surgical notes of the war
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restored to friends, and in the course of time it died also.These two latter experiments having proved unsatisfactory,would you presume the experiment of sending children tohospital, or restoring them to friends, likely to be discon-tinued ? The same with equal force will apply to nursing.
I see both the in- and out-patients, and am fully satisfiedmore could not be done than is done, not only for the benefitof the child, but also for the welfare of the mother. In con-clusion, allow me to remark that the nursing system an-swers admirably, and that there is no real source of anxietyto the health officer, nor to anyone else who will take thetrouble to understand the nature as well as the statisticsof the Home.
I am, Sir, your obedient servant,RICHARD PARAMORE,
ilunter-street, Brnnswick-square, Sept. 13th, 1870. Medical Officer.RICHARD PARAMORE,
UTILISATION OF SEWAGE.To the Editor of THE LANCET.
SIR,-The public interest is excited on the utilisationof sewage, and I fear much that has been done will haveto be undone in consequence of the ill-health that it willgenerate in the cattle, and in man directly and indirectly,by casting either the fluid or the solid in its impure state Iupon the land, vitiating the grass, and impregnating the airwith noxious gases. One of the proper modes of treatingit is as follows :-Erect machinery in all large towns; burnthe rubbish and the solid night-soil in confined vessels, orotherwise form it into pure carbon, and purify the fluidmanure by passing it through the carbon formed by thesolid manure.
If you will kindly permit the insertion of this you willoblige an old subscriber: and I have not burdened you,fearing to take too large a space in your columns.
I remain, Sir, your obedient servant,GEORGE WASHINGTON EvANS, M.R.C.S.
Reading, Sept. 17th, 1870.GEORGE WASHINGTON EVANS, M.R.C.S.
SURGICAL NOTES OF THE WAR.(FROM OUR CORRESPONDENT AT DARMSTADT.
————— Sept. 5th, 1870.MANY appeals have been made through the medium of
the English newspapers for surgeons who are willing toproceed to the seat of war, where they are said to be muchwanted. Now I can state from personal experience that thisis not the case to anything like the extent represented. No
one ought to come out to Germany unless he has a perfectcolloquial acquaintance with the language, and even thenit is extremely doubtful if he will be required, for on theGerman side they appear to be plentifully supplied withmedical attendance. In company with three other medicalTien sent out by the Prussian Embassy in London, I wassent from Mayence to the head-quarters of the army inthe front of Metz, but only to have our services perempto-rily declined by Dr. Weber, Medical Inspector-General tothe 2nd Army, on the ground that we could not speak Ger-man fluently; and if, on returning to Mayence, we had notmet from the authorities there with more kindness and ap-preciation than we did from our professional brother at thefront, ere this we should have returned to England withouthaving had charge of a single case. As it is, we have nowbeen nearly three weeks in Germany, and are only nowgetting into harness. Seemingly we are likely to be settledhere till the termination of the war, and as perhaps itmight interest the readers of THE LANCET to have fromtime to time a short account of any interesting cases, andas in a hospital containing over two hundred gunshotwounds there are sure to be many such, I will endeavour tosupply this, and anything relating to hospital adminis-tration &c. that it may be in my power to mention.The hospitals here, which are nearly all temporary, make
tip collectively from six to seven hundred beds, but thenumber of sick and wounded at present occupying them isnot more than four hundred. A large increase may be ex-pected when those wounded in the late battles before Metzarrive. The hospital of the greatest extent is the one
situated on what are called the Orangeries, or 0 -ardens of the
Grand Duke, and this contains at present between two andthree hundred beds. It is supported and managed by thelocal Hulfs Verein, or Association for the Relief of the Sickand Wounded, of the Ladies’ Committee of which H.R.H.the Princess Alice is president ; and in her case this is notmerely an honorary position. On the ccntrary, she takesthe superintendence of all the work, visiting the hospitals-twice a day; -indeed, in activity and business-like habits sheis an example to all, and that, too, under circumstances in.which rest would be quite excusable. The writer had an op-portunity of seeing her kindness to the patients, and howmuch it was appreciated by them in a visit he made to the-hospital with her Royal Highness. To her interest are we
mainly indebted for the privilege of having under ourcharge one of the pavilions of the hospital; although infairness we must state that in this matter Herr Weber, thePresident, and other members of the Hulfs Verein, havealso met us in the most cordial manner.The buildings devoted to hospital uses are, firstly, two
