitation, near or distant, aocordmg t, the extent of the wound and the amount of effusion in the larger air-tubes. 640 WOUNDS AND INJURIES OF THE CHEST. gunshot wounds in general.1 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. The injection 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 the 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 footnote2 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 haemorrhage, and will remember the encouraging assurance of the experienced Hennen,3 on the hopefulness of the case where "the third day has been safely i Medico-legal questions may sometimes depend upon the solution of this point. A Confederate officer was confined in the military prison at Norfolk, in 1863, under sentence of death for murder. While 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 within the left nipple were three wounds, one large and two small, the edges blackened, stellate, slightly inverted. Between the spine and lower angle ofthe 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 haemothorax, 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 charge taking effect 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, when 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. 2 John Bell (op. cit, Part n, p. 51) embodied his views ofthe 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 edg-es of the lungs ; and, as it is at a distance from the great veins and arteries, he maj' 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 much oppression, we put our finger into the wound, let some blood out, and so give relief, we are sure that the suffocation proceeds from blood extravasated in the thorax; and that kind of suffocation we know to be less dangerous by far than that proceeding from blood poured into the proper cavity or cells of the lungs, ?'. e. into the air-cells into which we draw the breath, and which, while they should be filled with air, are choked with blood, cthly. If a bullet passes 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 dangers, he is saved. 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 bands (to use so vulgar a phrase), more especially if, during a lingering distress, he has thought it necessary to support the friends with hopes and promises; for then it falls peculiarly on all concerned,—on the surgeon, who h:is 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 prognosis, we find that Hennen (Mil. Surg. 3d ed. p 391), while "unwilling to lull either a patient or a surgeon into a false security, or to underrate the real dangers of any case," has " seen many wounds of the thorax, 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; for, though occasional haemoptysis may come on at almost any period during a cure, and its approach can neither be entirely prevented nor anticipated, the more deadly haemorrhages are usually within the first forty-eight hours ; and yet 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 ofthe thorax received at the battle near Quebec, two only were fatal," have undoubtedly had much influence with practitioners in this country, in their prognosis of chest wounds, having been repeated with approval, for many years, in our leading medical school, by Professor W. Gibson. Sir GEORGE Ballingall taught (Outlines, etc., 5th ed.) that "the expanded surface of the thorax renders wounds of this region frequent in batile, while the vital importance of the organs lodged within it render them peculiarly dangerous." Guthrie (Comm. p. 462) is of opinion that "gunshot wounds of the chest, penetrating the DIAGNOSIS AND PROGNOSIS. 641 got over;" but will not forget that Hennen 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 cause 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 Chest,1 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 rules2 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 work3 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 dangerons." Mr. G. Lawson (Druitt's Surgeon's Vade 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 Bsll declares (Principles of Surgery, ed. 1826, 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 far from being mortal." Among "German authors, RlCHTER (Anfangsgrunde der Wundarzneykunst, Gottingen, 1800, B. IV, S. 326) says: "Lung wounds are generally dangerous on account of the fatal loss of blood, of the effusion of blood into the cavity of the chest, or of pneumonia." Schwartz, H. (Beit, age 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 um so schlechter." Among the French, the opinions of Bavaton, LaMotte, and others have been cited. VlDAL says (Traiti de Path. Ext et de Mid. Op., 5eme €d., 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." l TRIPLER, 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 immediately 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. We are to examine whether air escapes from the wound in respiration ; and whether there is any emphysema. C. 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 JllEItOME OF Bruysswvke's "The noble experyence of the vertuous handywnrke of surgeri," printed " in the yere of our lorde God MDXXV, and the XXVI day of Marche (reputed the first work on surgery in the English language), Hieronymus says : " And that token that the wounde gothe through the hreest, or in the holnes of the brest is, as the wynde cometh out the wounde, princypaly whan the nose and the mouth is stoppeth, than shall yow hage a lytell feder on a throde afore ye woude, is the vvoude through than shall meue the feder." 81 642 WOUNDS AND INJURIES OF THE CHEST. Treatment—Besides the rules that govern the management of wounds and injuries in general, the local and constitutional measures that are especially indicated in those of the chest, in their several subdivisions, are here to be considered. Local Treatment.—To secure rest, position and the broad chest bandage are the most generally applicable measures in injuries of the thorax, whether attended or not by breach of surface. In wounds, after stanching the bleeding, cleansing the parts, and removing all foreign bodies, the further conduct of the surgeon must be governed by the extent and nature of the lesion. All superficial wounds should be closed, with a view to early adhesion. In extensive incisions and lacerations, it wTill be proper to use sutures or serres-fines ; but, in coughing and inadvertent motions of the patient, they often tear out; and, usually, simple dressings1 will suffice. In many cases of penetrating wounds, surgeons preferred to support the injured side by broad strips of adhesive plaster made to encompass two-thirds of the chest and fenestrated at the wound. This was considered a very secure dressing, and acceptable to the patient. A few preferred the starch bandage, but its application was not always convenient in the field. The gypsum bandage, which enjoys much favor among the Russian,2 Austrian, and some North German military surgeons, was not reported to have been used. When there was profuse discharge, the compresses were conveniently covered with carded oakum.3 In profuse primary haemorrhages, it was always customary to make cold applications to the chest, ice being used when attainable. Then, if the bleeding point could be dis- covered, the prudent surgeon did not rest until the bleeding was arrested by the ligature, or, failing in this, by compression. The endeavor to find and secure wounded vessels, instead of plugging the wound with lint and Monsel's salt, was a distinction between skilful and heedless surgery. When it was impossible to reach the source of the internal bleeding, it was considered best to close the wound and to promote the occlusion of tlie bleeding vessels by general means. In connection with haemothorax, hermetically sealing, wounds of arteries, and operations, the circumstances that should decide whether the wound should be left open or closed have been fully discussed. The treatment of effusions by thoracentesis or incisions, the management of foreign bodies and of fractures, and the dilatations and excisions they sometimes necessitate, have also been considered at length. Stabs were not very common, as has been seen, and no instance of the use of suction or the " secret dressing"4 is mentioned in the reports. Whatever else pertains to the local treatment has been adverted to incidentally in connection with the complications or in details of individual cases. General Treatment.—The uncomplicated non-penetrating wounds of the chest require no exceptional measures beyond a judicious restriction of the diet and the means necessary to ensure rest. Contusions and concussions, with internal injuries, may call for active l What is understood by " simple dressing " in the United States service, is the approximation of the wound by adhesive strips, covered by a compress spread with cerate, or saturated with water, and supported by a light bandage, with oiled silk interposed if water dressing is used. Antiseptic dressings and carbolized ligatures did not come into use until after the war. •2P1ROGOFF (Grundziige der Allgemeinen Kriegschirurgie, Leipzig, 1864, S. 537) writes: "Had there been more time and a sufficient supply of gypsum, I should have ordered the gypsum bandage to be used much more frequently in complicated gunshot fractures of the ribs. Unfortunately, I had to reserve our gypsum supply solely for comminuted fractures of the extremities. But in several severe cases of gunshot fractures of the ribs the gypsum bandage was applied with excellent results. * * * I advise the young surgeon to bestow more time and zeal upon the proper application of this bandage, than upon the extraction of fragments of bone or wedged-in missiles." Nr.L'DOUFEU (Handbuch der Kriegschirurgie, Leipzig, 1867, Zweite Halfte, S. 00-2) says: " It is therefore necessary to prevent the voluntary or involuntary large expansion of the chest wall, and that can only be done by a suitable gypsum bandage." 3 This w..s a favorite dressing in all freely suppurating wounds. The tarry odor mas ked foul smells, and the fibres ol the oakum were light and absorbed well. According to Mr. Pollock (London Lancet, January, 1870) its advantages are appreciated in England. « Consult ANEL, L'Art de sucer les plaies, sans le servir de la bouche d'un homme, Amsterdam, 1707; Lui) WIG, De Suctione vulnerum Pectoris, Lipsiae, 1768 ; LaMotte, Traite complet de chirurgie, 1832, Vol. Ill, p. 20; J. Bell, Discourses on Wounds, 1795, Part II, p. 52. GENERAL TREATMENT. 643 restorative treatment; but the main interest in this subject centres in the questions whether, in penetrating wounds, venesection shall be practiced to avert hsemorrhage, or to arrest or subdue inflammation? There were no doubts on the subject until recently. The common voice of the profession sanctioned the paradox that bleeding was the surest means of arresting internal hsemorrhage, and concurred in placing venesection foremost among the remedies for inflammation. Long after the investigations of medical pathologists had undermined the foundations of the theory of bleeding for inflammation, the doctrine that venesection was indispensable in the treatment of wounds of the chest held its ground. Though there are in the writings of John Hunter and John Bell some evidences of misgivings as to the necessity of the heroic depleting measures long practiced in cases of penetrating wounds of the chest, I agree with Dr. Ashhurst, that the credit of the first formal protest against the common practice of venesection in these cases is due to Dr. Patrick Fraser, whose interesting monograph, giving the results of his extended personal observation during the Crimean War, I have repeatedly quoted. It was published in 1859, when it required no little courage to oppose the prevalent practice, described by Ballingall, at the military medical school at Edinburgh, in 1855, as that " which every sensible writer on this subject has taught and every experienced practitioner has adopted;" and Mr. Guthrie was alive, to castigate the cautious or recalcitrant medical officer who dared to question the teachings of the Peninsular campaign. Favored by the wide-spread distrust in the efficacy of depleting measures in inflammation, Dr. Fraser's views received much consideration, and their correctness in the main was conceded by several of the leading British military surgeons, particularly by Dr. Matthew,1 Mr. Lawson,2 and Mr. Blenkins.3 Dr. Macleod and Mr. Gant4 opposed the salutary change in practice, the former announcing, in contradiction of the official annalist, that, in the Crimea, " it was very generally observed that those cases did best in which early, active, and repeated bleedings were had recourse to," and the latter being "in favor of decided, and, as it may be termed, knock-down