Title: Commentaries on the Surgery of the War - in Portugal, Spain, France, and the Netherlands
Author: Guthrie, G. J.
Language: English
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OF THE WAR ***



  COMMENTARIES
  ON THE
  SURGERY OF THE WAR

  IN PORTUGAL, SPAIN, FRANCE, AND
  THE NETHERLANDS,

  FROM THE BATTLE OF ROLIÇA, IN 1808, TO THAT OF
  WATERLOO, IN 1815;

  WITH ADDITIONS RELATING TO THOSE IN THE CRIMEA IN
  1854-1855.

  SHOWING

  THE IMPROVEMENTS MADE DURING AND SINCE THAT PERIOD IN THE
  GREAT ART AND SCIENCE OF SURGERY ON ALL THE
  SUBJECTS TO WHICH THEY RELATE.

  REVISED TO OCTOBER, 1855.

  BY G. J. GUTHRIE, F.R.S.

  SIXTH EDITION.

  PHILADELPHIA:
  J. B. LIPPINCOTT & CO.
  1862.



  TO
  The Right Honorable
  The Lord Panmure,
  SECRETARY OF STATE FOR THE WAR DEPARTMENT,
  ETC. ETC. ETC.,

  THESE COMMENTARIES
  ARE, BY PERMISSION,
  INSCRIBED,
  BY HIS LORDSHIP’S VERY OBEDIENT
  AND FAITHFUL SERVANT,

  G. J. GUTHRIE.



PREFACE TO THE FIFTH EDITION.


Twenty months have elapsed since the Introductory Lecture was published
in THE LANCET; fifteen others succeeded at intervals, and fifteen
have been printed separately to complete the number of which the
present work is composed. Divested of the historical and argumentative,
as well as of much of the illustrative part, contained in the records
whence it is derived, it nevertheless occupies 585 pages--the essential
points therein being numbered from 1 to 423.

Sir De Lacy Evans, in some observations lately made in the House of
Commons on the subject of a Professorship of Military Surgery in
London, alluded to these Lectures in the most gratifying manner;
he could not, however, state their origin, scope, or object, being
unacquainted with them.

On the termination of the war in 1814, I expressed in print my regret
that we had not had another battle in the south of France, to enable
me to decide two or three points in surgery which were doubtful. I
was called an enthusiast, and laughed at accordingly. The battle of
Waterloo afforded the desired opportunity. Sir James M’Grigor, then
first appointed Director-General, offered to place me on full pay for
six months. This would have been destructive to my prospects in London;
I therefore offered to serve for three, which he was afraid would be
called a job, although the difference between half-pay and full was
under sixty pounds; and our amicable discussion ended by my going to
Brussels and Antwerp for five weeks as an amateur. The officers in
both places received me in a manner to which I cannot do justice.
They placed themselves and their patients at my entire disposal, and
carried into effect every suggestion. The doubts on the points alluded
to were dissipated, and the principles wanting were established. Three
of the most important cases, which had never before been seen in
London nor in Paris, were sent to the York Military Hospital, then at
Chelsea. The rank I held as a Deputy Inspector-General precluded my
being employed. It was again a matter of money. I offered to do the
duty of a staff-surgeon without pay, provided two wards were assigned
to me in which the worst cases from Brussels and Antwerp might be
collected. The offer was accepted; and for two years I did this duty,
until the hospital was broken up, and the men transferred to Chatham.
In the first year a Course of Lectures on Military Surgery was given.
The inefficiency of such a Course alone was soon seen, for Surgery
admits of no such distinctions. Injuries of the head, for instance, in
warfare, usually take place on the sides and vertex; in civil life,
more frequently at the base. They implicate each other so inseparably,
although all the symptoms are not alike or always present, that they
cannot be disconnected with propriety. This equally obtains in other
parts; and my second and extended Course was recognized by the Council
of the Royal College of Surgeons as one of General Surgery.

When the Court of Examiners of the Royal College of Surgeons of
England--of which body I have been for more than twenty years a
humble member--confer their diploma after examination on a student,
they do not consider him to have done more than laid the foundation
for that knowledge which is to be afterward acquired by long and
patient observation. When a student in law is called to the bar, he
is not supposed to be therefore qualified to be a Queen’s counsel,
much less a judge or a chancellor. The young theologian, admitted
into deacon’s orders, is not supposed to be fitted for a bishopric.
When the young surgeon is sent, in the execution of his duties, to
distant climes, where he has few and sometimes no opportunities of
adding to the knowledge he had previously acquired, it is apt to be
impaired; and he may return to England, after an absence of several
years, less qualified, perhaps, than when he left it. To such persons
a course of instruction is invaluable. It should be open to them as
public servants gratuitously, and should be conveyed by a person
appointed and paid by the Crown. He should be styled, in my opinion,
the Military Professor of Surgery, and be capable, from his previous
experience and his civil opportunities, of teaching all things in the
principles and practice of surgery connected with his office, although
he may and should annually select his subjects. Leave of absence for
three months might be advantageously granted to officers in turn for
the purpose of attending these lectures, and the Professor should
certify as to their time having been well employed. For thirty years I
endeavored to render this service to the Army, the Navy, and the East
India Company, from the knowledge I had acquired of its importance.
To the Officers of these services my two hospitals, together with
Lectures and Demonstrations, were always open gratuitously, as a mark
of the estimation in which I held them. By the end of that period the
enthusiasm of the enthusiast who wished for another battle in 1814
had oozed out, like the courage of Bob Acres in “The Rivals,” at the
ends of his fingers. The course of instruction was discontinued, but
not until such parts were printed, under the title of “Records of the
Surgery of the War,” as were not before the public, in order that
teachers of civil or systematic surgery should be acquainted with them.

  4 Berkeley Street, Berkeley Square,
  June 21, 1853.



PREFACE TO THE SIXTH EDITION.


The rapid sale of the fifth, and the demand for a sixth edition of this
work, enable me to say that the precepts inculcated in it have been
fully borne out and confirmed by the practice of the Surgeons of the
Army now in the Crimea in almost every particular. To several of these
gentlemen I desire to offer my warmest thanks for the assistance they
have afforded. Their names are given with the cases and observations
they have been so good as to send me, and a fuller “Addenda” shall be
made from time to time, as I receive further information from them, and
others who will, I hope, follow the example they have thus set. More,
however, has been done; they have performed operations of the gravest
importance at my suggestion, that had not been done before, with a
judgment and ability beyond all praise; and they have modified others
to the great advantage of those who may hereafter suffer from similar
injuries. They have thus proved that if the Administrative duties of
the Medical Department of the Army have not been free from public
animadversion, that its practical and scientific duties have merited
public approbation; which I am satisfied, from what they have already
done, they will continue to deserve.

The precepts laid down are the result of the experience acquired in the
war in the Peninsula, from the first battle of Roliça in 1808, to the
last in Belgium, of Waterloo in 1815, which altered, nay overturned,
nearly all those which existed previously to that period, on all points
to which they relate. Points as essential in the Surgery of domestic as
in military life. They have been the means of saving the lives, and of
relieving, if not even of preventing, the miseries of thousands of our
fellow-creatures throughout the civilized world.

I would willingly imitate the example lately indulged in, by many
of the best Parisian surgeons, of detailing circumstantially the
improvements they have made in practical and scientific surgery;
the manner in which they were at first contested, and the universal
adoption of them which has succeeded, were it not that I might run the
risk of being accused of gratifying some personal vanity, while only
desirous of drawing the attention of the public to the merits of the
men who so ably served them in the last war, nearly all of whom are no
more; and who have passed away, as I trust their successors will not,
with scarcely a single acknowledgment of their services, except the
humble tribute now offered by their companion and friend.

  4 Berkeley Street, Berkeley Square,
  October 7, 1855.



CONTENTS.


LECTURE I.

A wound made by a musket-ball is essentially a contused wound;
sometimes bleeds; attended by shock and alarm, particularly when from
cannon-shot, or when vital parts are injured; secondary hemorrhage
rare. Entrance and exit of balls. Course of balls. Position. Treatment:
cold or iced water; no bandage to be applied; wax candles. Progress of
inflammation. Extraction of balls in flesh wounds; manner of doing it.
Dilatation; when proper. Bayonet wounds; delusion respecting them. pp.
25-39


LECTURE II.

Peculiar phlegmonous inflammation. Erysipelatous inflammation;
internal treatment. Erysipelas phlegmonodes, or diffused inflammation
of the areolar tissue; treatment by incision; first case treated
in England by incision; caution with respect to the scrotum.
Mortification--distinction into idiopathic or constitutional and that
which is local; humid and dry; traumatic. Local mortification from
intense heat or cold; wind of a ball; electricity; search for these
cases after the battle of Waterloo; case of recovery after amputation;
appearances on dissection. Mortification from injury of the great
vessels; appearance of the skin. Patient dies when the mortification
passes the knee. Points of practice; amputation to be performed below
the knee. Wound being on the thigh, amputation not to be done above the
knee when the line of separation has formed below it. Wounds of the
axillary not so dangerous as wounds of the femoral. Wounds of nerves;
complete division of, followed by the loss of sensation, motion, and
the power of resisting cold and heat. Cases of Sir James Kempt, of
Sir Philip Broke, and Brigade-Major Bissett. Treatment; external and
internal remedies. pp. 39-51


LECTURE III.

Necessity for immediate amputation when an extremity is so wounded
as to preclude all hope of saving it; degree of danger attending
amputations of the upper and lower extremities; the question us to
immediate amputation--of the arm, or leg below the knee; in the upper
half of the thigh. Constitutional alarm of shock from the injury.
Illustrative cases by Dr. Beith, Dr. Dane, etc. Advantages of primary
over secondary amputations; consequences of secondary amputations.
Purulent deposits; cases by Dr. Irwin, Mr. Rose, and Mr. Boutflower;
case of purulent deposit in the thyroid gland; Daniel Lynch’s case.
Inflammation of the veins; cases; two varieties of phlebitis--the
adhesive and irritative, or unhealthy; symptoms and treatment of
the unhealthy inflammation. The case of Private A. Clarke; of Jane
Strangemore; cases of endemic fever after secondary amputation ending
in sub acute inflammation of the lungs and effusion into the chest.
Employment of the sulphuric acid lotion in sloughing stumps. Writers on
purulent deposits: the author’s claims; opinions of Mr. Henry Lee and
Dr. Hughes Bennett. Hemorrhage in sloughing stumps, and its treatment;
ligature of the principal artery of the limb in such cases, and its
failure; hemorrhage after amputation at the shoulder-joint; sloughing
of the stump caused by the bad air of the hospital; hemorrhages from
irritable stumps not unfrequent in crowded hospitals; symptoms and
treatment. pp. 51-73


LECTURE IV.

Aphorisms for amputations; necessity for the operation; compression
of the femoral artery as it passes over the edge of the pubes; no
necessity for the tourniquet in great amputations; the hemorrhage
greater when a tourniquet is applied; use of the instrument after
amputation; old mode of performing circular amputations; nicking the
periosteum injurious; ligature of wounded vessels; bringing together
the integuments; dressing the stump; subsequent treatment. AMPUTATION
AT THE HIP-JOINT; injuries justifying the operation; case of Captain
Flack; wound of the principal artery, with fracture of the femur,
necessitates the operation; in malignant diseases of the femur, the
operation affords the only chance of success; amputation at the
hip-joint not to be done when the bone can be sawn through immediately
below the trochanter major, and there be sufficient flaps; mode of
operating; prior ligature of the femoral artery, by Baron Larrey; not
practiced in the British army; directions for operating; Professor
Langenbeck’s mode; Mr. Brownrigg’s; illustrative engravings; amputation
by the circular incision; secondary amputation; number of vessels to be
tied in primary and secondary operations; Mr. Luke’s amputation of the
thigh by the flap operation; protrusion of bone after the operation;
exfoliation from badly sawing or splitting the bone, or unduly
separating the periosteum. Bulbous enlargement of the divided nerve.
pp. 73-89


LECTURE V.