old erections which answered formerly for greenhouses, al-though built mostly of stone. They are high in the roof,and great efforts have been made to provide for ventilation..Besides being at present overcrowded, they are not so wellsuited for hospital purposes as the other buildings I amabout to mention. These are pavilions, built with woodenroofs, and sides partly wood and partly canvas, and withample provision for light and ventilation. They possessthe advantages besides of containing only sixteen beds each,and of being detached and scattered through the gardens.They are seven in number, and two more are in course ofcompletion. These buildings, if they were built in a little-more substantial manner, and consequently more. suited forwinter weather, would be, to my thinking, the beau ideal ofhospital arrangement ; and already the German surgeons-notice a marked superiority in the results obtained in thesetents or barracks, as they are called, compared with those inthe permanent buildings. The offices, consisting of kitchen,,dead-house, post-mortem room, as well as the operatingtheatre, are all detached, but are well supplied with everymodern appliance ; indeed, it is astonishing to see all so wellarranged in so short a time, and is only another proof ofthe great capability of organisation and sense of methodinherent in the German mind. The medical staff has at itshead Professor Lutter, of Berne, a pupil of Langenbeck, asconsulting surgeon, and the other surgeons have each chargeof about sixteen beds, all the medical men of the towntaking their share. Prof. Lutter has several young Swis&surgeons with him. The nursing is amply provided for,great part being undertaken by the Sisters of Charity, andthe rest is under the immediate superintendence of theladies of the Hiilfs Verein. As all is done by voluntaryeffort, the great thing required is money, and that is thebest way in which assistance can be sent from Eng-land, for it can procure everything else. If any one-should feel inclined to help in that way, I hope he willnot forget the English Ward of the Orangeries Hospitalat Darmstadt.And now a word or two as to the patients. In going
round the wards one notices that the wounds are nearly allinflicted by shots from the chassepot; some few by the mi-trailleuse, but rarely indeed by the shell, those by the latterbeing usually too severe to allow of the sufferers beingbrought so far as this. Another thing is the great pre-ponderance of wounds of the extremities, especially of theright elbow and arm, arising from the shot striking whenthe soldier is in the firing position. Compound fracturesof the long bones or their extremities are very common, andin some cases they are extremely comminuted. One casewas mentioned where, in excising an elbow, it was necessaryto remove thirty-three fragments of bone. The operationsmostly required are amputations of both upper and lowerextremities, and excisions of joints ; that of the elbow verycommon indeed; that of the knee has been tried three or-four times, but does not appear to be in much favour.Then ligature of the arteries is frequently needed forwounds implicating them secondarily. Of course primarycases are treated on the field. The surgeons are extremelyconservative in their surgery, making every possible effortto save the limbs of their patients, sometimes perhapserring on that side. Carbolic acid is u-ed, but only as alotion, and not after Lister’s plan; but I hope to have anopportunity of trying it upon gunshot wounds. Pyæmia is
not unknown, and some cases of erysipelas have occurred, butit is not of a malignant form. There have been three deathsfrom tetanus, and in these Calabar bean was used; but, astwo died on the second and one on the third day, it could.not have been of much effect. In future communications Iwill endeavour to give detailed accounts of some of the cases,which I could not possibly do in such a short acquaintanceas I have yet had with the hospitals.
Sept. 14th.Since I last wrote the two buildings at the Orangeries,
one of which is intended to be used by the English depart-ment of the hospital, are rapidly approaching completion.They are built in a more substantial manner than the,others, and are accordingly better suited for the winterweather that is now coming on so rapidly. The wooden
parts of the huts are replaced, in great measure, by brick,-and the canvas by wood and glass. The roof is coveredwith waterproof felting, and provision is made for warming.by means of stoves; but the general plan of the buildingsis the same as that of the summer erections.The 240 beds which the hospital contains are not at
present fully occupied; the number of patients under treat-ment are but 170. Only thirteen new cases have beenadmitted during the last ten days ; but information has beenreceived that at any moment a large number of woundedmay arrive. In order to give an idea of the kind andamount of work done in this hospital, I will endeavour,without going into detail, to make a sketch of the opera-tions which have been performed here during the last tendays. I may state that all the patients, as is to be expected,are men in the prime of life, and that the wounds whichrendered operation necessary were received in the battleson or about the 18th August.On the 3rd September Professor Lutter amputated the
left arm of a French soldier at the shoulder-joint, for a,compound fracture of the humerus. In this case there wasa complete smash of the bone about three inches below thejoint, and there was shown no inclination to heal. Thesituation of the external wounds somewhat modified theshape of the deltoid nap, otherwise the operation wasperformed in the usual manner, if we. except-and theseremarks apply to all operations here-the extreme care
which is taken to secure all the arteries, and the greatnumber and contiguity of the sutures inserted, as well as-the tightness with which they are drawn together. This