blood-letting." But, as the facts adduced by the former did not sustain his l Dr. Matthew did not concede the utility of venesection in haemorrhage, but admitted that its value in traumatic inflammation was overestimated: "Supposing the first danger of death by excessive loss of blood not to have arisen, in consequence of no large vessel having been wounded, or this danger to have passed over, the means adopted by nature to repair the mischief appear to he the exudation of plastic material glueing the various parts involved in the injury together, and thus isolating them ; and the more effectually and perfectly she does this, the greater is the chance of safety to the patient; and, as before stated, in discussing the subject of wounds of the head we believe venesection (for any other purpose than that of a styptic, as pointed out above) to he not only useless, but positively and actively injurious, as tending to prevent or render less perfect the adhesive process. The doctrine of the older surgeons, that adhesion depended upon a less degree or smaller amount of the same process which produces pus, and that as inflammation was almost certain to follow these injuries, prophylactic bleedings, to as great an extent as could he borne with safety to life, should be employed as tending to limit the inflammation to the less degree, or the adhesive stage, seems not at all tenable in the present day. Adhesion and pus formation seem to depend upon two essentially different processes, although the term inflammation has been applied to both; and although we are at present not fully acquainted with the nature of the difference, the opinioa appears to be daily gaining ground that the too early abstraction of large quantities of blood favors the latter, while there can be little question that it impedes the former process. We are, however, by no means prepared to state that exceptional cases of plethora, in which such prophylactic venesection may be beneficial, do not occasionally occur; but they appear to be rare, and indeed are not likely to exist among soldiers on active field-service. Practioal experience also, to which all theoretical opinions must give way, seems, during the late war, to point in thi3 direction, and to do so independent of, and making allowance for, the cachectic state before alluded to, into whioh the bulk of the army had at one time fallen." 2 Lawson, G. (On Gunshot Wounds ofthe Thorax), gave his opinion that bleeding in these injuries is not called for as recommended by Guthrie, Hennen, and the older army surgeons, and certainly was not applicable to the cases occurring in the Crimea. 3 Blenkins. Article—Gunshot Wounds, in the 8th edition of Cooper's Dictionary of Practical Surgery, London, 1861. ■ * MACLEOD, Notes on the Surgery of the War in the Crimea, ChurchiU, 1858, p. 237; Gant, The Science and Practice of Surgery, Churchill, 1871, p. 885. I say that Dr. Macleod's facts do not support his conclusions, because, though he reports eight recoveries in thirteen cases of shot wounds of the chest, it is not at all clear that the eight recoveries were complete, or that they were all from penetrating wounds, or that the bleedings practiced were of benefit, and because what he thought was generally observed, was denied by others, who had equal or greater opportunities for observation. Of fifty- one of the Crimean cases of chest wounds, carefully analyzed by Drs. Matthew and Fraser, free venesection was employed in seven,—in six of thirty fatal cases, and in one of twenty-one cases of recovery. How lamely Dr. Macleod's facts support his conclusions is illustrated by the cases reported by him on page 241, a fatal case of haemothorax without pneumonia, largely bled, and on page 247, "a soldier ofthe Buffs. * * He was largely bled, and his symptoms thereby relieved. Ten hours afterward a return of the difficulty of breathing called for further depletion and the use of antimony. Pneumonia followed.'" Mr. Gant's work has not been reprinted in this country, and it is unnecessary to examine the results of his experience at Scutari. The cases cited by Mr. Hole (British Medical Journal, August 7, 1858) and Mr. MACKAY (Edinburgh Medical Journal, Vol. I, p. 924) in laudation of venesection, are their own best answer. 644 WOUNDS AND INJURIES OF THE CHEST. conclusions, and as practitioners generally were inclining to the opinion that it was better for their patients to be set up than to be knocked down, these adverse opinions had little influence. Opinions had also undergone a great change in this country, and, at an early period of the War of the Rebellion, the compilers of the Confederate surgical Manual1 used the following emphatic language on the subject: "Equally uuphilosophical and more injurious, in our opinion, than even the use of the last class of sedatives, is the time-honored absurdity of venesection. It comes to us embalmed in the dicta of ' the highest authority,' and consecrated by the owlish wisdom of ' the ancients,' and, until recently, the precept has met with submissive and unquestioning acquiescence. We are gratified to find that, in all the cases of arterial hsemorrhage collected in the office of the inspector, not one is reported wherein the expedient was practiced by a surgeon of the Confederate States. The measure is one which has doubtless been transferred from civil practice, where it has been found of the greatest value, but in a very different kind of haemorrhage from that to which some military surgeons have sought to apply it. It is the great reliance—the sheet-anchor—in the spontaneous haemorrhages resulting from general plethora or local visceral engorgements. For these too much cannot be said in its praise. But for traumatic pulmonary haemorrhages, the measure appears to us not only hazardous, but actually injurious. All the circumstances are different—the cause of the bleeding entirely dissimilar—and hence the result of the remedy is, doubtless, often fatally adverse to the ill-founded expectation on which it was applied. Exotics, however vigorous, seldom continue to thrive. So have we found that the traditions of civil practice, however reliable, will not always answer as principles of military surgery." In a report2 to the Surgeon General, published and circulated immediately upon the conclusion of the war, I observed that: " In the treatment of penetrating wounds of the chest, venesection appears to have been abandoned altogether. Haemorrhage was treated by the application of cold, perfect rest, and the administration of opium. These measures seem to have proved adequate generally." This statement has been fully corroborated by a more extended and careful examina- tion of the returns. I can learn of but five instances of venesection after chest wounds, practiced during the war, four observed in the Union and one in the Confederate hospitals.3 Twice bleeding was practiced, by direction of Surgeon T. Antisell, U. S. V., in cases of traumatic pneumonia, that terminated fatally (cases of A. G-------, p. 483, and-McClay, p. 550). Three patients, all of whom recovered, were bled for the arrest of primary profuse haemoptysis. The cases of Kuhn and Oglesby* have been recorded (pp. 479, 484). The following is an abstract of the third case: Case.—Private Eichard D. Phelps, Co. E, 25th Ohio Volunteers, aged 19 years, was wounded at Gettysburg, July 1st, 180:5, by a fragment of shell, which entered one inch above and just to the inside of the right axilla, fractured the third rib, and passed into the lung. He was treated in the hospital of the llth Corps, Surgeon Eobert'Thomaine, 29th New York Volunteers, in charge, until the llth, when he was transferred to Satterlee Hospital, Philadelphia. The patient stated that on the reception of the injury he bled so profusely that the vein of the left arm was opened, with the effect of soon checking the internal haemor- rhages. He spat up blood, however, until the 10th, but no secondary haemorrhage set in. His strength was almost exhausted, but he gained daily. Cold-water dressings were applied. When admitted to Satterlee Hospital, the wound, which was about an inch in length, was nearly healed. The probe was soon arrested, the track having closed centrally, but the direction of the wound was downward and forward. There was but slight discharge and no expectoration. The lung, on percussion and auscultation, revealed dulness and bronchial respiration over the central three-fourths, with no respiration over the point of wound. Expectorants, extra diet, and rest were ordered, and cold-water dressings applied to the wound. The case progressed i A Manual of Military Surgery, prepared for the use of the Confederate States Army, page 97, Richmond, 1863. -Circular No. 6, S. G. O., 1865, page 21. 3 See remarks of Surgeon C. S. Woods, 66th New York Volunteers (ArrENDIX, p. 88). « This is very probably the solitary case of vensection in chest wounds mentioned by Drs. Thom and Chisolm. See p. 607, ante, Note. • Nix'DORFEU (Handbuch der Kriegschirurgie, Zweite Halfte, S. 605, in 1867), after his experience in the Italian wars and the Mexican invasion, writes: "We would, therefore, banish venesection from the treatment of gunshot chest wounds not only as an antiphlogistic or curative, but as a pro- phylactic measure; and oven as an haemostatic means, we cannot admit its value; as venesection, aside from its uncertainty in preventing internal bleeding, reduces the tone of the wounded umn aud endangers his life." GENERAL TREATMENT. 645 favorably, and by July 18th the patient's general health was better ; he suffered slight pain in the chest a little below the wound. On August 1st, he was transferred to the hospital at Camp Dennison, Ohio, at which time the dulness had entirely disappeared, and he was doing capitally, with every prospect of complete recovery. Phelps was returned to duty on September 22d, 1863; he is not a pensioner. The case is reported by Acting Assistant Surgeon W. W. Keen, jr. Dr. Chisolm (op. cit, p. 329) deprecates venesection in chest wounds, and gives an outline of the general treatment employed by the Confederate military surgeons: " Where the heart and pulse are hoth weak—a common condition after severe wounds—in our experience the abstraction of blood will occasion a complete prostration of strength, and may- be fatal. There is no reason for changing the plan of treatment, already discussed in detail, for combating inflammation following gunshot wounds, and which is equally applicable to chest wounds. Even when the lung is inflamed, we prefer the mild antiphlogistic and expectant treatment to the spoliative. The large success in the treatment of perforating chest wounds in the Confederate hospitals puts forth, in a strong light, the powers of nature to heal all wounds when least interfered with by meddlesome surgery. Absolute rest, cooling beverages, moderate nourishment, avoiding over stimulation, with small doses of tartar emetic, veratrum, or digitalis, the liberal use of opium, and attention to the intestinal secretions, will be required in all cases, aud in most will compose the entire treatment." Dr. Ashhurst1 testifies that, in civil practice, he "has found no reason to adopt a different mode of treatment from that which has proved successful in the surgery of war." It may be regarded as generally admitted that venesection is unnecessary in penetrating wounds of the chest, and that it may be very harmful, and that the "draining of the system of blood," commenced by Bell, Hennen, Guthrie, and Cooper, is to be numbered with the errors of the past.2 Of the pharmaceutical preparations employed in the general treatment of the wounds of the chest, discussed in this chapter, opium, calomel, antimony, veratrum viride, aconite, digitalis, hyoscyamus, acetate of lead, gallic acid, saline and other purgatives, hydrochlorate of ammonia, mineral acids and salts of quinia, and epispastics, are prominently noticed. Opium.—This medicine merits the first place among these remedies.3 It was used almost universally in all cases of severe wounds, and was found peculiarly useful in pene- trating wounds of the chest, in quieting the nervous system, and, indirectly, in moderating hsemorrhage. When used with discretion, there can be no question of its great utility. The inexperienced practitioner should not forget that its effects upon the system are augmented l Ashhurst, Prime, and Prac of Surg., Phil., 1871, p. 399. In his additions to Mr. Erichsen's Science and Art of Surgery, Am. ed. 1869, p. 399, Dr. Ashhurst remarks: "The treatment which the author very fairly acknowledges to have been found most successful by military surgeons ofthe present day, I have found equally satisfactory in cases of penetrating wound of the chest, met with in civil practice. In the later stages, also, the restorative treatment, which is now almost universally adopted in cases of idiopathic pneumonia, will generally be found equally efficient, in those of a traumatic origin. Perfect rest, quiet, the administration of opium, with plenty of milk, beef-tea, and even brandy, if necessary, seem to me, in such cases, more truly antiphlogistic than either bleeding, antimony, calomel, or barley-water." 