Removal of the head of the femur, dislocated in consequence of
strumous disease, or for fracture of the head or neck of the bone,
caused by an external wound; cases most favorable for the operation;
anatomical description of the operation; the operation on the dead
body; commencing for the removal of the head of the bone: completing,
by amputation of the thigh at the hip-joint, the injuries being such
as to require that operation; ligature of a great artery, close to a
large branch, successful; completing the operation for the removal
of the head of the femur; case of removal of the head of the femur;
wounds of the knee-joint from musket-balls, with fracture of the bones,
require immediate amputation; secondary amputation does not offer such
a chance of success; compound fractures of the patella without injury
to other bones; the joint involved; lodgment of the ball in the joint;
the ball penetrating the condyles of the femur; wound of the popliteal
artery; cases for amputation; clean incised wounds of the knee-joint;
case of Colonel Donnellan; excision of the knee-joint; formerly rarely
successful; Mr. Jones, of Jersey, mode of operating; Dr. Gurdon Buck’s
case of excision of the knee-joint, for anchylosis, following a gunshot
wound; Mr. Jones’s improvement of the operation; amputation of the
leg; by the circular incision; the flap operation, as performed by Mr.
Luke; amputation at the tuberosity of the tibia: removal of the head
of the fibula; excision of the ankle-joint; removal of the os calcis;
Mr. Syme’s amputation at the ankle-joint; sloughing of the under flap,
and its causes; gunshot wounds of the foot; wounds of the fore part of
the foot by cannon-shot, grape-shot, or musket-balls; amputation at the
tarsus of the foot, leaving the astragalus and os calcis; operation
for the removal of the astragalus and os calcis by Mr. Wakley, jun.;
necessary not to wound the anterior tibial artery; amputation of a
single metatarsal bone; M. de Beaufort’s artificial foot. pp. 90-120


LECTURE VI.

Primary amputation of the upper extremity rarely to be practiced for
musket-shot wounds, or for injuries of the soft parts; treatment of
slight gunshot wounds of the head of the humerus; a depending opening
for the exit of matter to be made, if not previously existing; the
principal points to attend to in such cases; simple incised wounds
of the joint; splintering of the head of the bone, or the passage of
a ball through it, requires its being sawn off; cases for amputation
of the arm; site of the operation, the head of the bone being
uninjured; complete shattering of the arm; complicated with more
or less severe injury of the chest or abdomen; if the latter not
likely to cause a speedy dissolution, then amputation of the arm is
to be performed; moderate hemorrhage or expectoration of blood, under
such circumstances, not absolutely fatal; destructive injuries from
rebounding or nearly spent round shot, or flat pieces of shell, without
external signs of a wound; necessity for an immediate operation in such
cases; amputation at the shoulder-joint; the fear of hemorrhage passed
away; compression of the subclavian; amputation at the shoulder-joint
for malignant disease of the bone and periosteum; the acromion and
coracoid processes should not be exposed, nor is it necessary to
deprive the glenoid cavity of its cartilage; the nerves to be cut
short, after the operation has been completed, else they may cause
distressing pain for life; primary amputation at the shoulder-joint
a very simple operation; secondary amputation much less so; general
directions prior to the operation; the operation by two flaps, external
and internal; by one, or nearly one, upper flap; Lisfranc’s operation;
modification of it by M. Baudens; difficulties of the secondary
amputation; amputation of the arm immediately below the tuberosities
of the humerus; excision of the head of the humerus; Langenbeck’s
operation; this excision not easy of execution when the head and neck
of the bone are broken from the shaft, nor in secondary operations:
not to be practiced in every instance of compound fracture of the
part; cases; injury of the head of the humerus, with much loss of the
soft parts; giving way of the axillary artery during the treatment
not a cause for amputation; the vessel to be tied above and below the
opening, and the subclavian not to be ligatured till all other means
have failed; amputation of the arm by the circular incision; cases
requiring this operation; Mr. Luke’s operation by two flaps; excision
of the elbow-joint; injuries of the joint not requiring this operation;
cases in which it is admissible; mode of operating; amputation at the
elbow-joint recommended, but not often performed; mode of operating;
supposed advantage attending the retention of the olecranon; amputation
of the forearm; seldom requisite; the flap operation preferable,
particularly near the wrist; mode of operating; the circular operation
in the middle of the forearm; amputation at the wrist; in all injuries
of the hand, requiring an operation, the thumb and one or more fingers
to be preserved, if possible; treatment of metacarpal bones fractured
by a musket-ball; of injured metacarpal bones, the fingers being
destroyed; removal of the heads of the metacarpal bones when necessary;
amputation of the phalanges; Langenbeck’s operation for excision of
the phalangeal joints; excision of the metacarpal bone of the thumb
by Langenbeck, the periosteum being separated from the bone, and left
behind in the wound. pp. 120-141.


LECTURE VII.

Secondary amputations not so successful after injuries as after
incurable disease; circumstances under which the operation is
performed in military surgery, and the consequences; secondary
hemorrhage; non-union of the stump; phlebitis and sloughing of the
stump; depositions of matter in the viscera; in secondary amputations
larger flaps required, or the bone to be cut shorter; directions for
sawing the bone; larger number of arteries to be tied; torsion of
arteries; bleeding from a small branch, cut short, above the ligature;
mode of avoiding this; use of the tourniquet; and its inconveniences;
in oozing of blood, the wound not to be finally closed for some
hours; treatment in cases of non-union; cat-gut or other animal
ligatures; hemorrhage from large veins to be controlled by pressure,
not by ligatures; if the bone be too long, a piece to be sawn off;
consequences of not doing so. COMPOUND FRACTURES: definition of;
comminuted; compound fracture of the arm or leg does not necessitate
amputation; of the thigh, amputation is requisite; difficulty of
treating a gunshot fracture, with extensive splintering of the bone;
consequences of the splintering; necrosis of the bone, and formation of
sequestra; case of Lieut. Timbrell, fracture of both femurs; recovery
without amputation: lodgment of a ball in, or its passage through, a
bone, without splintering; consequences; its removal requisite when
lodged in a bone; mere grazing a bone by a ball; simple transverse
fracture of a bone by a ball; flattening of a ball; its lodgment
between the broken portions of a bone; extensive shattering of the
femur, a case for immediate amputation; gunshot fractures of head
and neck of the femur; excision of the injured portions of bone-if
the upper third, or middle of the bone, amputation necessary; in
fractures of the lower third, not communicating with the knee-joint, an
attempt is to be made to save the limb; when the femur is splintered,
if the limb is to be saved, the principal splinters to be removed;
the necessary incisions often neglected; if the splinters cannot be
got at, amputation is requisite; secondary danger from the smaller
splinters; a careful examination to be made for them when suppuration
is established, and incisions made if requisite for their removal;
consequences of their retention; proper bedsteads for the wounded
should form a part of military stores; position of the patient in
gunshot fractures of the leg or thigh; splints, and their application;
gunshot wounds of the leg; limb rarely to be amputated; removal of
splinters; position of the limb; Mr. Luke’s the best apparatus for a
compound fracture of the leg; illustrated by wood-engraving; bearers
for wounded men; gunshot wounds of the arm; more probability of saving
the limb; if an artery ulcerate, it should be tied at each end; primary
amputation in such cases rare; secondary, only for mortification, or
when the strength gives way; in incisions at a late period, the nerves
and arteries to be avoided; splints for the arm. Hospital returns.
pp. 141-162


LECTURE VIII.

HOSPITAL GANGRENE: its synonyms; may be caused by the use of charpie,
instruments, bandages, etc., which have been previously employed on
infected parts; is a highly contagious and infectious disease; its
prevalence at Leyden in 1798; if the disease be mild or chronic, wounds
on the arm may continue healthy for some days after those on the leg
are infected, but not so if the gangrene be acute; Mr. Blackadder’s
description of the disease, as it occurred in his own person, from
inoculation; M. Delpech attributed its spread in the French army to the
misfortunes and sufferings of the soldiery; Dr. Tice on the attendant
depression, apathy, and despair; description of the disease in its
most virulent and less destructive forms; characteristic signs of
the disease; the question as to its constitutional or local origin;
character of the fever; opinion of the French surgeons that the disease
was of local origin; local and constitutional treatment; use of mineral
acids at Santander in 1813; Dr. Boggie on large bleedings in the
disease at Bilbao; cases of hospital gangrene, with tetanus-bleeding
curing the one, and failing in the other; Dr. Boggie on the treatment
of phagedœna, and of inflammatory gangrene, after disorganisation; the
introduction of Fowler’s solution of arsenic, as an escharotic, by Mr.
Blackadder; dangers of that practice; Dr. Walker on hospital gangrene
at Bilbao: Delpech on phagedœnic ulcer, and its treatment; attributes
the first employment of mineral acids to the British surgeons in Spain,
and especially to Mr. Guthrie; Deputy Inspector-General Taylor on
hospital gangrene in India; considers it a local disease, to be cured
by local treatment; uses nitric acid to the circumference of the ulcer;
the burning, gnawing sensation removed by the acid; dirty fungous
growths from wounds of the hands and forearm. CONCLUSIONS: Return of
the number of cases in the hospital stations in the Peninsula during
the last six months of 1813. pp. 163-175


LECTURE IX.

On wounds of arteries, and the means adopted by nature and art for
the suppression of hemorrhage; their structure; ancient three coats
separated into six-1, the epithelial; 2, fenestrated; 8, muscular;
4, elastic; 5, elastic and areolar combined; 6, areolar. Nature of
epithelium; divided into three kinds--tesselated, cylindrical, and
spheroidal. Structure of epithelial (1) and of fenestrated coat (2);
structure of muscular (3) and elastic coat (4); structure of elastic
and areolar coats (5 and 6). Chemical composition, protein. Voluntary
and involuntary muscular fibers; difference between them. Muscular
fibers in arteries involuntary. White inelastic and elastic yellow
fibers in outer coat. Blood-vessels of arteries; nerves of. Production
of cells, nuclei, and nucleoli. Cyto-blastema or formative substance.
Collateral circulation of two kinds--by direct, large, communicating
arteries, and by the capillary vessels, both being incapable of
supporting life in the lower extremity after the receipt of a sudden
injury to the main trunk in the thigh. pp. 176-187


LECTURE X.

Proper treatment of wounded arteries due to the Peninsular war;
Hunterian theory inapplicable; opposing theory of Mr. Guthrie; means
supposed to be adopted by nature for the suppression of bleeding from
large arteries from the time of Celsus to 1811 disputed; their true
nature shown; important distinction drawn between the processes adopted
with the upper and lower ends of a divided artery; cases illustrative
of the facts stated; application of a small ligature; consequent
processes; opinions formerly entertained, erroneous; internal coagulum
not absolutely necessary; artery does not always contract up to its
next collateral branch, nor is it necessary; important case in proof;
ligatures should be small, round, and strong; undue interference to be
avoided. pp. 187-208


LECTURE XI.

Appearance of the femoral artery when torn across high up; illustrative
cases. A small puncture; illustrative cases. An artery of the size of
the brachial cut to a fourth of its circumference; when completely
divided; when wounded at some depth from the surface; course to be
pursued; illustrative case. No operation to be done on a wounded artery
unless it bleed; cases: John Wilson, Don Bernardino Garcia Alvarez, and
Captain Seton. pp. 208-226


LECTURE XII.

Mortification local and dry in the first instance. Case deserving of
great attention. Amputation not always to be had recourse to in such
cases; the case of Cook demonstrative on this point. General treatment
in such cases. Wounds of the arteries of the leg. Case of H. Vigarelie
decisive of the principle and the practice to be pursued. Remarks on
the bleeding from great arteries. The surgery of the Peninsular war in
advance of the surgery of civil life. Case of suppurating aneurism of
the axillary artery; bursting after ligature of the subclavian; wounds
of the radial in the hand. pp. 226-240


LECTURE XIII.