patient, so far, is doing well.On the 6th September there were two operations, one ofthem being an amputation of the arm in a case of compoundfracture of the humerus and ulna. It was intended in thiscase to make a resection of the elbow-joint, but a favourablechance did not occur, the wound became unhealthy, and,severe hemorrhage having set in more than once, the armwas amputated, and done by the usual circular operation.Although the patient looked extremely anaemic at the timeof the operation, he has done well since. On the same dayProfessor Lutter made a resection of the left hip-joint; theinjury was a bullet-wound opening the joint and breakingthe head of the femur. Besides this wound, the patienthad two others, both, however, only on the soft parts-onein the face and the other in the right side. The operationwas performed thus: A semilunar incision of about sixinches in length was made in the gluteal region over thejoint, which was then opened and the ligamentum teresdivided ; then, by inverting the foot and bending the kneeslightly., the head of the bone was displaced sufficiently toallow a chain-saw to be passed over it, and the operationwas completed without trouble. Nothing could exceed the.neatness and dexterity with which the Professor did hiswork. There was some venous bleeding, deep in the wound,which was rather difficult to stanch, but, by plugging, thiswas effected. For some days the patient appeared to dowell, but on the llth he began to fall off, and died on the13th, seven days after the operation, of exhaustion, as veri-jied by post-mortem examination. I may here state, inpassing, that up till now, in this hospital, gunshot woundsinjuring the hip-joint or pelvic bones have all proved fatal,and these form a large part of the 6 per cent. which hasbeen so far the proportion of deaths to admissions.On the 9th September, Dr. Kellar, the director of the
Orangeries Hospital, performed resection of the elbow-joint,for a shot-wound fracturing the olecranon and opening thejoint; the single median incision was used, great care being
taken to leave all the periosteum. There was a good dealof tumefaction about the joint before the operation, but itis now doing remarkably well. Two days after the opera-tion the arm was put up in a plaster-of-Paris bandage, withan opening over the joint, and it has answered admirably.This is the form of stiff bandages used universally in Ger-many, and it has now completely supplanted splints orother appliances in the treatment of compound frac-tures, &c.
I may here mention a remarkable case of resection of the
elbow-joint, under Professor Lutter’s care, in anotherhospital in the town, the same from which, as I stated inmy last, thirty-three fragments of bone were removed. Isaw the case yesterday, and already there is reproducedbony substance in the place of the olecranon, the head ofthe radius, and the condyles of the humerus. The woundmade in the course of the operation is completely healed,and there is a good amount of motion; the arm has nothingabnormal in its appearance except an enlargement at thejoint, and it is now only four weeks since resection wasmade.On the 7th also was removed about three inches of the
left clavicle. There was a bullet wound splintering it much;but the immediate cause of the operation was profusebleeding from a wound in the subclavian vein, which hadbeen opened by a splinter of bone. Great care was taken inthis case also to preserve the periosteum. After removingthe bone and securing the bleeding point, the bullet wassearched for, and found lying in the upper and back part ofthe neck, close to the spinal column. This patient died onthe third day after the operation.On the 8th, amputation of the thigh was performed for a
bullet wound of the knee-joint. The shot entered in front,and smashed the ends of both the femur and tibia, and thejoint, as a matter of course, was completely disorganised.The circular was the method adopted, and the operationdid not present any peculiarity, if we accept an abnormalityin the femoral artery, which divided into four above theseat of operation. Four days afterwards excessive hæmor-rhage occurred from the stump, and the femoral artery wastied higher up. Since then the patient has progressedfavourably in every respect.On the 10th there was another exarticulation at the
shoulder-joint, for compound fracture of the humerus froma musket-shot, perforating the arm and dividing the boneabout four inches below the articulation. A deltoid flap wasmade, and the operation presented nothing peculiar. The
patient has since done well.From this sketch it will be seen that operative surgery
is not confined in this war to the front, and that the rushto the battle-field to see operations is a mistake. Pri-
mary operations are, of course, only to be met with there,and no doubt they are more numerous than secondary ones;but you must sacrifice what is really the most instructivepart, the after-treatment; and even so far from the seat ofwar as Darmstadt, there is enough of manual work to
satisfy the most enthusiastic devotee of active surgery.
Obituary.DR. W. D. CHOWNE.
Tnis gentleman, whose death we regret to announce, hasoccupied a more or less prominent position in the professionfor a long series of years. Dr. Chowne, we believe, was
originally in practice in Lincolnshire, but subsequentlycame to London, and was associated with Dr. Golding inthe establishment of Charing-cross Hospital, of whichinstitution he was Consulting Physician at the time of hisdecease. He formerly held the post of Lecturer on Medicineand on Obstetrics at the same institution. Dr. Chownetook a very active part in the affairs of the Medical Societyof London, and was amongst its first members, having beenPresident of the old Westminster Medical Society. Amongsthis contributions to medical science, are papers "On theMovement of Atmospheric Air in Tubes," published in theProceedings of the Royal Society for 1855 ; 11 On the Rela-tions between Elastic Force of Aqueous Vapour at ordinarytemperature, and its Motive Force in producing currents of