2Fischeb, K. (Militairarztliche Skizzen aus Siiddeutschland und Bohmen, Aarau, 1867, p. 61), thus describes the expectant policy pursued in the Swiss Ambulance in the Bohemian war of 1866 : He states that he had accurate notes of forty-five cases of penetrating shot wounds of the chest. Twenty- one recovered and twenty-four died, or were likely to die, at the date of the report, or 54 per cent. " The search' for balls and fragments of ribs was always cautiously made, and without aggressive manipulation or operation. Even the incised wounds were not closed by sutures, but care was taken to assist the exit of pus by a suitable position of the patient. Neither general nor local bleeding was resorted to; no thoracentesis or drainage was employed; neither emetic nor laxative prescribed; but rest, well ventilated rooms, and nourishing food, with simple dressing of the wound, were provided." Dr. Fisher regards the results as contrasting very favorably with the results he witnessed in the Italian war of 1859, when venesection and antimonials were freely used. In relation to the removal of foreign bodies, Neudorfer (Handbuch der Kriegschirurgie, Zweite Halfte, Leipsig, 1867, S. 590) observes : "As desirable as it is to remove all foreign bodies from the lung, it must be remarked, that their presence in the lung is less injurious than in the pleural cavity. In the lung they are more readily encysted. Missiles have been found in the lung that had remained there for twenty or thirty years without causing much inconvenience, and. such cases would be more frequent, if the wounded did not so often perish from the opening of the pleural cavity. But here a discrimination among the different foreign bodies must be made. A leaden missile, a fragment of shell, a piece of stone, can be encysted in the lung; but all foreign bodies liable to decomposition, such as wood and bone splinters, pieces of cotton, linen, and cloth, will never become encysted." SOCIN, A. (Kriegschirurgische Erfahrungen gesammelt in Carlsruhe, 1870 and 1871, Leipzig, 1872, S. 86): " The result of a large number of cases cited proves that in penetrating gunshot wounds, where the lung is not at all or only superficially injured, or perforated in its long diameter, an entirely expectant treatment can prove successful. Where the entrance wound in the thorax wall does not remain open, but closes immediately after the passage of the ball, pneumothorax does not appear, a proof that, where the latter Exists, it was caused by the influx of the outer air into the pleural cavity, and very rarely by the egress of the air in the lung." 3N*FA"lx")RFER (Handbuch der Kriegschirurgie, Leipzig, 1867, Zweites Heft, Zweite Halfte, (3.607) remarks: "Of the pharmaceutic means employed in injuries of the chest, opium undoubtedly occupies the first place. I have previously shown the beneficial effect of opium after any injury or operation, as it moderates the reaction following each aggrossioiv and diminishes the interruption of the nervous equilibrium. But in cases of injuries of the chest'as well as of the abdomen, it is to be considered as possessing specific powers, not to be replaced by any narcotic whulcver." 646 WOUNDS AND INJURIES OF THE CHEST. after profuse loss of blood, and will be guarded in its administration under such circum- stances. Medical Director Hewit 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 promptly. 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, mercurial 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. Wharton1 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 any drug likely to appreciably diminish the normal proportion of fibrin.2 • Antimonials.—Tartrate of antimony and potash3 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 Viride.—The rhizome of the American hellebore or Indian poke, prepared as a tincture, was sufficiently valued to be admitted and retained on the Army Supply Table. " For controlling the circulation, liberal use," Professor Gross4 teaches, " should be made 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.5 Aconite.—Pharmacologists reckon this arterial sedative as useful in active hsemorrhage 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.6 i Wharton". Two Cases of Penetrating Wounds of the Chest. Dublin Quar. Jour, of Med. Sci., Vol. XL, 1865, 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. - By Surgeon General Hammond's Circular No. 6, S. G. O., May 4th, 1863, calomel and tartar emetic were directed to be stricken from the Army Supply Table, on the ground that "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., May 9th, 1867. 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 haemorrhage, 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-chirurgische Studien in den Italienischen Lazarethen von 1859, 'Wurzburg, 1861, B. II, S. 114) : "I cannot sufficiently caution the army surgeon against the routine treatment by tartarized antimony 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." 4 Gross, A System of Surgery, 1872, Vol. II, p. 447. Refer also to Professor GEORGE B. WOOD (A Treatise on Therapeutics and Pharmacology, Philadelphia, 18C8, Vol. II, p. 153); Professor WILLIAM TULLY (Materia Medica or Pharmacology and Therapeutics, Springfield, 1858, yol. I, Part U, p. 927). See Surgeon Crosby's remarks (Appendix, p. 11), and those of Surgeon Phelps (Appendix, p. 262); Percy (Trans. Am. Med.Assoc, 1864); BULLCCK (Am. Jour, of Pharm., Vol. XXIX, p. 204, and March, 1866, p. 98); NORWOOD, Va. Med. and Surg. Jour., Vol. I, p. 198. 5 Pharmacologists are not agreed as to the number or physiological effects of the alkaloids in veratrum viride. I have often observed the effects of the administration of this remedy in cases of pneumonia, in the practice of Professor Tully, who introduced the remedy, and in the practioe of his disciples, and thus became convinced of its uncertainty, and liability to produce, in large doses, toxic effects analogous to those caused by tobacco. ,; See PEREIRA. The Elements of Materia-Medica and Therapeutics, 3d Am. ed., 1854, Vol. II, p. 1085, and Edinb. Journ. of Nat. and Geogr.Sci., July, 1860, p. 235, and Fleming, An Inquiry into the Medicinal Properties of the Aconitum Napellus. I knew of two instances of fetal poisoning ol officers, through mistakes in dispensing the strong tincture of aconite at the field dispensaries. See ORFILA, Traite de Toxicologic, 56me ed., 185B. GENERAL TREATMENT. 647 Digitalis.—This medicine, usually in the form of alcoholic extract, was often employed; but 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 Wood, in its therapeutical applications.1 Hyoscyamus was occasionally used as a substitute or adjuvant to opium, or, in com- bination with colocynth, in purgative pills.2 Acetate of Lead.—The neutral acetate was employed not infrequently in haemoptysis, 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.3 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 haemorrhages or intestinal fluxes.4 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. With the same motive, turpentine was occasionally made a constituent of purgative and expectorant mixtures.5 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.6 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.7 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 augmented. The cautious use of ammonia and brandy was requisite in cases attended by great prostration at the outset.8 i Consult WOOD (A Treatise on Therapeutics and Pharmacology, Phila., 1868, Vol. II, p. 103); Gubler (Commentaires Thirapeutiques, Paris, 1868, p. 103); HOMOLLE and Quevenxe (Arch, de Physiologic, 1854, p. 223); Traube (Arch. Gen. de Mid. T. XXVIII, p. 338). 2 On its effects, consult Lemattke, Arch. Gin. de Med., Aoiit, 1865, p. 186; Ganod, Med. Times and Gaz., Dec., 1857, p. 589 ; Schroff, Wochen blatt der Ges. der Aerzte zu Wien, Juni 16, 1865; STILLE, Therapeutics and Materia-Medica, 3d ed., 1868, Vol. I, p. 765. 3 Consult GOULARD, Traite sur les effets des priparations deplomb., Pfizenas, 1760. * Refer to Weaver. Am. Jour, of Pharm., Vol. XXIX, p. 82; Gubler, Commentaires' Thirapeutiques, p. 579; Gmelix, Chimie Organique appliquie d, la Phys. et a la Mid., Paris, 1823; and papers hy Drs. Neale and Grantham and 31. Saumox. s 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. 6Consyilt GUBLER, Commentaires Thirapeutiques, 1868, p. 403. For its employment in inhalation, see Dacosta, Inhalations, etc., pamphlet, p.83, Phil., 1867; Garrod, The Essentials of Materia-Medica and Therapeutics. London, 1868, p. 49. 7 See CARSON, Synopsis of the Cours". of Lectures on Materia-Medica and Pliarmacy delivered at the University of Pennsylvania, Philadelphia, 1851, p. 72; ROYLE and HEADLAND, A Manuel of Materia-Medica and Pharmacy, 3d ed.; TULLY, Mit.-Mid. and Phar., Vol. I, Part II, p 1103; Bayle, Bibtiolhique de Thirapeutique, 1837, T. IV, p. 222; LlNDLEY, Flora-Medica, London, 1838, p. 426; Raffixesque, Medical Flora, Philadelphia, 1828, p. 206. sConsult 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 Lectures on the Principles and Practice of Medicine, 2d Am. ed., 1863, p. 646 ; Ashhurst, Prin. and Pract. of Surg., 1871: " Beef-tea and even brandy will, according to my experience, be more often required in cases of lung wound than calomel or antimony," p. 359. 648 WOUNDS AND INJURIES OF THE CHEST—CONCLUDED. In the later stages, alcoholic stimulants and carbonate of ammonia, in conjunction with concentrated nutriment, were important adjuncts to the restorative treatment. Ergotine was prescribed as an haemostatic in a few instances, but no evidence of its utility is given. Epispastics.—Large blisters were recommended by high authority1 and were often employed in cases of traumatic pneumonia, even in the early stages. There were 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 be of liquid form and easy of assimilation. I dwell upon this point, because the reports show that many surgeons erred in allowing solid animal food at too early a period.2* 1 See GROSS, A System of Surgery. Vol. II, p. 447. 2 Stadlander, Diss, de pulmonum vuln., Franc, 1683; Crosser, J. H., Dissertatio de thoracis vulneribus, Lugduni Batavorum, 1716 ; KOOY, A., Dissertatio de vulneribus thoracis, Lugduni, 1738; Fricke, J. H. G., Dissertatio de coyitusionibus pectoris, Gottingen, 1792; HERlIOLDT, Bemerkungen uber die chirurgische Behandlung tiefer Wunden der Brust, Kupenhagen, 1801; VER1NG, Uber die eindringenden Brustwunden, 4to, Wien, 1801; RUMEBE, E., Dissertation sur les Plaies d'Armes ct feu penetrantes dans la Poitrine, 4to, Paris, 1814 ; Baudon, Dissertation sur les plaies penetrantes de poitrine, 1815, Th6se de Paris, No. 366; Fauret, F., Dissertation sur les plaies penetrantes de poitrine, etc., 1823, Thdse de Paris, No. 107; Mayer, C, Traclatus de vulneribus pectoris penetrantibus imprimis cum Hiemorrhagia conjunctis, Heidelberg, 1823; Fraser, P., A Treatise upon Penetrating Wounds of the Chest, London, 1859. 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: "Lancet, 1832, August llth, p. 604; October 27th, p. 159; 1838, June 2d, p. 350; 1841, August 14th, p. 724; 1846, May 9th, p. 533; 1847, January 9th, p. 67; 1851, April 6th, p. 416; 1852, February 14th, p. 193; 1856, June 21st, p. 682, and p. 685; MEDICO-CHIRURGICAL TRANSACTIONS, 1825, Vol. VII, p. 315; 1826, Vol. IX, p. 204; 1841, October, p. 564 ; 1842, October, p. 615; Medical Gazette, 1828, March 29th, p. 512; 1829, October 24th, p. 124; 1830, January 16th, p. 520; 1835, May 2d, p. 146 ; 1837, November 18th, p. 302; 1838, August 18th, p. 802; 1840, February 7th, p. 721; 1843, May 20th. p. 322; 1845, September 26th, p. 980;. 1847, January 22d, p. 1362; 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. 5l5; April 8th, p.---; 1853, December 17th, p. 638; MEDICAL Times AND Gazette, Vol. XXXVI, pp. 242, 604." For practical observations on gunshot wounds of the ohest during the War ofthe Rebellion, see Appendix lo Part I, ofthe Medical and Surgical History, as follows: By Surgeon A. B. Crosby, U. S. V., p. 11; by Surgeon C S. Wood, 66th New York Volunteers, p. 88-; by Assistant Surgeon J. S. Billings, U. S. A., p. 200; by Surgeon A. J. Phelps, TJ. 