Primitive carotid artery not to be tied for a wound of the external or
internal carotid; danger of doing it. Wounds of the vertebral artery;
illustrative cases. Opinion of Velpean. Parisian in advance of some
London surgeons. Wound of internal carotid; case by Dr. Twitchell.
Operative process described; case by Dr. Keith. pp. 241-250


LECTURE XIV.

Ligature of the common iliac artery; abdominal hernia; ligature of the
aorta; of the internal iliac artery; of the external iliac artery--two
methods; in cases of aneurism of the gluteal or sciatic artery, the
internal iliac artery should be the vessel secured--in all cases of
wounds, the wounded artery itself; Dr. Tripler’s (U. S. army) case of
wound of the gluteal artery; unsuccessful ligature of that artery,
followed by ligature of the internal iliac, and death; errors in the
treatment of this case; ligature of the femoral artery in the groin;
compression not to be made upon it when the operation is done for
aneurism; operation for popliteal aneurism; suppression of urine;
constitutional irritation after these operations; popliteal artery only
to be tied, when wounded and bleeding; case of wound of the popliteal
by a heavy mortising chisel; secondary hemorrhage; unsuccessful
ligature of the femoral; subsequent ligature of the popliteal, followed
by cure; ligature of the posterior tibial and peroneal arteries; of the
anterior tibial artery; of the plantar arteries. pp. 250-269


LECTURE XV.

Ligature of the common carotid artery: the external; the internal; the
arteria innominata; the subclavian, the axillary, the brachial, the
ulnar, the radial, and their terminations in the palm of the hand.
pp. 270-283


LECTURE XVI.

General remarks. Balls lodged in the brain. Respiration consists of
four movements. Excito-motor system of Dr. Marshall Hall. Concussion
of the brain; symptoms of first stage; of second stage. Treatment:
blood-letting in large and small quantities; mercury; blisters on the
head, between the shoulders, and on the nape of the neck; refrigerating
lotions; ice. Supervention of mania. Effects of concussion at a later
period. Relapses from irregularities. pp. 283-302


LECTURE XVII.

Compression, meaning of. Brain compressible; motions of the brain.
Symptoms of compression. Paralysis of the opposite side to the injury;
of the same side, and of both. Convulsions. Illustrative cases of
paralysis. Fissure or fracture of the skull; treatment. Symptoms in
more serious cases. Injury to the middle meningeal artery; trephine
necessary. Fractures on one side of the skull from blows on the other.
Fractures of the base from a fall on the vertex; not always fatal.
pp. 302-321


LECTURE XVIII.

Fracture of inner table without injury to the outer, of rare
occurrence. Illustrative cases. Subsequent mischief relieved by
operation at the end of two years. Peculiar division and fracture of
inner table. Principle in surgery on this point. Illustrative cases.
Trephine less dangerous at the first than at a later period. Fragments
of bone injuring the brain to be removed; propriety of division of
scalp in an adult, to examine the state of the bone beneath. Operation
dangerous; illustrative cases. Brain bears pressure best in young
persons. Symptoms of concussion are frequently accompanied by those of
compression. Contre-coup. pp. 321-340


LECTURE XIX.

Immediate and secondary tumors of the scalp. Suppuration on the
dura mater; on the brain; elevation or rising up of the dura mater,
indicating fluid beneath. Balls penetrating the brain. Sutures
separated by musket-balls. Injury of the frontal sinuses; of the orbit
and brain. Fungus, or hernia cerebri. Presumed cause of permanent
defects. Application of trephine; abuse of. Erysipelas of the scalp.
pp. 340-364


LECTURE XX.

Wounds of the chest most dangerous. Incised wounds require a treatment
essentially distinct from those made by gunshot. Contused wounds.
Auscultation of primary importance; distinctive sounds learned from
it. Symptoms of inflammation. Serous effusion the most important
evil in wounds of the chest. Respiratory murmur; pleuritic effusion.
Symptoms of pneumonia. Pulse. Difficulty of breathing; cough; sputum.
Differences of delirium. Rhoncus crepitans. Effects of inflammation
of the pleura; thickness of pleura in or after chronic inflammation.
Changes in the lung, subsequent on pneumonia, are principally three.
pp. 364-381


LECTURE XXI.

General blood-letting in pleuritis and pneumonia; local bleeding.
Internal remedies; tartar emetic; mercury; opium; blisters. Typhoid
pneumonia; treatment. Empyema or effusion of fluids into the cavity
of the chest; symptoms of. State of lung. Auscultation; operation for
empyema; place of election. Admission of air into the chest when in a
healthy state harmless; illustrative cases. Pneumothorax, nature of,
as ascertained by auscultation. Metallic tinkling; illustrative cases;
treatment. Emphysema; nature of; treatment. pp. 382-414


LECTURE XXII.

Simple injuries to the chest from sword or knife; involving the lung;
wound not to be probed; to be closed by a continuous suture; patient to
lie on the wounded side. Treatment of incised wounds of greater extent;
not to be examined by the probe or finger; absolute quietude necessary;
to relieve the oppression in breathing; to suppress hemorrhage; closure
of the wound; secretion of fluid into the cavity; necessity for a
depending opening. Illustrative cases. Ecchymosis, pathognomonic of
blood effused into the chest. Conclusions, six in number. pp. 414-425


LECTURE XXIII.

Penetrating gunshot wounds of the chest; always dangerous; statistics
of cases after Toulouse, the Three Days in Paris in 1830, and the
battles of Waterloo and the Sutlej; appearances of the orifices of
entrance and exit; symptoms; balls passing round the chest, but not
penetrating the cavity; lodging in the sternum; enlargement of the
wound sometimes necessary for the removal of foreign bodies, or of
blood; also when the wound is too small to admit the finger-end in
order to ascertain the state of the ribs, etc.; not to be greater than
absolutely requisite; pieces of shell, of a sword or lance, broken off,
and partly lodged in the thorax, or a ball sticking firmly between two
ribs; to be carefully extracted. Gunshot fracture of a rib; removal
of splinters, and of foreign bodies; case; comminuted fracture; wound
of costal cartilage; oblique gunshot wound; the ball running round
between lung and pleura for some distance; the lung sometimes only
slightly bruised, at others distinctly grooved by the ball; a ball
fairly passing through the lung; condition of the organ; symptoms;
effusion of blood; if the lung previously adherent, the cavity of the
chest not opened by the ball, its track only communicating externally;
illustrative cases of Generals Sir Lowry Cole, Sir A. Barnard, the Duke
of Richmond, Major-General Broke, Colonel Dumaresq; condition of the
track of the ball; can be detected after death, but not so during life,
as it does not cause any disturbance of the respiration after recovery
has taken place; case of Mrs. M.; wounds of the upper part of the lung
more dangerous than those of the lower; danger from effusion where the
external wound does not communicate freely with the chest; necessity
for its removal by operation; illustrative cases. pp. 426-442


LECTURE XXIV.

Appearances after death in various instances. Cases of Mr. Drummond,
etc. Splinters of bone to be removed. M. Guerin’s case, extensive
incision for the extraction of a splinter sticking in the lung. Balls,
or other foreign bodies, loose, or rolling about on the diaphragm.
Illustrative cases. Case of General Sir Robert Crawford. Consequences
of traumatic inflammation of the chest; effusion. Presence of a ball
or other foreign body rolling on the diaphragm, to be ascertained by
means of the stethoscope. M. Baudens on the encysting of balls and
splinters of bone; on the withdrawal of fluids by a syringe. Necessity
for an operation for the removal of balls, etc.; anatomy of the parts
concerned; manner in which the operation should be performed.
pp. 442-456


LECTURE XXV.

Hernia of the lung. Wounds of the diaphragm; cases of Captain Prevost
and of others; such wounds never heal; symptoms and treatment; are
often followed by hernia; operation recommended when the hernia is
strangulated. Wounds of the heart; anatomical position of the heart;
theory of the sounds of; endocardial, exocardial sounds: symptoms when
the heart is wounded; treatment; Larrey’s operation for opening the
pericardium, in cases of hemorrhage from wounds of the heart, or of
hydrops pericardii. Skielderup’s operation; case of J. Dierking, with a
diagram; the heart insensible to the touch; death from a blow on that
organ; treatment of wounds of; laceration and ruptures of the heart.
pp. 456-472


LECTURE XXVI.

Wounds of the internal mammary artery; operation proposed by M. Goyraud
for ligature of the internal mammary artery, when wounded; wounds of
the intercostal artery; suppression of hemorrhage from; case of General
Sir G. Walker. Wounds of the neck; two principles of treatment; cases
of Captain Hall and General Sir E. Packenham. Wounds of the face;
treatment. Wounds of the eyelids; treatment. Wounds of the ball of
the eye. Wounds of the nose and ear. Gunshot wounds of the eyeball.
Musket-shot lodged behind the eye; may cause ophthalmitis; loss of
sight by musket-balls passing across the back of both orbits. Wounds of
the first branch of the fifth pair of nerves. Injuries to the bones of
the face; to the bones of the nose. Wounds of the cheek; of the parotid
gland and duct. Salivary fistula. Wounds of the lachrymal bones and
sac; lachrymal fistula; case of General Sir Colin Halkett. Wounds of
the lower jaw; treatment; M. Baudens’s cases; case of Colonel Carleton;
incised and gunshot wounds of the tongue. Case of Captain Fritz;
lodgment of the iron breech of a gun in the forehead; its descent into
the mouth, and partial protrusion through the palate. Lodgment of balls
in the forehead, etc.; their descent into the throat or soft or hard
palate. Lodgment of a ball in the maxillary sinus for months and years.
pp. 473-482


LECTURE XXVII.

Structure of an intestine; eight distinct layers. Valvulæ conniventes
peculiar to man. Nature of villi: manner of absorption. Mucous membrane
of the stomach. Glands of Brunner, Grew, and Peyer. Solitary glands.
Muscular coat of the intestine. Wounds of the abdomen affecting its
wall or paries. Illustrative cases. Entrance and exit of a ball.
Lodgment of a ball in the abdominal paries. Incised wounds of the
paries followed by suppuration. Rupture of viscera from a blow. In
incised wounds the muscular parts are not reunited; formation of an
abdominal hernia; treatment. Admission of atmospheric air a bugbear.
Penetrating wounds. Protrusion of omentum; of intestine. Illustrative
cases. Treatment of wounded intestine. Large effusions of blood into
the cavity of the abdomen. Travers’s experiments on wounded intestines.
Treatment of a divided intestine; by ligature; by continuous suture.
Ramdohr’s treatment of a completely divided intestine. Manner of making
a continuous suture. pp. 482-508


LECTURE XXVIII.

Treatment of incised wounds of the intestine of small extent; when
larger; enlargement of the external wound when necessary. Intestine or
artery injured to be secured by suture; wound to be reopened. Bleeding
from the mesenteric or epigastric artery; effusion of blood into the
cavity; to be evacuated by enlarging the wound, when in quantity; if
the effusion be a small one, the blood will coagulate, and be absorbed;
suppuration in the abdomen a consequence of the non-absorption or
non-evacuation of blood effused to a large amount; illustrative cases;
treatment. Wounds of the intestines from musket-balls. Illustrative
cases of Captain Smith, Ensign Wright, Mathews, etc. Balls passed per
anum. Remarks. Cases of gunshot wounds of the abdomen occurring during
the Crimean campaign. pp. 508-525


LECTURE XXIX.

Abnormal or artificial anus; mode of formation. Valve or septum in
the orifice of the lower end of the bowel generally present, but
occasionally wanting. Treatment by compression. Desault’s mode of
treatment; Dupuytren’s; Mr. Trant’s. Wounds and injuries of the
liver. Cases of General Sir S. Barns, Corporal Macdonald, Lieutenant
Hooper, etc. Removal of portions of the liver, the patient surviving.
Illustrative cases by Blanchard, Dieffenbach, and Dr. Macpherson.
Wounds of the stomach; treatment. Fistulous opening in that viscus.
Knife swallowing; the operation of opening the abdomen and stomach
for the removal of knives which have thus passed into that organ.
Interesting cases. Wounds and injuries of the spleen; removal of the
organ entire or in part. Treatment of incised, punctured, and gunshot
wounds of the spleen. Wounds of the kidney and ureter. Illustrative
cases. Wounds of the spermatic cord and testis; case of medullary
sarcoma of the testis and lumbar glands, following a gunshot wound of
the testicle; wounds of the penis. Illustrative case. pp. 525-540


LECTURE XXX.