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. Hewit, U. S. V., p. 312. In the American medical periodicals, the following articles may be found, in addition to those already referred to : Galloupe, Gunshot Wound of Chest; Ball removed after seventeen years, Boston Med. and Surg. Jour., N. S., 1872, Vol. IX, p. 267; Kirkbride, T. S., Gunshot Wound of the Thorax, Am. Jour. Med. Sci., Vol. XV, p. 357, O. S., 1834 ; D'Ayignon, F. J., Extensive Wound of the Thorax, Recovery, Boston Med. and Surg. Jour., Vol. XXXIV, p. 231, 1846; BLANTON, A. M., Case of Gunshot Wound of the Chest, Am. Jour. Med. Sci., Vol. XVII, p. 23, 1849; HOOKER, A., Penetrating Wound ofthe Chest, Death in eighteen days, Boston Med. and Surg. Jour., Vol. LXII, p. 223, 1860; ASHHURST, J., Jr., Cases of Penetrating Wounds of the Chest and Throat, illustrating some important Practical Points, Am. Jour. Med. Sci., Vol. XLIII, p. 61, 1862 ; Lombard, J. S., Case of Pneumonia following Gunshot Wound of the Chest, Boston Med. and Surg. Jour., Vol. LXVIII, p. 471,1863 ; Cabot,, Gunshot Wound of the Chest, Boston Med. and Surg. Jour., Vol. LXVIII, p. 100, 1863; WALES, P. S., Gunshot Wound ■of tlie Chest, Am. Jour. Med. Sci., N. S., Vol. XLV, p. 380, 1863; Smiley, T. T., Gunshot Wounds, from Arkansas Post, Two Cases of Chest Wounds, Boston Med. and Surg. Jour., Vol. LXIX, p. 153, 1863. The following references may also be advantageously consulted: Warren, J. M., Wound in Chest from Grapeshot, Surgical Observations, with Operations, Boston, 1867, p. 550; CARRE, M., Considerations sur les Plaies pinitrantes de la Poitrine, compliquies de Lesions aux Poumons, in Rec. de Mem. de Med., Paris, 1826, T. XIX, p. 144; GAMA, Observation d'une Plaie Pinetrante de la Poitrine, Rec. de Mem. deMed., Paris, 1822, T. XII, p. 177; HlRN, Observation sur une Plaie Pinitrante de la Poitrine, suivie de VExpulsion de plusieurs Portions de la Membrane muqueuse qui tnpisse Vinterieur de la Trachie artlre, Rec. de M§m. de M6d., Paris, 1819, T. VI, p." 276; Kries, H. O., De Vulner is Pectoris Penetrantibus, Berolini, 1828; Pechlin, J. N., Sistens Historiam Vulneris Thoracis et in earn Commentarium in Haller'S Disput. Chir. T. U, p. 531; SCIIMLD, H., Ueber Penetrirende Brustwunden, Jena, 1867; RlCHTER, A. G., Anfangsgrunde der Wundarzneykunst, Gottingen, 1800; SffiMERIKG. S. T., De Morbis Vasorum Absorbentium, Trajecti ad Moen, 1795; HEURMANN, G., Abhandlung der Vornehmsten Chirurg. Operationen, Kopenhagen und Leipzig, 1756; Valentin, Des plaies de poitrine avec epanchement; des signes des epanchements de sang, etc., in Rech. crit. sur la eJiirurgie moderne, Paris, 1762; Marjolin, Dictionnaire en 30 volumes, 1842, T. XXV, p. 413; ANGER, B., Plaies Penetrantes de Poitririe, Paris, 1866. *Besides the specimens already referred to, the following preparatinos in the Army Medical Museum, Section I, illustrate shot wounds of the lung: Spec. 603.—" A wet preparation of the left lung, showing ulceration of the apex, following gunshot. Private W. B. T., Co. E, 4th Maine Volunteers. A bullet entered to the left of the seventh cervical vertebra, and was cut out on the field, just behind the right stemo-cleido-mastoidous, opposite the fourth cervical vertebra, Fredericksburg, December 13th ; admitted hospital, Washington, December 18th ; haemorrhage from the anterior wound and cough appeared on 21st; air issued from posterior wound on 27th; died on 28th December, 1862. The right humerus was fractured near the elbow, also. Contributed by Acting Assistant Surgeon F. P. Sprague " (Cat. Surg. 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 sterno-cleido-mastoideus, three-fourths of an inch above the clavicle, and escaped an inch to the right of the fourth dorsal vertebra. The specimen is badly cut, as if in dissection. Private V. B. C, Co. C, 16th Maine Volunteers; Fredericksburg, 13th December; admitted hospital at Washington on 18th; cough appeared on 20th; haemorrhages from anterior wound until 24th; died 30th December, 1862. Contributed by Acting Assistant Surgeon F. P. Sprague " (Cat. Surg. Set Army Med. Museum, p. 479). Spec. 960.—"A preparation of a portion of the left lung, with a battered conoidal ball lodged near the apex. M. F., 88th New York Volunteers; Antietam, September 17th, 1862; admitted hospital at Frederick on 21st, with gunshot fracture head of humerus, which was excised on the 25th ; died on October £tb, 1863, from pleuro-pneumonia" (Cat. Surg. Sect. Army Med. Museum, p.478). GENERAL TREATMENT. 619 There are a certain number of cases of penetrating wounds of the chest 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 eye 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,1 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,2 that in which the mortality was lowest, was taken from the army lists, for periods when moderate bleeding was the prevailing practice. But the assumption that blood-letting, by withdrawing from the circulating medium its excess of fibrine, 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 I GROSS, A System of Surgery, 5th ed., 1872, Vol. n, p. 447. 2 See the British and Foreign Med-Chir. Review, Vol. XXII, July, 1858. They are collected from very various 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 the figures which he gives as a whole. S2 650 WOUNDS AND INJURIES OF THE CHEST,—CONCLUDED. tlie fallacy of these assumptions 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.1 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.2 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 this 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 temporization 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. l 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; Bryant, The Practice of Surgery, London, 1872, p. 152. 2Dr. BARCLAY, 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 efficacy 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 death, 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 haemorrhage; 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 oaused 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........................ ~M Adolphus......................... 171 Adams........................... 440 Adler............................ 494 A-ard........................... 461 Ainsworth....................... 56 Akin............................ 4S1 Albright......................... 43 Alexander....................... 56 Alden...........S:l. 92. 329, 34*, 398, 567 Allen, H..........SU, 112,160,288, 351, 438, 4S7, 505. 520, 511, 568, 575. 587 Allen, B. W......................107, 12i>, '244.245, 246, 27;>, 287 Allen, L.H...................... 190 Allen X.......................... 222 Allen, J. L....................... 330 Alsdorf.......................... 226 Alexander........................ 273 Aries, A. E....................291, 470 Ames. A. H...................... 491 Ahtisell. - .118,367, 477, 483,528,550,154 Ana wait......................... 172 Ansell........................255, 435 Anderson......................... 285 Armsbv.......................... 45 Arthur"...................167.202,437 Armstrong, J. E.................. 240 Armstrong. J. A.................. 520 Artand...'.....................2*3, 363 j Atwood.......................... 59 j At water.......................... Ill Atkinson......................274,417 Atwater, H. H.................... 430 Avery........................... 330 Avres.....................23,444,546 Ayer............................. 290 Azpell.........................58,538 Bailey..........................37,45 Bailv............................ 220 Bache, O......................... 38 Bache. T. H............40,80.163,367 Barnum..............-.......... 39 Bacon. F., jr...................83,276 Bacon! C......................... 118 Bardiu.......................... 119 Batwell...............147,209, 265, 412 Baldwin, L. K................161,277 Bates. E. F...................168,349 Bates, W. S...................... 239 Bates, J.......................292,479 Bardwell.....................178,226 Baxter.......................189,^74 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 Bentley..................44, 45, 53,54, 58, 76, 86, 88,133,183,184,183, 201, 206, 248,265, 208, 289, 302, 350,351, 353, 354, 356, 360, 364, 365, 426, 436, 437,441,445, 150, 467, 473 557,628 Benedict......................101,539 Beel............................. 119 Page. Bellows.......................... 15(1 Bell, .liinies...................... 178 Bell, John........................ 203 Bell, J. B.............,.......... 227 Benson.......................178.208 Beach........................... 213 Beck............................ 218 Belknap......................... 289 Beeser........................... 291 Beust............................ 430 Becker........................... 547 Billings................60,231,292, 302 Bigelow, J. K.................... 164 Bigelow, H.J.................... 193 Bigelow, O. P.................... 249 Bin-............................. 461 Bliss, D. W................49,59,125, 143,171,238,248,266,268, 269, 272,278,279, 281, 284, 296,301, 346, 349, 408, 412, 516, 583, 590 Bliss, Z. E.;....,....,......53;217;356 Blossum.........•. .•---.......... 175 Blackburn........................ 236 Blackman........................ 369 Blein............................ 559 Bontecou..................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 Bosworth........................ 41 Bobbs..............,............ 54 Bowling......................... 59 Bow-en/Vr". H..................... 201 Bowen, C. H..................414,584 Bowen, W........................ 461 Bowen, H. F..................221,456 Bockee.......................... 274 Boynton......................... 413 Bradley, W. A.................... 47 Bradley, W. H.................175,481 Breed...........54,73, 302,526, 546, 573 Brown, E. O....................54,78 Browne, P. F...........78, 451,503,542 Brown, J. N...................... 231 Brown, J. A..................233,419 Brown, J. H..................... 238 Brown, F. H...................... 540 Brown, J. M..................... 618 Brinton, J. H..... ............58,367, 401,402,515,589,628 Bryant, H......................... 562 Brinton, O. G..................183,501 Briggs........................... 59 Brumley...................78,501,506 Bradley, E....................178, 289 Brillantowski..................92, 200 Brewer.......................141, 461 Bradford, G. W............. ..... 177 Bradford, F. G. H................216 Breakey..............178,192, 505,506 Brookes.......................... 180 Brooks, E.................203,246,431- Brooks, O. D..................... 285 Brattan.......................... 186 Brock........................... 211 Brubaker........................ 577 Bryant........................213,490 Breneman........................ 2)1 Burke..........................43,58 Page. Buchanan........................ 59 Buchanan, J. W.................. 114 Buckman W. F.................. 244 Butler, J.H...................... 18 Butler, T. S...................... 240 Butler, W. H..................... 476 Buzzell.......................... 101 Burpee...............108,159, 354, 364 Burmeister....................139,163 Burdick...................172, 239, 613 Burt............................. 229 Bundy........................... 234 Buck, A. A....................... 354 Buck, G.....:............373,375,376 Buck, H. A....................... 405 Buckingham, A................... 573 Buell............................ 411 Byrne..........................74,75 143,201,273,349, 355, 425, 435, 438 Byles, C......................... 635 Calhoun............. 39, 48,77, 363, 367 Camac.,...................... — 41 Carter.........................92,354 Cahoon.......................... 100 Carvallo......................116,441 Cabell........■-.......126,215, 300, 557 Canniff........................... 129 Cake............................ 134 Carson........................... 187 Campbell, J...................... 205 Campbell,C................-.....229 Carroll, T........................ 206 Carroll, R. W. W.................. 418 Cass..........................249,360 Cantwell......................277,420 Castle............................ 410 Cameron......................... 496 Carpenter........................ 584 Chambers......................40,458 Chapel........................... 71 Chamberlain. C. N...............98,501 Chamberlain,W. M.....234, 371, 409, 559 Cherbonnier...............105, 619, 620 Christian......................... 114 Chandler......................... 134 Churchill.................190,237, 240 Chase, I. S....................236,473 Chase, E. G...................... 247 Choate........................... 238 Christ............................ 275 Cheever.......................... 279 Chapin........................... 566 Clark, A. P....................... 21 Clark, C. R....................... 138 Clark, C.C.P.................•---- 174 Clark, E. A....................211, 370 Clark, A. M................251,503,504 Clark, CM....................293,362 Cloak...........................41, 55 Clapp.A.M....................... 48 Clapp.W. A..i................... 355 Cleizer........................... 196 Cleaver.......................... 208 Clendenin, W..............229, 303, 524 Clendenin, W. H.................. 291 Clements......................... 227 Cleary........................... 393 Cooper........................... 22 Colby............................ 17 II INDEX OF REPORTERS. Page, Conner........................54,181, 224,249,254,301,327,560 Collins........................... 72 Co-swell......................... 83 Cobb............................ £4 Coventry......................... 116 Cornell.......................119,501 Coale............................ 143 (oleman.......................... 164 Oowgill.......................164,212 Cowles..........................- 175 Corlis............................ 186 Conkling.......................186,290 Cook, G. XV...................238,526 Cook, A. P....................... 451 Colbum........................... 240 Colvin........................... 288 Combs........................... 290 Conover..................294,473,593 Cole............................. 298 Coombs.......................... 393 Coe.............................. 480 Croshv, T. R................51,73,330 Crosby, A. H..................... 445 Croshv, R......................... 588 Crowe........................... 57 Cropp........:.................. 119 Craig, XV. II..................442,488 Craig, B. F....................363,182 Crawford........................ 398 Cuniminskev.................103,130, 189,215,230,403,501 Currey........................... 160 Cummins......................... 197 Cutter........................... 239 Cutler........................... 294 Culbertson............369, 372, 378,418 Curtis........................... 539 Curtis, 1. B...................... 573 Dairm-tt.......................... 407 Dana............................. 186 Dare............................. 205 Davies........................419,432 Davis, A......................... 221 Davis, J......................... 41 Davis, P. C................55,406,462 Dawes........................... 77 Dav, H. B........104,120,208, 223,237 Dav, B.J........................ 288 Day, W. E....................... 423 Dean................111,205,213,248, 249,252,253,273,435, 480, 493,556 DeGraw.......................... 534 Derby, A. R...................... 85 Derby. G......................... 71 Devendorf........................ 180 Devens.......................... 232 Delavan.......................... 488 Dickenson........................ 75 Dieffenbach....................... 177 Dickie........................... 528 Dorr............................. 274 Dodge........................... 108 Draine........................... 38 Draper........................... 301 Dunglison........................ 227 Dunton.......................... 372 Dusenlmrv...................... 426 Dutton..."......................... 433 Dudley.......................488,489 Dwinelle..................181,488,489 Dyer............................ 462 Eastman.......................... 132 Edwards......................... 33 Edelin........................... 266 Edtrar........................... 270 Ellis. C. M....................... 22 Ellis, J. AV....................... 494 Elliot............269,274, 418, 574, 587 Elswortb, J. W................291, 495 Elrod............................ 292 Page Ella............................. 397 Ely, Smith....................... 577 Emanuel.......................... 209 Emory........................... 445 Evans........................... 183 Everts....................501,502,506 Falley, C. F...................... 105 Fallev, J. W...................... 574 Fav, J. K........................ 2(8 Fay, J. W....................... 363 Fa'squelle........................ 458 Farnsworth...................... 491 Farrar........................... 586 Fergusson---.................163,192 Feris............................ 186 Finlev, C. A...................... 22 FinleV, S. M...................59,451 Finn."............................ 462 Fitch............................ 107 Fisher........................... 149 Fischer.......................... 588 Fisk, C. L................197,240,496 Fisk, S. A........................ 500 Flandrau.......................92,174 Folsom.......................... 46 Foye..........................55,516 Forwood......................... 71 Foward.......................... 290 Forbes........................... 370 Foster, F. P...................... 418 Foster, T. A...................238,458 Fossett.......................... 128 Fox..........................242,286 Fonts............................ 271 Frantz..........................50,54 French, J. O.................... 232 French, G. F..............363,451,489 Franklin..........289,292,350, 452,523 Frasse.......................... 356 Fuller, G.E...................... 442 Fuller, S. E...................... 539 Fulley............................ 585 Gallagher.............114,179,480,620 Gale, G. 8...,.........191,192, 366, 397 Galloway........................ 239 Galloupe......................... 242 Gnv............................. 277 Ga'rcelon......................302,360 Gadd............................. 430 Gardner.......................496,550 Germaine........................ 334 Gesuer................'-........... 290 Geiger........................... 596 Gibson, F...............--........ 250 Gill.............................. 487 Gilroy............................ 526 Gouley........................... 58 Goldsmith, M..................... 74 Goldsmith XV. XV.................. 102 Goddard..............131,435,494,535 Gosling.......................211,254 Good................. .......... 223 Goodman..............*........351,408 Gordon.......................... 461 Graham........................37,347 Green, W. F...................... 56 Green, M. L...................... 179 Green, J. B....................... 484 Greene, A. S...................... 559 Gray............................ 85 Gross........130,133,236,249,291,539 Gruhe........................... 142 Griswold, C. D................... 239 Griswold, L. D................... 297 Greenleaf........................ 243 Grove.....................275,373,546 Griffith..-......................... 279 Grier.........................326, 405 Guilford.......................... 120 Happersett.....................40, 470 Hammer....................42,129,369 i Phrc. | Hartshorn........................ 53 llavwood........................ 76 Haves........54, 75, 76, 82, 8H, 107, 177, 222,229,230, 231, 330, 347, 191, 558 Hammond, W. A.................. 58 Hammond, R D.................. 188 Hammond, W. L..........200, -147, 521 Hand. D. W....................74, 408 Hand, A. F....................193,222 Hamilton, F. H........110, 488,517,532 Hamilton, C. A................... 476 Harding......................172,194 Hasbrouck....................... 178 Hanna........................... 183 Hay..........................188,433 Hazen........................... 197 Hart......................... 219,586 Hartswiek........................ 233 Hazleton........................ 239 Hall, A. D....................364,574 Hall, J. A........................559 Hachenberg...............•....... 439 Harris............................ 459 Hamlin.....:.................... 459 Herrmann......■.................. 17 Hewitt................21, 352, 356,566 Heiehhold....................... 31 Heard........................... 32 Helshy.........................41,228 Hening, T. 8................46,135,239 Herbst.....................54, 301, 461 Heger........................... 72 Herrick........................... 78 Henry............................ 129 Hendrick........................ 136 Henson.......................... 171 Helm, J.C....................... 225 Helm, W. H...................... 468 Helmer.......................223,230 Herndon......................... 279 Hendricks, J. G.................. 284 Hendricks, E. F.................. 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 Hoppin.......................... 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 Hobar........................... 463 IIov............................. 500 Hood............................ 528 Hupp..........................31,192 INDEX OF REPORTERS. Ill Page. Hunt............................ 53 Hubbard, S....................... 56 Hubbard, H. B................... 229 Hubbard, V. B................... 550 Hubon........................... 60 Huber........................... 533 Hurd. H. S....................... 133 Hurd, J. S....................... 190 Huntington....................... 173 Hubbell.......................... 215 Hiitton........................... 221 Hutchings........................ 238 Hutchinson....................... 262 Hvde, J. N....................... 367 Hyde, J. H...................104,476 Impey............................ 42 Ingram............37,286, 292,475, 529 Isham....................42,470,573 Irwin............................ 506 Janes..........................72,350 Jamar........................... 265 Jackson___:..................... 496 Jewell................105,116,295, 502 Jewett........... .......1....... 480 Jessup...........................290 Johnson, H. B.................... 234 Johnson, RlL.................... 560 Jones.....................;»...... 30 Jones, XV. P...................... 75 Jones, G. S...................118,119, 232,242,291,351,409,451 Jones, R. K...................208,232 Jones, W........................ 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, V. W...................... 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............................. 260 Kedzie........................... 487 Kipp..........................32,146 Kitchen.......................... 33 King, J. >S........................ 58 King, 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 Lesher........................... 191 Leighton......................201,229 Pago. Levergood...'..................... 239 Leavitt...................248,252,556 LeConte......................... 257 Leslie............................ 292 Leedom.......................... 331 Leidy.........................431, 569 Livesey.......................... 293 Lidell..........40,49,110,122,161,195, 203,263,264,349, 446, 524, 543, 559 Lineaweaver..................347, 499 Liebold........•.................. 416 Longwill......................104,482 Longenecker..................132, 585 Loomis...........223, 232,282,410,533 1 -ogan........................... 356 Lowell........................... 388 Lord............................. 582 1 joughran.....................458, 577 Loughridge....................... 499 Lockhart.......................,. 533 Ludlow........................37, 554 Lyman, J. B..................... 129 Lyman, 8. XV..................... 510 Lynn............................ 191 Lvster........................... 199 Lytie............................ 529 MacDonald....................... 116 Matlock, J. M.................... 4 Matlock, W. H................... 569 Mackenzie........................ 58 Manson.......................... 77 Marshall......................... 82 Maull........................... 120 Mace............................ 550 Martin, O.........176,194,238, 411, 461 Martin, H. A..................... 269 May..................201,268, 449,574 Mahon........................... 228 Mansfield.....................216, 328 Mackey.......................... 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.......56, 60, 297, 347, 471, 571 McClellan......................71,74, 80,83,87,113,287,461,541 McClelland....................... 538 McDermont............75,124,225, 492 McParlin....................76,81,352 McEwen......................... 83 McCall.......85,106. 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......................194,231 McKnight.....................208,480 McNulty.......................... 272 McLean.......................... 286 McGlaughlin..................... 295 McArthur........................ 326 McDonnell....................... 356 McClure, A. R.................... 358 McClnre, A. W................... 460 McFalls.......................... 369 McNeilly........................ 419 McQueston, C. A................. 452 McQueston, C. B................. 521 McReynolds...................... 479 McKay.......................482,497 McJilton, W. D................... 582 McMillan........................ 526 McElderry....................... 