Wounds of the pelvis from musket-balls; fistulous opening in
consequence. Paralysis of one or of both limbs, complete or incomplete.
Balls lodging in bone should be removed: cases of Colonel Wade, Sir
Hercules Packenham, Sir John Wilson, John Bryan, Sir E. Packenham,
etc. Case by La Motte. Captain Campbell’s case. Wounds of the bladder;
consecutive accidents; employment of the catheter and its permanent
use. Treatment of inflammatory swelling and sloughing; operations when
required; illustrative cases. Cases of balls lodging and forming the
nucleus of calculi, successfully removed. Wounds of the bladder and
rectum; operation frequently required to save life. Operation in the
back for artificial anus. Conclusions. pp. 541-559


ADDENDA.

REPORTS FROM THE CRIMEA.

Use of chloroform in the Crimea; case of Martin Kennedy; amputation of
finger; death following the exhibition of chloroform. Mr. Hannan’s case
of double amputation without chloroform. Effects of chloroform in cases
of amputation at the hip-joint or at the upper third of the thigh; the
operations not successful. Deputy Inspector-General Taylor on the want
of success attending operations on the lower extremities in the Crimea,
and its causes; his opinion corroborated by Deputy Inspector-General
Alexander. Use of chloroform in the Light Division; Alexander’s
statistics of operations in the Light Division. Five cases of excision
of the head, neck, and trochanter of the femur; four unsuccessful;
the third, Mr. O’Leary’s, doing well at date of report. Staff-Surgeon
Crerar’s case; extensive comminuted fracture of neck, trochanter, and
shaft of the femur, by a fragment of an exploded grenade; excision of
head, neck, trochanter, and part of shaft of the bone; death on the
fifteenth day; P.M.:--the muscles infiltrated with pus; no attempt to
repair the loss; Dr. Hyde’s case; comminuted fracture of neck of and
bone of great trochanter by a grape-shot, during the attack on the
Great Redan, on the 8th of September; operation the day after; death
on the sixth day. Dr. M’Andrew’s cases of excision of the head of the
humerus; attended with success. Dr. Gordon’s case of fatal wound of
the larynx and pharynx, with fracture of the thyroid cartilage; Deputy
Inspector-General Taylor’s comments on this case; Surgeon De Lisle’s
cases of wounds of the profunda femoris and popliteal arteries; case
of loss of the right leg below the knee by a round shot; Dr. Burgess’s
case, showing the effects of strychnia in injury of the spine and
spinal cord. Dr. Rooke’s case of severe and extensive injury to the
right hand and forearm, and the right side of the abdomen, (the bowels
being exposed by the destruction of skin, muscles, and peritoneum,)
with comminuted fractures of the ilium and neck and trochanter of the
femur; recovery at the end of three months. Mr. Lyons’s fatal case of
gunshot fracture of the left femur. Dr. Milroy’s, Mr. Atkinson’s, and
Dr. Scott’s cases of excision of the elbow-joint; Mr. Atkinson’s case
of round shot fracture of the superior maxillary and the malar bones;
recovery. Mr. De Lisle’s case of musket-shot wound of the right temple;
the supra-orbitar ridge broken off. Mr. Ward’s, Mr. Wall’s, and Mr.
Longmore’s cases of gunshot fracture of the cranium, with or without
injury to the brain. pp. 561-586


REMARKS.

SURGICAL COMMENTARIES ON THE PRECEDING CASES: Amputations at the
hip-joint; excision of the head and neck of the femur; the balls used
by the Allies and by the Russians; gunshot fractures of the lower
extremities; the utility of the chain saw; the machines for moving
the wounded soldiers in bed; the apparatus for slinging a broken
leg; excision of the knee-joint; of the head of the humerus; of the
elbow-joint; the head of the humerus to be retained in the socket, when
practicable; wounds penetrating the chest and abdomen; future reports
for the ADDENDA desired. pp. 586-590

Index.           pp. 591-608

Index of Cases.  pp. 608-614

Medical Works    pp. 615-624



  COMMENTARIES
  ON
  SURGERY.



LECTURE I.

ON GUNSHOT WOUNDS, ETC.


1. A wound made by a musket-ball is essentially contused, and attended
by more or less pain, according to the sensibility of the sufferer,
and the manner in which he may be engaged at the moment of injury. A
musket-ball will often pass through a fleshy part, causing only the
sensation of a sudden and severe, although sometimes of a trifling
blow. If it merely strike the same part without rupturing the skin, the
pain is often great. Major King, of the Fusiliers, was killed at New
Orleans by a musket-ball, which struck him on the pit of the stomach,
leaving only the mark of a contusion.

2. Wounds from musket-balls, particularly of the face, sometimes
bleed considerably at the moment of injury, and for some little time
afterward, although no large vessel shall be injured to render the
bleeding inconvenient or dangerous. The application of a tourniquet is
then seldom if ever necessary, unless a vessel of some magnitude should
be partially torn or divided.

3. When a limb is carried away by a cannon-shot, any destructive
bleeding usually ceases with the faintness and failure of strength
subsequent on the shock, and a hemorrhage thus spontaneously suppressed
does not generally return; it is the effort of nature to save life.
The application of a tourniquet is rarely necessary, unless as a
precautionary measure, when it should be applied loosely, and the
patient, or some one else, shown how to tighten it if necessary.
A musket-ball will often pass so close to a large artery, without
injuring it, as to lead to the belief that the vessel must have receded
from the ball by its elasticity. A ball passed between the femoral
artery and vein of a soldier at Toulouse without doing more injury
than a contusion, but it gave rise to inflammation and closure of the
vessels, followed by gangrene of the extremity. General Sir Lowry
Cole was shot through the body at Salamanca, immediately below the
left clavicle; a part of the first rib came away, and the artery at
the wrist became, and remained, much diminished in size. General Sir
Edward Packenham was shot through the neck on two different occasions,
the track of each wound being apparently through the great vessels. The
first wound gave him a curve in his neck, the second made it straight.
His last unfortunate wound, at New Orleans, was directly through the
common iliac artery, and killed him on the spot. Colonel Duckworth,
of the 48th Regiment, received a ball through the edge of his leather
stock, at Albuhera, which divided the carotid artery, and killed him
almost instantaneously.

4. Secondary hemorrhage of any importance from small vessels does not
_often_ occur. On the separation of the contused parts, or sloughs, a
little blood may be occasionally lost; but it is then generally caused
by the impatience of the surgeon, or the irregularity of the patient,
and seldom requires attention.

5. A large artery does sometimes give way by ulceration between the
eighth and the twentieth days; but the proportion is not more than four
cases in a thousand, requiring the application of a ligature; exclusive
of those formidable injuries caused by broken bones, or the inordinate
sloughing caused by hospital gangrene, when not properly treated.

6. A certain constitutional alarm or shock follows every serious wound,
the continuance of which excites a suspicion of its dangerous nature,
which nothing but its subsidence, and the absence of symptoms peculiar
to the internal part presumed to be injured, should remove. The
opinion given under such circumstances should be very guarded; for if
this symptom of alarm should continue, great fears may be entertained
of hidden mischief. Colonel Sir W. Myers was shot, at Albuhera, at
the head of the Fusilier Brigade, at the moment of victory, by a
musket-ball, which broke his thigh, and lodged. The continuance of
the alarm and anxiety satisfied me it had done other mischief. He
died next morning, of mortification of the intestines. General Sir
Robert Crawford was wounded at the foot of the smaller breach at the
storming of Ciudad Rodrigo, by a musket-ball, which entered the outer
and back part of the shoulder, and came out at the axilla. There was a
third wound, a small slit in the side, apparently too small to admit
a ball. The continuance of the anxiety and alarm pointed out some
hidden mischief, which I declared had taken place; and when he died his
surgeon found the ball loose in his chest. It had been rolling about on
his diaphragm. Surgery was not sufficiently advanced in those days to
point out the situation, or to authorize an attempt for the removal of
the ball. It must in future be done.

This constitutional alarm and derangement are not always present to so
marked an extent. A soldier at Talavera was struck on the head by a
twelve-pound shot, which drove some bone into, and some brain out of
his head: he was walking about, complaining but little, immediately
after the accident, although he died subsequently.

7. It is not always possible, from their appearance, to decide which
opening is the entrance, which the exit of an ordinary sized round
ball; or when two holes are distant from each other, to ascertain
whether they have been caused by one, or by two distinct balls. When a
ball is not impinging with much impetus, it may become a penetrating,
without being much of a contused wound, which will close in and heal
with little suppuration. If the ball do not press upon, or interfere
with some important part, the slight degree of irritation which follows
may give rise to the formation of a sac, which adheres to it and
possibly keeps it quiet for years, if not for life.

8. The wound made by the entrance of an ordinary musket-ball is usually
circular, depressed, of a livid color, and capable of admitting the
little finger, the exit being more ragged, and not depressed. It is
sometimes little more than a small slit or rent, although at others, as
in the face or in the back of the hand, it may be much torn, giving to
an otherwise simple wound a more frightful appearance, such as is not
usually seen in the thigh, or other equally firm fleshy part.

9. Wounds from flattened or irregular-shaped musket-balls, pieces of
shells, or other sharp-edged destructive instruments, are often very
much lacerated, and their entrance is less marked. The part thus torn
can generally be preserved, and the wound healed with comparatively
little loss of substance.

10. When it is desirable to ascertain the exact course of a ball, and,
if possible, the internal part injured by it, the sufferer should be
placed in the position he was in when he received the injury, with
especial reference to the probable situation of the enemy, when that
will often become very intelligible which was before indistinct. My
attention was directed, after the battle of Toulouse, to a soldier,
whose foot was gangrenous without an apparent cause, he having received
merely a flesh wound in the thigh, not in the exact course of the main
artery, which, nevertheless, I said was injured. On placing the man
in the same position with regard to us, that he supposed himself to
have been in toward the enemy when wounded, the possibility of such an
injury was seen; and dissection after death proved the correctness of
the opinion.

11. When one opening only can be seen, it is presumed the ball has
lodged; but this does not follow, although the finger of the surgeon
may pass into the wound for some distance. At the battle of Vimiera, I
pulled a piece of shirt, with a ball at the bottom of it, out of the
thigh of an officer of the 40th Regiment, into which it had gone for
at least three inches. After the battle of Toulouse, a ball, which
penetrated the surface of the chest, and passed under the pectoral
muscle for two inches, was ejected by the elasticity of the rib against
which it struck. Scarcely any inconvenience followed, and the officer
rapidly recovered. After the battle of Waterloo, I was requested to
decide whether a young officer should be allowed to die in a few days,
or to have a chance for his life by losing his leg above the knee. The
joint was open, the suppuration profuse. A large or grape-shot was
supposed to be lodged in the head of the tibia. The limb was amputated,
and he is now alive, forty years afterward, but no shot was found in
his limb. It had dropped out after doing the injury.