574 Meacham....................36,43,470 Page. Meagher..............163,359,474,590 Mears.....................102,179, 292 Means........................... 129 Metcalf.......................... 292 Merrill, A........................ 363 Merrill, C. S...................... 577 Mendenhall....................408, 412 Mead............................ 477 Miles, B. B....................55,169, 169,300,354,361,439,444, 468,593 Miles, W. H...................... 468 Mitchell.......................... 106 Mintzer.......................... 116 Miller............................ 416 Mosely........................72,76, 120,171,240,247,253, 254,255,266, 277,298,346,349, 359, 360, 393, 540 Mott.......................76,165, 461 Moon.........164, 225,267,275, 295, 362 Morrison......................... 211 Morris, T. C...................... 228 Morris, J......................... 484 Morgan, D........................ 276 .Morgan, W. P.................... 347 Morton...............277, 378, 413, 555 Moody........................... 416 Moses.....73,144,262,274, 393,551, 630 Morehouse....................... 124 Montgomery..............103,243, 378 Mullen........................146,449 Mursick......................200, 247 248,250,254,353, 366,446,459,502 Mulhallen........................ 490 Munn............................ 504 Mygatt........................... 462 Nagle..............,............. 489 Newell........................... 9» Nelson, J. C...................121, 350 Nelson, A. W..................... 582 Neff............................. 162 Neill.................168,177,182,197, 236,280, 357, 358, 360, 364, 474, 526 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. F..........417, 418, 492, 568 Norris, A.L...................... 433 Norris, J......................... 545 Nordman......................... 372 North............................ 493 Nye............................. 230 Oakley.......................191,582 O'Brien.......................... 403 O'Connell........................ 330 Oliver........................... 493 O'Keefe...........210,245,276,281,491 Orton, S. H....................72, 438 Orton, J. G............102,166,234,368 Ormsby.......................... 204 Otis, D. A........................ 233 Otto............................. 224 Otterson......................... 368 Owen, G. S....................... 183 Owen, D. C...................... 190 Owens........................237,484 Owings.......................409, 442 Palmer, J. C..........-..-........ 558 Paullin........................... 21 Palmer, E........................ 34 Palmer, G. S...................41,185 Palmer, T. M...................79,120 Palmer, H....................133,215, 286, 346, 350, 456, 523 Pancoast.......................41, 82, 217,297,353,364,396,443,467,539 Page,CG....................... 42 IV INDEX OF REPORTERS. Page. Pa-re. 0.......................202,499 l'a-e. W. H...................... 240 Patten........................... 117 Parker, W. S..................... 162 Parker, F. S..............179,245,295 Paine............................ 174 Packard......................... 358 Parke............................ 352 Peters........................44,113, 122,165,196,416,467,492,549 Peter, P.......................... 197 Peter, R......................... 470 Peabody......................... 72 Pettinos.......................... 202 Perry, D. O...................... 238 Perry, 1.......................... 441 Perin............................ 2-7 Peck..........................369,419 Perdue........................... 477 Pfoutz........................... 117 Phelps, 8........................ 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 Piquette............:............. 476 Pick............................. 589 Pineo............................ 636 Plumb........................... 269 Plant............................ 5*3 Powers, E. M...................37,351 Powers, C........................ 88 Pope............................. 78 Porter, G. L..................171,446 Porter, P. C...................... 188 Porter, C......................224, 327 Porter, F. S...................235,469 Porter, I. G...................... 578 Pomeroy......................... 194 Powell........................241,558 Post, John....................... 209 Post, L.......................... 241 Potter, W. XV..................331, 529 Potter, H. A...................... 357 Prall............................ 109 Prince............................ 239 Price............................ 296 Purdy........................... Ill Putnam.......................... 286 Quick.... 2(15,233, 365, 180, 481,564,589 Rankin, S........................ 50 Rankin, A. C..................... 471 Kamsev......................291,409 Eahter........................329, 451 Read, J. B...................54, {JS, 99 Reed, T. B.....................72,76, 116,173,215,279,458,539,555 Reed.Z.......................... 103 Relier........................... 73 Reeder.......................... 284 Reber............................ 348 Raamy........................... 396 Reynolds........................ 420 ReVbum.........-................ 436 Reese............................ 541 Rhodes.......................... lyi i Rice, X. P........................ 4H Rice, CD...................74,78,214 Rice, P. B........................ 226 Rich............................ 78 Rivers........................... 225 Rims............................ 228 Richardson...................... 406 Riger............................ 47(1 Rockwell........................ 49 Robie........................... 57 Robbins......................1^2, 239 Page. 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 Rulisou........................... 17 Rust............................ 19 Rush............................ 77 Rubach.......................... 237 Russell, J.......................-. 290 Russell, E........................ 461 Salter...............:.......73,77,468 Sanger........................117,501 Sanders___..................... 125 Sanborn.......................... 177 Sargent, G. P..................... 262 Sargent, W........<.............. 462 Sapp, Si C....................... 293 Sapp, E........................ 496 Sawtelle..............____352, 410, 461 Safford.......................... 359 Sands............................ 370 Sohell......38,112,129,182,193,226, 171 Schultz.......................... 40 Schafhirt......................... 57 Scholl............................ 187 Scovill........................... 237 Scarff........................... 174 Seyffarth.....<................33,567 Searle........................136,197 Selden........................... 543 Sheldon...........41,74, 82, 88,289,540 Sharp..........................•. 108 Shumard........................ 139 Sherman, S. N.........141,198,230,555 Sherman, A. M................... 393 Sherman, B. S.................... 515 Shurlock...................... 243,270 Sheets........................... 251 Shipman......................... 269 Shedd............................ 584 Shimer........................437, 447 Shrady.......................539, 562 Sim.........................19,54,436 Simons........................... 87 Simington......_...............100,634 Silliman........'................. 113 Skillern......................... 411 Smith, E. H....................33,129 Smith, S.B...................... 50 Smith, J. S......................50,92 Smith, E.S................,....... 54 Smith, J.R......................55,81 Smith, J.B...................... 73 Smith, G. M...................... 75 Smith, G.K....................81,618 Smith, E. A.......100,104,258,289, 356 Smith, T.F....................... 116 Smith, D. P...............125, 266, 268 Smith, J.O..................____ 201 Smith, A. G...................... 272 Smith, J. XV...................... 373 Smith, A. A...................485, 522 Smith, L. A....................... 487 Smith, T. B...................... 585 Smith, A. H...................... 631 Smith, L......................... 634 Smvser, H. S..................113,134 Smiley. .•.............133,213,271, 331 Small............................ 442 Smull...... ..................205,437 Smart............................ 509 Snow............................ 238 Spencer.....................74, 83, 552 Spalding, J. W................133, Ste Tape. Spalding, P...................... 224 Sprague.......................... 331 S()iiire....................210,407,553 Suickslager....................... 50 Stahl............................ 51 Storrow...............73, 264, 351, 522 Stearns, H. P...........79,122, 355,466 Stearnes, J. G..................98,187 Sterling.......................134, 58<) Stickney......................... 173 Stanford......................... 202 Stewart, J. L..................... 224 Stewart, P....................... 279 Stewart, W. D.................... 585 Stilwell.......................204,297 Striekler......................... 228 Stone, B......................... 233 Stone, L. R....................... 461 Stratton.......................... 236 Strickland.....................240,563 Stevens.......................... 240 Streeter.................. .•....... 278 Study....................____285, 470 Stan way___..................... 2-0 Stanchfield....................... 330 Stanton, D....................... 361 Stanton, J. O..................467,585 Stonelake........................ 5-1 Sturgis.......................... 419 Stichley.......................... 579 Suckley....................38,237, 504 Sutton........................... 88 Summers.................331,362, 499 Swift.................117,171,226,515 S warts........................... 184 Swesserott....................... 281 Sweet........................... 300 Swartzwelder..................... 477 Taylor, R. R...................... 38 Taylor, G........................ 72 Taylor, J. H................72, 88,145 Taylor, L...............72,74,115,350 Taylor, M. K..................... 218 Taylor, J. S...................... 116 Taliaferro...............50,55,105,106 Teed............................. 102 Terry............................ 198 Threlkeld.......................39,81 Thom..........................76,597 Thayer, S.W..................... 113 Thompson, J. W.................. 233 Thompson, E. A.................. 130 Thompson, J. H................... 219 Thomson........................123, 181,207,297, 351, 354, 361,392, 105, 421,436,440,444, 446, 447,460,4*7, 527,572,573, 576, 578, 579, 583, 5-9 Thorne.......................... 125 Thorn.......<................... 221 Thomas, II. L.............456,538, 540 Thomas, XV. B.................225,494 Thorpe.......................... 460 Thomain......................... 515 Titts............................ 228 Tice............................. -^:.i Todd, J..M....................209,228 Todd, CH......................420 Toward.......................370,498 Townsend........................ 540 Trull...........................79,87 Trenor, J.B...................... 102 Trenor, J........................242 TreadwelL-.:.................163,238 Tryon, A. W..................251,290 Tryon, J.R...................... 558 Trowbridge...................287,330 Treganowan...................... 506 Tutt..........................147,161 Turner.......................... 286 Turner.........................289 Udell."........................... 192 INDEX OF REPORTERS V Page. Upham, J.B..............124,184,347 Upham, G.B..................... 550 Vanderkieft.....57, 71,121, 170, 355, 432 Varian. W................114,117,559 Vanderveer....................131, 162 Vanderbull....................... 186 Van Duvn........................ 193 Van Slv'ck....................... 516 Vallc.".......................... 303 Venable.......................... 58 Vosbnr-h.............,.......... 149 VanTayen.....................567 Wardner.. ..19,41,102,108,268, 410,523 Ward, W. F....................39,13,5 Ward, S. B.....................•-. 58 Watson. A.T....... ............. 57 Watson, R. R..................... 499 Waters. E.G..................103,574 Waterman....................... 131 Wagner, F. B.................... 189 Wagner, C............267,300, 467, 588 Wacenseller...................... 191 Walker.......................... 241 Wakefield........................ 365 Walsh........................... 459 Watkins, A. P.................... 585 Webster........18, 74, 214,269, 352,555 Page. Weir.........21,142,235,299,303,355, 360,377,417,420,431,456,531,559 Wells............................ 54 Wellford.......................73,125 Weston.......................117,225 Wetmore......................232, 282 Welch........................... 458 \Y lute, J. A....................... 40 White, J.I....................... 108 White, H, B...................... 271 Whitehill......................... 