12. The treatment of simple gunshot or flesh wounds should be, under
ordinary circumstances, as simple as themselves. Nothing should be
applied but a piece of linen or lint, wetted with cold water; this
may be retained by a strip of sticking-plaster, or any other thing
applicable for the purpose of keeping the injured part covered. A
compress of linen, or other similar substance, moistened with cold
or iced water when procurable, will be useful; and a few inches of a
linen bandage may be sewed on, to prevent the compress from changing
its position during sleep. When the wound becomes tender, a little
oil, lard, or simple ointment may be placed over it. A roller, as a
surgical application, is useless, if not injurious. At the first and
second battles in Portugal, every wound had a roller applied over it;
it soon became stiff, bloody, and dirty. They did no good, were for the
most part cut off with scissors, and thus rendered useless. When really
wanted, at a later period, they were not forthcoming. An advancing
army cannot, and ought not to carry casks full of rollers into the
field; and the apothecary-general had better have instead, two casks or
boxes full of good wax candles; for, although every regimental surgeon
ought to have four in his panniers, kept as carefully for emergencies
as his capital instruments, they will require from time to time to be
replaced. No roller should be more than two inches and a quarter wide,
and made of good, strong, coarse linen, very much, in fact, the reverse
of the rollers which have until lately been supplied to the army.

13. Cold or iced water may be used as long as cold is grateful to the
sufferer. When it ceases to be so, it should be exchanged for warm,
applied in any convenient way which modern improvements have suggested,
whether by piline, gutta-percha, oiled silk, etc. An evaporating
poultice may be used in private life, but no poultices should be
permitted in a military hospital, until the principal surgeon is
satisfied they are necessary. They are generally cloaks for negligence,
and sure precursors of amputation in all serious injuries of bones and
joints. They are properly used to alleviate pain, stiffness, swelling,
the uneasiness arising from cold, and to encourage the commencing
or impeded action of the vessels toward the formation of matter. As
soon as the effect intended has been obtained, the poultice should be
abandoned, and recourse again had to water, hot or cold, with compress
and bandage. I was in the habit of calling a poultice when misapplied a
_cover-slut_.

14. Many simple flesh wounds are cured in four weeks; the greater part
in six. Fresh air and cold water are essential. Purgatives may be
occasionally given, and abstinence is an excellent remedy. Emetics,
bleeding, and something approaching to starvation as to solids, are of
great importance if the sufferers should be irregular in their habits,
or the inflammatory symptoms run high. In weakly persons, a generous
diet with tonic remedies will be necessary.

15. In wounds of muscular parts inflammation usually occurs from twelve
to twenty-four hours after the injury, and the vicinity of the wound
becomes more sensible to the touch, with a little swelling and increase
of discoloration. A reddish serous fluid is discharged, and the limb
becomes stiff and nearly incapable of motion, from its causing an
increase of pain. These symptoms are gradually augmented on or about
the third day; the inflammation surrounding the wound is more marked;
the discharge is altered, being thicker; the action of the absorbents
on the edges of the wound may be observed; and, on the fourth or fifth,
the line of separation between the dead and living parts will be very
evident. The wound will now discharge purulent matter mixed with other
fluids, which gradually diminish as the naturally healthy actions take
place. The inside of the wound, as the process of separation proceeds,
changes from a blackish-red color to a brownish yellow, moistened by
a little good pus. On the fifth and sixth days, the outer edge of the
separating slough is distinctly marked, and begins to be displaced;
the surrounding inflammation extends to some distance, the parts
are more painful and sensible to the touch; the discharge is more
purulent, but not great in quantity. On the eighth or ninth day, the
slough is, in most cases, separated from the edges of the track of the
ball, and hanging in the mouth of the wound, although it cannot yet be
disengaged; the discharge increases, and the wound becomes less painful
to the patient, although frequently more sensible when touched.

If there be two openings, the exit of the ball, or the counter-opening,
is in general much the cleaner, being often in a fair granulating
state before the entrance of the ball is free from slough. If the
inflammation have been smart, the limb is at this time a little swollen
and discolored for some distance around; fibrin and serum are thrown
out into the cellular membrane, or areolar tissue, as it is now termed;
the redness diminishes; the sloughs are discharged, together with any
little extraneous substances which may be in the wound; and there is
frequently a slight bleeding, if the irritable granulations are roughly
treated. The limb on the twelfth, and even fifteenth day, retains the
appearance of yellowness and discoloration which ensues from a bruise,
and which continues a few days longer. The sloughs do not, sometimes,
separate until this period, and, in persons slow to action, not even
until a later one. The wound now contracts; the middle portion of the
track first closes, and is no longer pervious; the lower opening soon
heals, while the upper, or that usually made by the entrance of the
ball, continues to discharge for some time, and toward the end of six
weeks, or sometimes two months, finally heals with a depression and
cicatrix, marking distinctly the nature of the injury that has been
received.

16. The state of constitution, the difficulties and distresses of
military warfare, exposure to the inclemency of the weather, the season
of the year, or the imprudence of individuals, will sometimes bring on
a train of serious symptoms, in wounds apparently of the same nature as
others in which no such evils occur. After the first two or three days,
the symptoms gradually increase, the swelling is much augmented, the
redness extends, and the pain is more severe and constant. The wound
becomes dry, stiff, with glistening edges, the general sensibility is
increased, the system sympathizes, the skin becomes hot and dry, the
tongue loaded, the head aches, the patient is restless and uneasy,
the pulse full and quick; there is fever of the inflammatory kind.
The swelling of the part increases from deposition in the areolar
tissue to a considerable extent above and below the wound, and the
inflammation, instead of being entirely superficial or confined to
the immediate track of the ball, spreads widely. The wound itself the
sufferer can hardly bear to be touched; it discharges but little,
and the sloughs separate slowly. Pus soon begins to be secreted more
copiously, not only in the track of the wound, but in the surrounding
parts; sinuses may form in the course of the muscles, or under the
fascia, and considerable surgical treatment be necessary, while the
cure is protracted from three to four, and even to six months; and is
often attended for a longer period with lameness, from contraction of
the muscles or adhesions of the areolar tissue. The parts, from having
been so long in a state of inflammation, are much weaker, and if the
injury have been in the lower extremity, the leg and foot swell on
any exertion, which cannot be performed without pain and inconvenience
for a considerable time. The treatment should be active; the patient,
if robust, ought to be bled if no endemic disease prevail, vomited,
purged, kept in the recumbent position, and cold applied so long as
it shall be found agreeable to his feelings; when that ceases to be
the case, warm fomentations ought to be resorted to, but they are to
be abandoned the instant the inflammation is subdued and suppuration
well established. The feelings of the patient will determine the
period, and it is better to begin a day too soon than one too late.
If the inflammation be superficial, leeches will not be of the same
utility as when it is deep seated; but then they must be applied in
much greater numbers than are usually recommended. The roller and
graduated compresses, or pressure made by slips of adhesive plaster
under them, are the best means of cure in the subsequent stages, with
change of air, and friction to the whole extremity, which alone, when
early and well applied, will often save months of tedious treatment.
If the limb become contracted and the cellular membrane thickened, it
is principally by friction (shampooing) that it can be restored to its
natural motion.

17. If the ball should have penetrated without making an exit, or have
carried in with it any extraneous substances, the surgeon must, if
possible, ascertain its exact situation, and remove it and any foreign
bodies which may be lodged; indeed, if there be time, every wound
should be examined so strictly as to enable the surgeon to satisfy
himself that nothing has lodged. This is less necessary where there are
two corresponding openings evidently belonging to one shot; but it is
imperiously demanded of the surgeon, where there is one opening only,
even if that be so much lacerated as to lead to the suspicion of its
being a rent from a piece of shell; for it is by no means uncommon for
such missiles, or a grape-shot, to lodge wholly unknown to the patient,
and to be discovered by the surgeon at a subsequent period, when much
time has been lost and misery endured. A soldier during the siege of
Badajoz had the misfortune to be near a shell at the moment of its
bursting, and was so much mangled as to render it necessary to remove
one leg, an arm, and a testicle, (a part of the penis and scrotum being
lost.) In one of the flesh wounds in the back part of the thigh and
buttock a large piece of shell was lodged, and kept op considerable
irritation until it was removed. The man recovered.

18. In examining a wound, a finger should be gently introduced, if
possible, in the course of the ball, to its utmost extent; in parts
connected with life, or liable to be seriously injured, it is the only
sound usually admissible. While this examination is taking place, the
hand of the surgeon should be carefully pressed upon the part opposite
where the ball may be expected to lie, by which means it may perhaps be
brought within reach of the finger, and for want of which precaution,
it may be missed by a very trifling distance. While the finger is in
the wound the limb may be thrown as nearly as possible into that action
which was about to be performed on the receipt of the injury, when
the contraction of the muscles and the relative change of the parts
will more readily allow the course of the ball to be followed. If this
should fail, attention should be paid to the various actions of the
limb, the attendant symptoms arising from parts affected, and what may
be called the general anatomy of the whole circle of injury. A muscle,
in the act of contraction, may oppose an obstacle to the passage of an
instrument in the direction the ball has taken, especially if it should
have passed between tendons or surfaces loosely connected by cellular
membrane; as by the side of, or between the great blood-vessels, which
by their elasticity may make way for the ball, and yet impede the
progress of a sound. When the ball is ascertained to have passed beyond
the reach of the finger, a blunt silver sound or elastic bougie may be
used, and the opposite side of the limb should be carefully examined,
and pressure made on the wounded side, when it will probably be found
more or less deeply seated. If the ball should not be discoverable by
these means, the surgeon should consider every symptom, and every part
of anatomy connected with the wound, before he decides on leaving the
ball to the operations of nature.

19. It is unnecessary to dilate a wound without a precise object
in view, which might render an additional opening requisite. This
dilatation or opening, when made, should always be carried through
the fascia of the limb. A wound ought not to be dilated because such
operation may at a more distant period become necessary. The necessity
should first be seen, when the operation follows of course.

Suppose a man be brought for assistance with a wound through the
thigh, in the immediate vicinity of the femoral artery, which he says
bled considerably at the moment of injury, but the hemorrhage had
ceased. Is the surgeon warranted in cutting down upon the artery, and
putting ligatures upon it on suspicion? Every man in his senses ought
to answer, No. The surgeon should take the precaution of applying a
tourniquet loosely on the limb, and of placing the man in a situation
where he can receive constant attention in case of need; but he is not
authorized to proceed to any operation, unless another bleeding should
demonstrate the injury and the necessity for suppressing it. By the
same reasoning, incisions are not to be made into the thigh on the
speculation that they may be hereafter required. If the confusion which
has enveloped this subject be removed, and bleeding arteries, broken
bones, and the lodgment of extraneous substances be admitted to be the
only legitimate causes for dilating wounds in the first instance, the
arguments in favor of primary dilatation in other cases must fall to
the ground.

When the inflammation, pain, and fever run high, the tension of the
part being great, an incision should be made by introducing the knife
into the wound, and cutting for the space of two or three inches,
according to circumstances, in the course of the muscles, carefully
avoiding any other parts of importance. The same should be done at the
inferior or opposite opening, if mischief be seriously impending, not
so much on the principle of loosening the fascia as on that of taking
away blood from the part immediately affected, and of making a free
opening for the evacuation of the fluids about to be effused.

It is no less an advantageous practice in the subsequent stages of
gunshot wounds, where sinuses form and are tardy in healing. A free
incision is also very often serviceable when parts are unhealthy,
although there may not be any considerable sinus. Upon the necessity of
it where bones are splintered, there is no occasion in this place to
insist.