174 Wheeler......................... 231 Whinery......................... 285 Whiting.......................... 351 Williams, J. W.................17,214 Williams, P...................... 174 Withers.......................... 53 Wilder, A. M...........82, 200, 201, 212 Wilder, B. G......362, 427, 445, 533,553 Wiley........................... 88 Willey........................217, 289 Willard, S. D..............134,185, '2ti^ Willard, J........................ 276 Willard, A....................... 461 Wilson, B. B..................... 123 Wilson, J. F...............193, 471, 531 Wilson, J.R...................... 239 Page. Wilson, M. W.................... 526 Wilson, Albert.................... 582 Wilcoxson........................ 288 Winants......................... 326 Winslow......................... 421 Willis............................ 462 Wirth............................ 582 Woodward, A.T.................. 53 Woodward, J.J.................. 77 Woodward, B.................... 210 Woodworth.....................77, 79 Wol verton........................ 79 Woodhull...............,.....131, 285 Wolfe............................ 214 Wood................221,233,242,275 Woods........................... 501 Woodruff......................... 366 Wright.......................... 137 Wynkoop.................138,187, 486 Wvman.......................... 231 Yates............................ 34 Yargan.......................... 97 Yandell.......................... 272 Young........................165,235 Younglove........................ 436 Zearing.......................... 527 LIST OF LITHOGRAPHS. Plate I, facing p. 4. Sabre Wounds of the Head. Three figures: Right hand, case of Butcher, p. 3; middle, case of Howard, p. 20 ; left hand, case of Rogers, p. 22. Plate II, facing p. 22. Sabre Fractures of the Vault of the Cranium; case of Strandburg, p. 22. Two figures: Left hand, external view; right hand, internal view. Plate III, facing p. 105. Gunshot Scalp Wounds and Contusions of the Skull. Four figures: Right hand, case of Wheeler, fracture of temporal bone, p. 225; upper middle, case of Beam, contusion of parietal,' p. 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. Gunshot Fractures of the Cranium. Two figures: Left hand, case of McK-----, p. 280; right hand, case of Hughes, p. 206. Plate VII, facing p. 295. Gunshot Fracture of the Cranium,—Hernia Cerebri. Two figures: Case of Kennedy, p. 294. Plate 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 Mediastinum; 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, facing p. 516. Gunshot Wound of Thorax and Abdomen,—wound healed; case of Captain S-----, p. 515. Plate XHI, facing p. 628. Metastatic Focus in the Lung ; case of S-----, p. 628. OMISSA, ERRATA, AND CORRIGENDA. VII OMISSA. Page LXXXVIII. Sept. 27, 2d column, after Arkansas, insert also called Haguetcood Station. Page 23, 32d lino, before fractures, insert cases of. Page 104, Kith line from bottom, insert after June 10th, "1864." rage 228, ;iod line, after Hook, insert and, on September 27, admitted to the hnspitiil at Frederick. Fage 232, 12th line from bottom, before 6, insert " 1." Page 386, 2."ith line, after even, insert the loss of. Page XIX, note 3, fifth line, for Chisholm, read Chisolm. I regret that this error recurs in note 2, p. XX, p. 141, and elsewhere. Page XXXIV. third line from bottom, for Falling Waters, Maryland, read Falling Waters, Virginia. Page XXXVII, Sept. 15th, for Pritchard's Mills, Virginia, read Pritchard's Mills, Maryland. Page XXXVHI. Oct. 13th. for West Glaze, read Wet Glaze. Page XLIV, April 6th and 7th, for A. M. D. Cook, read A. McD. i/eCook. Page LXXVII, May 27th, tenth column, lor W. T. Sherman, read T. W. Sherman. Page LXXX, July 1st, third column, for G. E. Meade, read G. G. Meade. Page LXXX, July 1st, tenth column, for R. B. Gurnett, read R. B. Garnett. Page LXXXVI, Sept. 1st, third column, for Cryor, read Cryer. Page CXI, June 9tb to 30th, tenth column, read Harker killed, and Daniel McCook, U. S. V., dangerously wounded. Page CXIH, fourth line from bottom, for July 21st, read June 21st Page 12, third line from bottom, for aberation, read, aberration. Page 13, thirteenth line from bottom, for Satterlie, read Satterlee. Pace 16, note *, third line, for two, read too. Page 26, note 1, fifth line, for denem, read denen. Page 23, note 1, eighteenth line, for Schadverletzungen, read Schddelver- letzungen. Page 26, note 1, thirtieth line, for Thiel, read Theil. Page 27. note 3 belongs on page 28. Page 34, note 1, ninth line, for Kopfeiletzungen, read Kopfverletzungen. Page 34, note 3, fifth line, for superciliar, read superciliary. Page 47, fourteenth line, for four following, read three following. Page 73, case of Jones, last line, for Relier, read Keller. Page 75, case of Allington, last line, for McDermot, read McDermont. Page 83, twentieth line, for morphia, read morphia. Page 84, twenty-second line from bottom, for pleural, Tea.<\pleurse. Page 87, twenty-fourth line, for, T. Simons, read J. Simons. Page 101, twenty-second line from bottom, for Aug. 12th,read September 15th. Page 103, third line, for twenty-five, read twenty-seven. Page 103, seventeenth line from bottom, for 1862, read 1863. Page 104, nineteenth line, for December 10th, read December 19th. Page 105, case of Jarvis C. Wilson, 7th line, for drown, read drawn. Page 106, tenth line, for siter, read situ. Page 109, fourth line, for transferred, read transferred. Page 113, ninth line from bottom, for Thompson, read Thayer. Page 114, thirty-first line, for J. W. Buchanan. Surgeon U. S. V., read J. W. Buckman, Surgeon 5th New Hampshire. Page 117, eighth line, for Assistant Surgeon, read Acting Assistant Surgeon. Page 141, note *, 2d line, fur Academie, read Acadimie. Page 141, note *, 10th line, for Kopferletzungen read Kopfverletzungen. Page 152, thirtieth line, for Dean, read Deans. Page 161, eighteenth line, for May 31st, read May 23d. Page 175, twenty-ninth line, for April 18th, read June 27th. Page 198, fifth line from bottom, for M. G. Sherman, read S. N. Sherman. l'age 202, case of Urch, second line, for conoidol, read conoidal. Page 202, case of Tucker, last line, for Petinus, read Pettinos. Page 205, second line from bottom, for Small, read Smull. ' Page 209, thirty-first line, for June 24th, read July 2ith. Page 216, case of Montague, last line, for Keenan, read Keenon. Page 218, case of Upham, seventh line, for specula?, read spiculse. Page 221, case of Sebers, last line, for Bown, read Bowen. Page 222, twenty-third line, for May 3lst, read August 31St. Page 227, 5th line from bottom, for Hays, read Hayes. Page 228, thiity-fifth line, for Acting A'ssistant Surgeon Helsey, read Assist- ant Surgeon Helsby. Page 232, twelfth line from bottom, for August 6th, read August 16th. Page 234, fifth line from bottom, for August 15th, read August 17th. Page 236, second case, sixth line, for June 27th, read September 27th. Page 240, twenty-second line from bottom, for impared, read impaired. Page 243, fifth line, for February 25, 1864, read February 25th, "1867." Page 244, fifth line, for Surgeon, read Assistant Surgeon. Page 252, sixteenth line, for 1865, read "1863." 83 Pago 403, 37th line, after exit, insert of. Page 472, 7th line, after duty, insert or to modified duty. Pago 547, 5th lino from bottom, after the word recorded, read and another on p. 456, in wounis and injuries of the spine. Pago 594, case 14, under column "Reference," insert Fig. 298, p. 592. Page .V)4, case 19, under column "Reference," insert Fig. 293, p. 589. Page 595, case 31, under column " Reference," insert Fig. 296, p. 590. rENDA. Page 257, eighth line, for December 13th, read December Zlst. Page 264, third line, for Starrow, read Storrow. Page 270, third line, for 1865. read "1864." Page 273, fifth line from bottom, for 1863, read "1862." Page 277, twenty-first line, for S. Y. Cantwell, read J. Y. Cantwell. Page 278, twenty-second line, for 26th, read " 20th." Page 279, seventh line, for Thomas B. Reeve, read Thomas B. Reed. Page 287. ninth line from bottom, for thirty-five, read thirty-six. Page 290, sixth line, for Foward, read Toward. Page 291, ninth line, for W. Ellsworth, read J. W. Ellsworth. Page 296, thirteenth line, for prehenson, read prehension. Page 300, twenty-first line from bottom, for 1863, read " 1861." Page 332, eighteenth line, for Surgeon, read Assistant Surgeon. Page 337, fifteenth line, for 1865, read " 1864." Page 343, note *, second line, for J. Hays, read /. I. Hayes. Page 345, twenty-ninth line, for thirty-five, read thirty-eight. Page 345, third line, for leison, read lesion. Page 345, fourth case, third line, for primative, read primitive. Page 354, last line, for Thompson, read Thomson. Page 358, thirteenth line from bottom, for auditorious, read auditorius. Page 362, sixth line, for 52d New York, read 52d Pennsylvania. Page 362, fifteenth line, for William P. Moore, read William P. Moon. Page 362, seventh line from bottom, for tramatic, read traumatic. Page 365, third case, fourth line, for Bate well, read Batwell. Page 367, ninth line from bottom, for abstract, read abstracts. Page 368, third case, second line, for lachrinal, read lachrymal. Page 378, fifth line from bottom, for six months, read six weeks. Page 383, fourth line, for 26, read "2.6." Page 398, note *, first line, for Virinerurn, read Vulnerum. Page 405, fifteenth line from bottom, for Baltimore, Maryland, read Alexan- dria, Virginia. Page 417, fourth line, for U. S. V., read P. A. C. S. Page 423, fifteenth line, for .78, read 78 per cent. Page 423, seventeenth line, for .75, read 75per cent. Page 426, sixth line, for 1863, read "1865." Page 426, twenty-fourth line, for W. Dusenbury, read H. Dusenbury. Page 432, twenty-second line from bottom, for Baltimore, Maryland, read Harper's Ferry, Virginia. Page 435, seventeenth line, for 1865, read "1864." Page 442, fourth line from bottom, for T. Kriker, read J. Kirker. Page 445, ninth line from bottom, for dorsal, read lumbar. Page 448, thirty-first line, for promply, read promptly. Page 463, twenty-second line, for Ballingal, read Ballingall. Page 473, case of Pierce, fourth line, for extrance, read entrance. Page 474, thirtieth line from bottom, for 1864, read "1862." Page 489, fifteenth line from bottom, for 101st, read 106£ft. Page 509, twenty-first line from bottom, for anditorious, read auditorius. Page 527, second line from bottom, for bony substauce, read lung substance. Page 537, fourth line from bottom, for ateriaiim, read arteriarum. Page 547 fourth line from bottom, for fifty-two read fifty-three, and, on next line, for forty-one, read'forty-two, and for 78.8, read "79.2," and, for Bilroth, read Billroth. Page 557, twenty-second line, transfer asterisk to line fifteen, after the word management. Page 570, note 4, first line, for Verhandes, read Verbandes. Page 573, case of Bivens, seventh line, for Tsa, read Ira. Page 582, second line, for lodgment, read loelgcmcnt. Page 595, case fifty-seven, for 4455, read ''56 4(1." Page 607, twenty-third line, for Bead, read Rend. Page 610, note 4, eleventh line, for cordfonn. road eordiform. Page 613, note 5, fourth line, for kave, read have. Page 613, fifth line from bottom, for 1713, read "1813." Page 614, note 1, first line, for Ferrien, read Fcrrein. Page 617, thirty-first line, for nine-four, read ninety-four. Page 629, note "4, for Wolf, read Wolfe. Page 638, twenty-fourth line, for symtoms, read symptoms. Page 645, twenty-second line, for commenced, read commended. Page 617.—In a note, it was intended to draw attention to the fact that a hernia of the lung existed in the case of Alexis St. Martin, as reported by Surgeon-General Joseph Lovell, in the American Medical Recorder, Vol. VIII, 1825, p. 14. Page 621, notes.—Socix (Kriegschirurgische Erfahrungen, Leipzig, 1872, S. 74). " T 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 have no doubt that a wound through the lung tissues may heal perprimam. I can also remember eases of shot wounds, in which the thorax was entirely perforated, where I could trace, with the greatest difficulty, the healed or to-a-narrow-fistula-contracted passage of the missile, while the pleural cavity was in a state of complete suppuration." Page 648. notes.—Klebs, E. (BeitrKge zur Pathologischen Anatomic der Schussivunden, Leipzig, 1872, note, S. 123). "I may be permitted to express my regrets, that the large material under Billroth's direction, as regard pathological anatomy, was not entrusted to a technically-educated investigator, as was done at Carlsruhe. 