20. In making incisions for the removal of balls in the vicinity of
large vessels, particularly in the neck, the hand should always be
unsupported, in order to prevent an accident from any sudden movement
of the patient. This caution is the more necessary on the field of
battle, where many things may give rise to sudden alarm. At the affair
of Saca Parte, near Alfaiates, in Portugal, I stationed myself behind
a small watch-tower, and the wounded were first brought to this spot
for assistance. A howitzer had also been placed upon it, being rising
ground, and at the moment I was extracting a ball situated immediately
over the carotid artery, the gun was fired, to the inexpressible alarm
of surgeon, patient, and orderly, who bolted in all directions. From
my hand being unsupported, no mischief ensued, and the operation was
completed as soon as all had recovered their usual serenity. When a
ball is discovered on the opposite side of a limb, through which it
has nearly penetrated, but has not had sufficient power to overcome
the resistance and elasticity of the skin, it should be removed by
incision. An opening is thus obtained for the evacuation of any
matter which may be formed in the long track of such a wound, and
any other extraneous bodies are more readily extracted. When a ball
has penetrated half through the thick part of the thigh, in such a
direction that it cannot readily be removed by the opening at which
it entered; or, from the vicinity of the great vessels, it may be
considered unadvisable to cut for it in that direction; or if the
ball cannot be distinctly felt by the finger through the soft parts,
it ought not to be sought for at the moment, for an incision of
considerable extent will be required to enable the surgeon to extract
it. Much pain will be caused, and higher inflammation may follow than
would ensue if the wound were left to the efforts of nature alone,
by which, in time, the ball would in all probability be brought
much nearer to the surface, and might be more safely extracted. It
frequently happens, that after a few days or weeks, a ball will be
distinctly felt in a spot where the surgeon had before searched for it
in vain. A wound will frequently close without further trouble, the
ball remaining without inconvenience in its new situation; and the
patient not being annoyed by it, does not feel disposed to submit to
pain or inconvenience for its removal. A very strong reason for the
extraction of balls during the first period of treatment, if it can be
safely accomplished, is, that they do not always remain harmless, but
frequently give rise to distressing or harassing pains in or about the
part, which often oblige the sufferer to submit to their extraction at
a later period, when their removal is infinitely more difficult; and
may be more distressing than at the moment of injury.

Nothing appears more simple than to cut out a ball which can be felt
at the distance of an inch, or even half an inch below the skin, but
the young surgeon often finds it more difficult than he expected,
because he makes his incision too small; and cannot at all times oppose
sufficient resistance to prevent the ball from retreating before the
effort he makes for its expulsion with the forceps or other instrument.
The ball also requires to be cleared from the surrounding cellular
substance, to a greater extent than might at first be imagined; for
all that seems to be required is, that a simple incision be made down
to the surface of it, when it will slip out, which is not usually
the case. When a ball has been lodged for years, a membranous kind
of sac is formed around it, which shuts it in as it were from all
communication with the surrounding parts. If it should become necessary
to extract a ball which has been lodged in this manner, the membranous
sac will often be found to adhere so strongly to the ball that it
cannot be got out without great difficulty, and sometimes not without
cutting out a portion of the adhering sac.

It often occurs that a ball lodges and cannot be found, especially
where it has struck against a bone, and slanted off in a different
direction. If the ball should lodge in the cellular tissue between two
muscles, it often descends by its gravity to a considerable distance,
and excites a low degree of irritation, which slowly brings it to
the surface, or terminates in abscess. Colonel Ross, of the Rifle
Brigade, was wounded at the battle of Waterloo by a musket-ball, which
entered at the upper part of the arm and injured the bone. More than
one surgeon had pointed out the way by which it had passed under the
scapula and lodged itself in some of the muscles of the back. About
a year afterward I extracted it close to the elbow, the ball lying
at the bottom of an abscess, which was only brought near the surface
by time, by the use of flannel, and by desisting from all emollient
applications.[1]

[Footnote 1: Various instruments have been invented for the removal
of balls which have been deeply lodged in soft parts; but little
assistance has been derived from them hitherto, although many of them
are very ingenious.]

21. A ball will frequently strike a bone, and lodge, without causing
a fracture, although it will a fissure. It will even go through the
lower part of the thigh-bone, between or a little above the condyles,
merely splitting without separating it, and some balls have lodged in
bones for years, with little inconvenience. It should nevertheless be
a general rule not to allow a ball to remain in a bone, if it can be
removed by any reasonable operation. The rule is not entirely devoid of
exception. Lieutenant-Colonel Dumaresq, aid-de-camp to the present Lord
Strafford, was wounded at Waterloo by a ball which penetrated the right
scapula, and lodged in a rib in the axilla. The thoracic inflammation
nearly cost him his life, but he ultimately quite recovered, and died
many years afterward of apoplexy, the ball remaining enveloped in bone.

22. When a bayonet is thrust into the body it is a punctured wound made
by direct pressure; when of little depth, much inconvenience rarely
ensues, and the part heals slowly, but surely, under the precaution of
daily pressure. A punctured wound, extending to considerable depth,
labors under disadvantages in proportion to the smallness of the
instrument, and the differences of texture through which it passes.
When the instrument is large, the opening made is in proportion, and
does not afford so great an obstacle to the discharge of the fluids
poured out or secreted as when the opening is small. Lance wounds are
therefore less dangerous than those inflicted by the bayonet. When a
small instrument passes deep through a fascia, it makes an opening in
it which is not increased by the natural retraction of parts, inasmuch
as it is not sufficiently large to admit of it; and which opening,
small as it is, may be filled or closed up by the soft cellular tissue
below, which rises into it, and forms a barrier to the discharge of any
matter which may be secreted beneath. If the instrument should have
passed into a muscle, it is evident that if that muscle were in a state
of contraction at the moment of injury, the punctured part must be
removed to a certain distance from the direct line of the wound when in
a state of relaxation, and vice versa. The matter, secreted, and more
or less in almost every instance will be secreted, cannot in either
case make its escape, and all the symptoms occur of a spontaneous
abscess deeply seated below a fascia. That inflammation should spread
in a continuous texture is not uncommon; that matter, when confined,
should give rise to great constitutional disturbance is, if possible,
less so; but that this disturbance takes place without the occurrence
of inflammation, or the formation of matter, may be doubted; and it
may be concluded that there is no peculiarity in punctured wounds that
may not be accounted for in a satisfactory manner. Serious effects have
been attributed to injuries of nerves, but without sufficient reason;
nevertheless, those who have seen locked-jaw follow a very simple
scratch of the leg from a musket-ball, more frequently than from a
greater injury, are not surprised at any symptoms of nervous agitation
that may occur after punctured wounds. As many bayonet wounds through
muscular parts heal with little trouble, it is time enough to dilate
them when assistance seems to be required. Cold water should be used at
first; care should be taken not to apply a roller or compress of any
kind over the wound; matter, when formed, should be frequently pressed
out, and, if necessary, a free exit should be made for it.

23. A great delusion is cherished in Great Britain on the subject
of the bayonet--a sort of monomania very gratifying to the national
vanity, but not quite in accordance with matter of fact. Opposing
regiments, when formed in line, and charging with fixed bayonets, never
meet and struggle hand to hand and foot to foot, and this for the very
best possible reason, that one side turns round and runs away as soon
as the other comes close enough to do mischief; doubtless considering
that discretion is the better part of valor. Small parties of men may
have personal conflicts after an affair has been decided, or in the
subsequent scuffle if they cannot get out of the way fast enough.
The battle of Maida is usually referred to as a remarkable instance
of a bayonet fight; nevertheless, the sufferers, whether killed or
wounded, French or English, suffered from bullets, not bayonets. The
late Sir James Kempt commanded the brigade supposed to have done this
feat, but he has assured me that no charge with the bayonet took
place, the French being killed in line by the fire of musketry; a fact
which has of late received a remarkable confirmation in the published
correspondence of King Joseph Bonaparte, in which General Regnier,
writing to him on the subject, says: “The 1st and 42d Regiments charged
with the bayonet until they came within fifteen paces of the enemy,
when they turned, _et prirent la fuite_. The second line, composed of
Polish troops, had already done the same.” Wounds from bayonets were
not less rare in the Peninsular war. It may be that all those who were
bayoneted were killed, yet their bodies were seldom found. A certain
fighting regiment had the misfortune one very misty morning to have a
large number of men carried off by a charge of Polish lancers, many
being also killed. The commanding officer concluded they must be all
killed, for his men possessed exactly the same spirit as a part of the
French Imperial guard at Waterloo. “They might be killed, but they
could not by any possibility be taken prisoners.” He returned them
all dead accordingly. A few days afterward they reappeared, to the
astonishment of everybody, having been swept off by the cavalry, and
had made their escape in the retreat of the French army through the
woods. The regiment from that day obtained the ludicrous name of the
“Resurrection men.”

The siege of Sebastopol has furnished many opportunities for partial
hand to hand bayonet contests, in which many have been killed and
wounded on all sides, but I do not learn that in any engagements which
have taken place regiments advanced against each other in line and
really crossed bayonets as a body; although the individual bravery of
smaller parties was frequently manifested there, as well as in the war
in the Peninsula.



LECTURE II.

ON INFLAMMATION, MORTIFICATION, ETC.


24. In some very rare cases, an intense, deep-seated inflammation
supervenes after some days, almost suddenly and without any obvious
cause. The skin is scarcely affected, although the limb--and this
complaint has hitherto been observed only in the thigh--is swollen, and
exceedingly painful. If relief be not given, these persons die soon,
and the parts beneath the fascia lata appear after death softened,
stuffed, and gorged with blood, indicating the occurrence of an intense
degree of inflammation, only to be overcome by general blood-letting;
and especially by incisions made through the fascia from the wound,
deep into the parts, so as to relieve them by a considerable loss of
blood, and by the removal of any pressure which the fascia might cause
on the swollen parts beneath.

25. Erysipelatous inflammation is marked by a rose or yellowish
redness, tending in bad constitutions to brown or even to purple, but
in all cases terminating by a defined edge on the white surrounding
skin. It frequently spreads with great rapidity, so that the limb,
and even the whole skin of the body, may be in time affected by it,
the redness subsiding and even disappearing in one part, while it
extends in another direction. When this inflammation attacks young
and otherwise healthful persons of apparently good constitution, it
should be treated by emetics, purgatives, and diaphoretics, in the
first instance, with, perhaps, in some cases, bleeding. When the habit
of body is not supposed to be healthy, bleeding is inadmissible, and
stimulating diaphoretics, combined with camphor and ammonia, will be
found more beneficial after emetics and purgatives; these remedies may
in turn be followed by quinine and the mineral acids, with the infusion
and tincture of bark. Little reliance can be placed on large doses of
cinchona in powder; they nauseate and therefore distress.

When the inflammation extends deeper than the skin, into the areolar
or cellular tissue, it partakes more of the nature of the healthy
suppurative inflammation, commonly called phlegmonous, is accompanied
by the formation of matter, and tends to the sloughing or death of this
tissue at an early period. The redness in this case is of a brighter
color, although equally diffuse, and with a determined edge; the limb
is more swollen and tense, and soon becomes quagmiry to the touch. The
skin is then undermined, and soon loses its life, becomes ash colored
and gangrenous in spots, and separates, giving exit to the slough and
matter which now pervade the whole extremity affected. If the patient
survive, it will probably be with the loss of the whole of the skin and
the cellular substance of the limb.

As soon as the inflamed part communicates the springy, fluctuating
sensation approaching, but not yet arrived at the quagmiry feel alluded
to, an incision should be made into it, when the areolæ or cells of
the cellular tissue will be seen of a bright leaden color, and of a
gelatinous appearance, arising from the fluid secreted into them, being
now nearly in the act of being converted into pus. The septa, dividing
the tissue into cells, have not at this period lost their life, and
the fluid hardly exudes, as it will be found to do a few hours later,
when the matter deposited has become purulent. When this change has
taken place, the patient is in danger, and if relief be not given, he
will often sink under the most marked symptoms of irritative fever of
a typhoid type. Nature herself sometimes gives the required relief by
the destruction of the superincumbent skin; but this part is tough,
offers considerable resistance, and does not readily yield until the
deep-seated fascia is implicated, and the muscular parts are about to
be laid bare.

An incision made into the inflamed part through the cellular tissue,
down to the deep-seated fascia, which should not be divided in the
first instance, gives relief. One of four inches in length usually
admits of a separation of its edges to the amount of two inches, by
which the tension of the skin, which principally causes the mischief
which follows the inflammation, is removed. As many incisions are
required as will relieve this tension, according to the extent of the
inflammation, which is also relieved by the flow of blood, but that
requires attention, as it is often considerable, particularly if the
deep fascia be divided on which the larger vessels are found to lie. If
the necessary incisions be delayed until the quagmiry feeling is fully
established, the skin above it is generally undermined and dies. The
following case is given as the first known in London, in which long
incisions were made for the cure of this disease, and their effect in
relieving the constitutional irritation is so strongly marked as to
need no further explanation:--

Thomas Key, aged forty, a hard drinker, was admitted into the
Westminster Hospital, under my care, on the 21st of October, 1823,
having fallen and injured his left arm against a stool, four days
previously. On the 30th, the skin being very tense, the part springy,
and yielding the boggy feel described, pulse 120, mind wandering,
I proposed, in consultation with my colleagues, to make incisions
into the part, but which were considered to be unusual and improper.
On the 31st, the pulse being 140, and everything indicating a fatal
termination, I refrained from any further consultation, although
directed by the rules of the hospital; and, after my old Peninsular
fashion, made an incision eight inches long into the back of the arm,
and another of five on the under edge, in the line of the ulna, down to
the fascia, which was in part divided; one vessel bled freely. The next
day, November 1, the pulse was 90; the man had slept, and said he had
had a good night. The incision on the back of the arm was augmented
to eleven inches; and from that time he gradually recovered, being
snatched as it were from the jaws of death.

This case, published at the time, has been the exemplar on which this
most successful practice has been followed throughout the civilized
world--a practice entirely due to the war in the Peninsula.

When this kind of inflammation attacks the scrotum, which it sometimes,
although rarely, does, as a sporadic disease, independent of any
urinary affection, incisions into it should be made with great caution,
not extending beyond the discolored spots, in consequence of the loss
of blood which would ensue from the great vascularity of the part.
They should be confined to, and not extend beyond, the parts obviously
falling into a state of slough or of mortification.

26. Mortification is the last and most fatal result of inflammation,
although it may occur as a precursor of it in the neighboring parts,
and not as a consequence. The essential distinction is, between that
which is _idiopathic_ or _constitutional_ and that which is _local_;
and has not existed long enough to implicate the system at large, or to
become _constitutional_. Idiopathic or constitutional mortification,
sphacelus or gangrene, may be _humid_ or _dry_. _Humid_, when the death
of the part has been preceded by inflammation and a great deposition
of fluid in it, followed by putrefaction and decomposition, as after
an attack of erysipelas following an injury. It may then be said to
be acute. Dry, when preceded by little or no deposition of fluid in
it, and followed by a drying, shriveling, and hardening of the part,
nearly in its natural form and shape, unless exposed to external causes
usually leading to putrefaction. The most remarkable instances have
occurred in persons suffering from typhus fever, and exposed to cold,
without sufficient covering or care. When it occurs in old persons, or
in those who have lived on diseased rye or other food, it may be called
chronic. The gangrene which follows wounds has been termed _traumatic_,
which explains nothing but the fact of its following an injury.

_Local_ mortification may be the effect of great injury applied direct
to the part, or of an injury to the great vessels of the limb. It may
occur from intense cold freezing the part, or from intense heat burning
or destroying it.

27. It sometimes happens that a cannon-ball strikes a limb, and without
apparently doing much injury to the skin, so completely destroys the
internal textures that gangrene takes place almost without an effort
on the part of nature to prevent it. This kind of injury was formerly
attributed to the wind of a ball; but no one who has seen noses, ears,
etc. injured or carried away, and all parts of the body grazed, without
such mischief following, can believe that either the wind, or the
electricity collected by it, can produce such effect.

The patient is aware of having received a severe blow on the part
affected, which does not show much external sign of injury, the skin
being often apparently unhurt or only grazed; the power of moving the
part is lost, and it is insensible. The bone or bones may or may not
be broken, but in either case the sufferer, if the injury be in the
leg, is incapable of putting it to the ground. After a short time the
limb changes color in the same manner as when severely bruised, and the
necessary changes rapidly go on to gangrene. The limb swells, but not
to any extent, and more from extravasation between the muscles and the
bones than from inflammation, which, although it is attempted to be set
up, never attains to any height. The mortification which ensues tends
to a state between the humid and the dry, and rather more to the latter
than the former. These cases are not of frequent occurrence, and are
not commonly observed until after the blackness of the skin, and the
want of sensibility and motion attract attention; for the patient is
generally stupefied at first by the blow, and the part or parts about
the injury feel benumbed. I made these cases an object of particular
research after the battle of Waterloo, but could find only one among
the British wounded. The man stated that he had received a blow on the
back part of the leg, he believed from a cannon-shot, which brought him
to the ground, and stunned him considerably. On endeavoring to move,
he found himself incapable of stirring, and the sensibility and power
of motion in the limb were lost. The leg gradually changed to a black
color, in which state he was carried to Brussels. When I saw it, the
limb was black, apparently mortified, and cold to the touch; the skin
was not abraded; the leg was not so much swollen as in cases of humid
gangrene; the mortification had extended nearly as high as the knee;
there was no appearance of a line of separation; and the signs of
inflammation were so slight that amputation was performed immediately
above the knee. On dissecting the limb, I found that a considerable
extravasation of bloody fluid had taken place below the calf of the
leg, and in the cavity thus formed some ineffectual attempts at
suppuration had commenced. The periosteum was separated from the tibia
and fibula; the popliteal artery was, on examination, found closed
in the lower part of the ham by coagulated lymph, proceeding from a
rupture of the internal coat of the vessel. Two inches below this the
posterior tibial and fibular arteries were completely torn across, and
gave rise, in all probability, to the extravasation. The operation was
successful. The proper surgical practice in such cases is to amputate
as soon as the extent of the injury can be ascertained, in order
that a joint may not be lost, as the knee was in this instance. It
is hardly necessary to give a caution not to mistake a simple bruise
or ecchymosis for mortification. To prevent such an error leading to
amputation, Baron Larrey has directed an incision to be previously made
into the part, and to this there can be no objection.

When a large shot or other solid substance has injured a limb to
such an extent only as admits of the hope of its being possible to
save it, this hope is sometimes found to be futile, at the end of
three or four days, from a failure of power, in the part below the
injury, to maintain its life for a longer time: mortification is
obviously impending. In military warfare, uncontrollable events often
render amputation unavoidable in such a case. Under more favorable
circumstances, the surgeon should be guided by the principle laid
down of _constitutional_ and _local_ mortification; and, although the
line cannot perhaps be distinctly drawn between them at the end of
three, four, or more days, it will be better to err on the side of
amputation than of delay. If the limb should be swollen or inflamed to
any distance, with some constitutional symptoms, in a doubtful habit of
body, the termination will in general be unfavorable, whichever course
be adopted, more particularly if the amputation must be done above the
knee. The consideration of the circumstances in which the patient is
placed, his age, and habit of body, should have great weight in forming
a decision in the first instance, as to the propriety of attempting
to save the limb, which ought only to be done in persons of good
constitution and apparent strength.

28. Whenever the main artery of a limb is injured by a musket-ball,
mortification of the extremity will frequently be the result,
particularly if it be the femoral artery; it will be of certain
occurrence if both artery and vein are injured, although they may not
be either torn or divided. There may not then be such a sudden loss
of blood, in considerable quantity, as to lead to the suspicion of
the vessel being injured. The fact is known from the patient’s soon
complaining of coldness in the toes and foot, accompanied by pain,
felt especially in the back part or calf of the leg, or in the heel,
or across the instep, together with an alteration of the appearance
of the skin of the toes and instep, which, when once seen, can never
be mistaken. It assumes the color of a _tallow candle_, and soon the
appearance of _mottled soap_. Although there may be little loss of
temperature under ordinary circumstances of comfort, there is a feeling
of numbness, but it is only at a later period that the foot becomes
insensible. This change marks the extent of present mischief. The
temperature of the limb above is somewhat higher than natural, and some
slight indications of inflammatory action may be observed as high as
the ham, and the upper part of the tibia in front; it is at these parts
that the mortification usually stops when it is arrested. The general
state of the patient, during the first three or four days, is but
little affected, and there is not that appearance of countenance which
usually accompanies mortification from constitutional causes. In a day
or two more, the gangrene will frequently extend, when the limb swells,
becomes painful, and more streaked or mottled in color; the swelling
passes the knee, the thigh becomes œdematous, the patient more feverish
and anxious, then delirious, and dies.

An extreme case will best exemplify the practice to be pursued. A
soldier is wounded by a musket-ball at the upper part of the middle
third of the thigh, and on the third day the great toe has become
of a tallowy color and has lost its life. What is to be done? Wait
with the hope that the mortification will not extend. Suppose that
the approaching mortification has not been observed until it has
invaded the instep. What is to be done? Wait, provided there are no
constitutional symptoms; but if they should present themselves, or the
discoloration of the skin should appear to spread, amputation should
be performed forthwith, for such cases rarely escape with life if it
be not done. Where in such a case should the amputation be performed?
I formerly recommended that it should be done at the part injured in
the thigh. I do not now advise it to be done there at an early period,
when the foot only is implicated; but immediately below the knee, at
that part where, if mortification ever stops and the patient survives,
it is usually arrested; for the knee is by this means saved, and the
great danger attendant on an amputation at the upper third of the thigh
is avoided. The upper part of the femoral artery, if divided, rarely
offers a secondary hemorrhage. The lower part, thus deprived by the
amputation of its reflex blood, can scarcely do so; and if it should,
the bleeding may be suppressed by a compress. The blood will be dark
colored. If the upper end should bleed, the blood will be arterial, and
by jets, and the vessel must be secured by ligature.

29. When from some cause or other amputation has not been performed,
and the mortification has stopped below the knee, it is recommended
to amputate above the knee after a line of separation has formed
between the dead and the living parts. This should not be done. The
amputation should be performed in the dead parts, just below the line
of separation, in the most cautious and gentle manner possible, the
mortified parts which remain being allowed to separate by the efforts
of nature. A joint will be saved, and the patient have a much better
chance for life.

30. A wound of the axillary artery rarely leads to mortification of the
fingers or hand. If it should do so, the principle of treatment should
be similar, although the saving of the elbow is not so important as
that of the knee: neither is the amputation in the axilla, below the
tuberosities of the humerus, as dangerous as that above the knee.

31. Mortification after the sudden application of intense cold or heat
is to be treated on similar principles.

32. When a nerve or plexus of nerves conveying sensation and motion,
and going to a part, or an extremity of the body, is divided, the part
or limb is deprived of three great qualities: motion, sensation, and
the power of resisting with effect the application of a degree of heat
or of cold, which is innocuous when applied in a similar manner to the
opposite or sound extremity. In other words, it will be scalded by hot
water and frost-bitten by iced or even cold water, which are harmless
when applied to another and a healthy part.

An officer received, at the battle of Salamanca, two balls, one under
the left clavicle, which was supposed to have divided the brachial
plexus of nerves, as the arm dropped motionless and without sensation
to the side. The other ball passed through the knee-joint, which
suppurated. The left side of the chest became affected; he suffered
from severe cough, followed by hectic fever, and was evidently about
to sink. As a last chance, I amputated his leg above the knee, after
which he slowly recovered. Fourteen years afterward he showed me his
arm in the same state, and told me he had been indicted for a rape, but
that the magistrates, seeing the wooden leg and the useless arm, while
admitting the attempt, would not assent to the committal of the offence.

33. When one nerve only of several going to an extremity such as the
arm and hand, is divided, the loss sustained is confined to the extreme
part more immediately supplied by the injured nerve. Thus, if the ulnar
nerve only be divided, the little finger and the adjacent side of the
ring finger suffer, perhaps in some degree the inner side of the thumb
and the adjoining fingers; if the median nerve, the thumb and other
fingers; if the radial, the back of the hand next the thumb. In some
instances there seems to be a kind of collateral communication by which
a degree of sensibility is after a time recovered.

34. If any foreign substance should lodge in and continue to irritate
the nerve, the wounded part often becomes so extremely painful as not
to be borne; the nerve at that part forms a tumor of a most painful
character, requiring removal, or in extreme cases even the amputation
of the extremity.