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 so-called chirurgical importance, a term of frequently very doubtful significance." ERRATA. Page CVI, May 5th to 7th, loth column, dele Pickett. | Page 220, 21st line, before Assistant, dele Acting. CORRIC TABLE OF CONTENTS OF VOLUME II OF PART I OF the MEDICAL AND SURGICAL HISTORY OF THE REBELLION, BEING THE FIRST SURGICAL VOLUME. Page. Prefatory, by the 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................................................................... 1 Plate I. Sabre wounds of the Head..........................................................opp. 4 Incised Fractures of the Cranium.........................■......................................... 16 Plate II. Sabre fracture of the vault of the Cranium..........................................opp. 23 Punctured wounds of the Head.................................................................... 30 Bayonet and sword thrusts through Cranium........................................................ 32 Section II. Miscellaneous Injuries of the Head................................._---■......................... 35 Railroad Accidents............................................................................... 35 Concussion of the Brain.....................„..................................................... 37 Falls producing Scalp Wounds.................................................................... 39 Contusions, Commotions, and Concussions.......................................................... 40 Compound fractures of the Cranium from Falls...................................................... 42 Contusions, lacerations, and cerebral commotion caused by Blows...................................... 43 Head injuries from falling trees.................................................................... 45 Contusions and fractures from kicks by Animals...................................................... 47 Contusions and fractures by clubs or other Blunt Weapons............................................ 47 Head injuries from unspecified Causes.............................................................. 51 Removal of fragments after Cranial Fractures........................................................ 55 Trephining, eighteen Abstracts of Cases................................................-............ 57 Analytical review of the cases in this Section........................................................ 61 Table I. Cases of Concussion and Compression of the Brain.......................................... 66 Table II. Seat of injury in one hundred and five Fractures of the Skull............................... 68 Section III. Gunshot Wounds of the Skull......................'............................................. 70 Gunshot Wounds of the Scalp..................................................................... 70 Table III. Results of seven thousand seven hundred and thirty-nine cases of Gunshot Wounds ofthe Scalp 70 Abstracts of fifty-four fatal gunshot Scalp Wounds................................................... 71 Gunshot scalp wound followed by Encephalitis...................................................... 75 Erysipelas in gunshot wounds of the Scalp....................-.................................... 77 Gangrene in gunshot wounds of the Scalp.......................................................... 79 Haemorrhage in scalp wounds, Abstracts of eleven Ligations of the Temporal and Occipital.............. 80 Tetanus following Scalp Wounds by Gunshot....................................................... 83 Pyaemia consecutive to gunshot Scalp Wounds.......................-............................... 84 Complications of gunshot Scalp Wounds by intercurrent diseases..................................... 85 Summary of cases of gunshot wounds of the Cranial Integuments...................................... 89 Table IV. Seat of injury in two thousand four hundred and ninety-three gunshot Scalp Wounds......... 90 Table V. Nature of missile in four thousand and two Scalp Wounds................................... 91 Balls lodged beneath the Cranial Integuments....................................................... 92 X TABLE OF CONTENTS. Section III—Continued. I'age. (iunshot contusions of the Cranial Bones..........................................!................ 95 lLcmorrhage and Erysipelas in this class of Wounds—ligation of Temporal........................ 1111 (iaiiLjrene and Periostitis after gunshot Contusions of the Skull.....'................................... 10-2 Exfoliations following Contusions of the Skull by Balls................................................ KCJ Plate III. Gunshot Scalp wounds and contusions of the Skull...................................opp. 105 ('aries after gunshot contusions of the Cranium...................................................... 10G Persistent pain in the head following gunshot Contusions............................................. KK! Vertigo, giddiness, and headache after gunshot contusions of the Skull................................. I(i7 Chronic Irritability 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...................................... 11 o 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 Pyaemia and Tetanus after gunshot contusion of the Skull............................................. 122 Trephining in cases of this subdivision, sixteen abstracts......................................... 123 Recapitulation 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 (1 unshot fractures of both Tables of the Cranium.................................................... 159 Linear or capillary 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 hones..................................................... 163 Balls lodged in the sinuses or diploe................................................................, 104 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 discharged 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 Avithin the Skull and unsuspected................................ 204' Perforating gunshot fractures of the Skull.......................................................... 206 Plate VI. Gunshot 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 pensioners 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 net 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 Haemorrhage, pyaemia, and other complications of such operations—ligation of Carotid.............. 2;w Trephining after gunshot fractures of the Skull...................................................... 2;>1 Abstracts of fatal cases of this class, with many illustrations...................................... ^62 Ligation of a Cerebral artery...................................................................... '^"^ Tiephining after gunsliot fractures of the Skull—abstracts of cases of recovery, with disabilities........... 2// Abstracts of fifteen cases of complete recovery.................................................... ^°° TABLE OF CONTENTS. XI Section III—Continued. Page. Trephining afte'r gunshot factures of the Skull—absti'aets of four cases of patients sent to modified duty... 286 Six patients recovering from trephining aud exchanged or furloughed.................................. 287 Abstracts of thirty-five cases of partial recovery................................................. 287 Ligation of superficial 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 fractures from gunshot (?)..............................................„e,.......... :ji)4 Summary of gunshot injuries of the 11 e;;.................... 519 Wounds of the Aorta and Cavae.................................................................... 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 eases of wounds of Internal Mammary Artery....................................... 523 Remarks by Surgeon J. 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........................................................................ 5~7 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 from wounds............................................................. 533 Incised wounds of Heart and Pathological specimens................................................ 534 " Gunshot wounds .of the Mediastinum............................................................... 535 Gunshot wounds of the Thoracic................................................................... 535 Gunshot wounds of the CEsophagus................................................................ 535 Gunshot wounds of the Nerves of the Chest.......................................................... 536 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 thousaud six hundred and seven cases of wounds and injuries of the Chest 599 Table XXV. Statement of wounds of the Chest in the field or primary hospital, 1864-65................ 600 Relative frequency of wounds of. the Chest......................................................... 601 XIV TABLK OF CONTENTS. Page. Section III—Continued. (.(1) Mortality of wounds of the Chest................................................................• " Table XXVI. Statement of eight thousand seven hundred and fifteen eases of penetrating gunshot wounds of the Chest...............................................................\---"'."."." 'J Table XXVII. Number of penetrating wounds of the Chest, with ratio of mortality, from various authorities t .1 m Complications of injuries of the Chest.............................................................. I hemorrhage in wounds of the Chest.............................................................. Emphysema following penetrating wounds of the Chest.............................................. Fractures of the bones of the Chest................................................................ ' ' Hernia of the Lung.............................................................................. Lodgement of Foreign Bodies---........ ...................................................... Traumatic Pleurisy.......................................................................... Traumatic Pneumonia..................................................................... Carditis and Pericarditis...................................................................... ~ Pneumothorax.............................................................................* Hydrothorax.................................................................................... _, „ , .............. 624 Haemothorax...........................- • -.................................... „_ -p .............................. 526 Empyema....................................................... 62g Abscesses in the Lung......................................-..................................... Plate XIII. Metastatic Abscess in Lung.......................................................°PP- ° ° Phthisical tendencies............................................................................ Thoracic Fistulae........-....................................................................... .. Collapse of the Lung.............................................................................. Contraction of the Chest........................................................................... Secondary Emphysema and Pneumothorax....................................................... Wounds of the CEsophagus, Thoracic Duct, Nerves, and Diaphragm................................... Wounds of both Lungs................................................................... Erysipelas and Gangrene.......................................................... ""......... Tetanus..................................................................".............. Diagnosis and Prognosis.......................................................................... ' _ " ................................ o35 1 romatopnoca................................................ _„„ „ . . ......................................... 636 Haemoptysis............................................. Dyspnoea... ....................................................;;;;;;:.;;;_: ■.;::.;"...7...". 638 Nervous anxiety................................................... /-.., . ___...________... — —............• o«9 Other signs................................................ Treatment............................-.............................................. Local treatment............................-.................................................... General treatment............................................................................... Index of Reporters.............................................................................. List of Lithographs...................................................... Omissa, Errata, et Coriigenda.................-.................-................................ NATIONAL LIBRARY Of MIDICINE ".' NLI1 DD0flT7T7 D