35. After an ordinary amputation, the extremity of a nerve enlarges so
as to resemble a leek, and if this should adhere to the cicatrix of
the wound, painful symptoms, referred to the toes and other parts of
the removed leg, are experienced often to an almost unbearable degree;
the end of the nerve should be removed. The pain apparently felt in
and referred to the toes is merely the effect of irritation of the
extremity of the nerve.

36. Wounds or injuries of nerves, which do not entirely divide the
trunk, or a principal branch given off from a plexus of nerves,
may give rise to general as well as to local symptoms; that is, by
sympathy, connection, or continuity of disease, other nerves and organs
of the body are affected. This applies also to the spinal marrow,
when the injury does not destroy at once. General Sir James Kempt was
wounded at the storming of the castle of Badajoz, on the inside of
the left great toe, by a musket-ball which, from the appearance of
a slit-like opening, was supposed to have rebounded from the bone,
but was discovered a fortnight afterward flattened and lying between
it and the next toe. Inflammation had ensued, followed by great
irritability and numerous spasmodic attacks, appearing to render
locked-jaw probable. The spasms soon became general, extending from
the foot to the head, but tetanus did not take place. On his return to
England, they gradually subsided, but he did not sleep at night for a
year. After the battle of Waterloo the spasms became more frequent and
troublesome, attacking the muscles at the back of the neck and throat,
causing considerable anxiety. The attack was often traced to exposing
the foot to cold or to undue pressure, and frequently to derangement
of stomach, although he was most regular in diet. After the lapse of
six or seven years these severe symptoms subsided; but during the last
forty years of his life he suffered occasionally from them.

Admiral Sir Philip Broke received a cut with a sword on boarding the
Chesapeake, on the left side of the back of the head, which went
through his skull, rendering the brain visible; the wound healed in
six months, although splinters of bone came away for a year. A second
cut on the right side did not penetrate the bone. After a temporary
paralysis of the right side, he recovered, with a loss of power and a
disordered sensation in the second, third, and little fingers of the
right hand, aggravated by cold weather and by mental anxiety.

Seven years afterward, he fell from his horse, and suffered from
concussion of the brain, which added to his former sensations by
rendering the left half of his whole person incapable of resisting
cold, or of evolving heat. In a still atmosphere abroad, at 68° Fahr.,
he said, “the left side requires four coatings of stout flannel, which
are augmented as the thermometer descends every two degrees and a half,
to prevent a painful sense of cold; so that when it stands at the
freezing point the quantity of clothing of the affected side becomes
extremely burdensome. When exposed to a breeze, or even in moving
against the air, one or even two oilskin coverings are necessary in
addition, to prevent a sensation of piercing cold driving through the
whole frame. Moderate horse exercise and generous diet improved the
general health; the warm bath caused a distressing effect; the shower
bath, cold or tepid, increased the paralytic affection. Frictions,
with remedies of all kinds, increased it also, and so did sponging
with vinegar and water, as well as any violent, stimulating, quick
excitement, or earnest attention to any particular subject. The Admiral
died unrelieved, twenty-six years after the receipt of the injury, of
disease of the bladder.”

37. Brigade-Major Bissett was wounded on horseback, in the Kaffir war,
by a musket-ball, which entered on the outside of the lower part of
the left thigh, passed upward across the perineum, wounding the rectum
within the anus--from which part he lost a quantity of blood--and
came out through the pelvis on the opposite side. The course of this
ball was accounted for by the fact that he saw the Kaffir who shot
him standing some yards below him when he fired. The ball, in its
passage upward and across the thigh, injured the great sciatic nerve,
and the consequence is continued pain in the toes, instep, and foot,
with contraction of the muscles, and lameness, together with the usual
incapability of bearing heat or cold, particularly the latter, against
which he is peculiarly obliged to guard. The skin shows no sign of
discoloration or derangement. Position gives the explanation why the
ball took such a peculiar course; the symptoms show the nature of the
injury. From other effects he has perfectly recovered, but his leg is
comparatively useless, while it is a constant source of suffering.

38. The cases related in the Lectures on wounds of arteries, of
mortification taking place in the foot and leg, after the division
of the principal artery in the thigh, show that the maintenance of
the life of a part depends on the blood. The cases now related show
that neither an injury nor the division of the principal nerve, nor,
perhaps, of all the nerves going to a part, will destroy that life.
The complete failure of the circulation, in a part such as the foot,
impairs, but does not totally destroy, the sensibility imparted by
the nerves, until after the loss of life has taken place, or until
decomposition is about to occur. An injury then to the nerve causes
great pain, not usually at the part injured, but in the extreme parts
supplied by it; some loss of the power of motion; some deprivation of
its ordinary sensibility, as shown by a feeling of numbness, and an
incapability, to a certain extent, of resisting heat or cold. When all
the nerves have been divided, the power of moving the limb is lost, as
well as its sensibility in a general sense. The temperature remains at
a natural standard under ordinary circumstances, but no extra evolution
of heat can take place by which cold is resisted, nor any absorption
of it, which perhaps renders the application of a high temperature,
particularly when combined with moisture, dangerous. The circulation
is capable of maintaining the ordinary heat of a part, although it is
deprived of the influence of the special nerves of sensation and of
motion; but a greater evolution of heat appears to depend on something
communicated by the nerves in a state of integrity. In the case of Sir
P. Broke, this something appeared to be derived from the brain, on
which part the wound was inflicted, and the transmission of which was
interrupted by the injury. The evolution of animal heat has of late
been supposed to be dependent on electricity, from the resemblance
which exists between it and the nervous power, although the attempts to
identify them have not been successful. That the evolution of heat is
the result of nervous power, appears to be indisputable; in what that
power consists, physiologists have yet to ascertain.

39. The best means of mitigating the pain, independently of the
application of warmth--and cold rarely does good, as the sufferer soon
finds out--is by the application of stimulants to the whole of the
extremity affected, followed by narcotics. The tinctures of iodine and
lytta, the oleum terebinthinæ, the oleum tiglii or cajeputi, the liquor
ammoniæ or veratria, may be used in the form of an embrocation, of such
strength as to cause some irritation on the skin, short, however, of
producing any serious eruption. After the parts have been well rubbed,
opium, belladonna, or henbane may be applied in the form of ointment;
or the tincture of opium, henbane, or aconite may in turn be applied on
linen. Great advantage has been derived in many neuralgic pains from
the application of an ointment of _aconitine_, carefully prepared, in
the proportion of one grain to a drachm of lard, at which strength it
will sometimes irritate almost to vesication, as well as allay pain.

When the pains return from exposure to cold, particularly in the
lower extremity, great advantage has been derived from cupping on the
loins, from purgatives, opiates, and the warm bath. Benefit has been
obtained occasionally from quinine, and from belladonna, aconite, and
stramonium, administered internally in small doses frequently repeated,
but not suffered to accumulate without purgation; as the accumulated
effects are sometimes dangerous.



LECTURE III.

AMPUTATIONS, ETC.


40. When the wound of an extremity is of so serious a nature as to
preclude all hope of saving the limb by scientific treatment, it should
be amputated as soon as possible.

41. An amputation of the upper extremity may almost always be done from
the shoulder-joint downward, without much risk to life. When necessary,
the sooner it is done the better.

42. An amputation of any part of the lower extremity below the knee
may be done forthwith, with nearly an equal chance of freedom from
any immediate danger, as of the upper extremity at or near the
shoulder-joint.

43. It is otherwise with amputations above the middle of the thigh, and
up to the hip-joint. They are always attended with considerable danger.

44. There can be no doubt that if the knife of the surgeon could in all
cases follow the ball of the enemy or the wheel of a railway carriage,
and make a clean good stump, instead of leaving a contused and ragged
wound, it would be greatly to the advantage of the sufferer; but as
this cannot be, and an approach to it even can rarely take place,
the question naturally recurs,--At what distance of time, after the
receipt of the injury or accident, can the operation be performed most
advantageously for the patient?

45. In order to answer this question distinctly, it should be
considered with reference to distinct places of injury:--

1st. When injuries require amputation of the arm below the
shoulder-joint, or of the leg below the knee, these operations may
be done at any time from the moment of infliction until after the
expiration of twelve or twenty-four hours, without any detriment being
sustained by the sufferer with regard to his recovery; although every
one, under such circumstances, must be desirous to have the operation
over. The surgeon having several equally serious cases of injury of
the head or trunk brought to him at the same time as two requiring
amputation of the upper extremity, may defer the latter more safely
perhaps than the assistance he is also called upon to give to the other
cases, the postponement of which may be attended with greater danger.

2d. This state embraces those great injuries in which the shoulder is
carried away with some injury to the trunk; or the thigh is torn off
at or above its middle, rendering an amputation of the upper third,
or at the hip-joint, necessary. It is this or nearly this state which
alone implies a doubt as to the propriety of immediate amputation, and
demands further investigation. It is the state to which attention is
earnestly drawn for future observation.

46. It has been implied, if not actually maintained, that a man could
have his thigh carried away by a cannon-shot without being fully aware
of it, or, if aware of it, that it did not cause much alarm--in fact,
that it did not materially signify as to his apprehension, whether the
ball took off his limb or the tail of his coat, or only grazed his
breeches. An instance of this kind has not fallen under my observation.

47. A surgeon on the field of battle can rarely have a patient brought
to him, requiring amputation, under less time than from a quarter to
half an hour; a surgeon in a ship may see his patient in less than
five minutes after the receipt of the injury; and to the surgeons of
the navy we must hereafter defer for their testimony as to the absence
or presence of the constitutional alarm and shock to which I have
alluded, and to what degree they follow, immediately after the receipt
of such injury. The question must not be encumbered and mystified by
a reference to all sorts of amputations after all sorts of injuries,
but to the one especial injury, viz., that of the _upper third of the
thigh_.

48. My experience, which may be erroneous, like everything human,
has taught me, that when a thigh is torn, or nearly torn off, by a
cannon-shot, there is always more or less loss of blood, suddenly
discharged, which soon ceases in death, or in a state approaching to
syncope. When the great artery has been torn, this fainting saves life,
for an artery of the magnitude of the common femoral does not close its
canal by retracting and contracting in the same manner as a smaller
vessel; it can only diminish it; and the formation of an external
coagulum is necessary to preserve life, which the shock, alarm, and
fainting, by taking off the force of the circulation, aid in forming;
and without which the patient would bleed to death. An amputation, in
this state of extreme depression, might destroy life, although aided by
the exhibition of chloroform.

49. If the cannon-shot, or other instrument capable of crushing the
upper part of a thigh, should not divide the principal artery, and
the sufferer should not bleed, it is possible he may be somewhat in
the state alluded to in which the patient, for he may not be called
sufferer, is said to be just as composed as if he had only lost a
portion of his breeches. Nevertheless few have seen a man lose even
a piece of his skin and of his breeches by a cannon-shot, without
perceiving that he was indisputably frightened. Dr. Beith, surgeon
of the _Belleisle_, hospital ship, in the Baltic, informs me that
Mr. Wrottesley, of the Engineers, was struck by a cannon-shot, at
Bomarsund, on the upper part of his right thigh, which shattered it
and his hand, which was resting upon it. His leg was also broken by a
splinter from the gun which the ball had previously struck. The femoral
artery was not injured, and it was said he lost but little blood. He,
however, never rallied from the blow, but sank in twenty minutes after
he was brought to Dr. Beith. The constitutional shock and alarm were
great; countenance sunk and pallid, pulse scarcely perceptible.

“An East Indian, twenty-two years of age, of healthy aspect, in the
month of October, 1854, when proceeding on a shooting excursion, at
Moulmein, in Burmah, was most severely wounded by the accidental
explosion of his gun, the entire charge of large shot lodging in the
center of the left thigh, and causing a bad compound fracture, with
fearful laceration of the soft parts. I was asked to see the patient
by Dr. Reynolds, the staff-surgeon of the station, at half-past seven
A.M., an hour after the injury had been inflicted, and found him
laboring under most urgent collapse and great nervous depression. It
was of course impossible to save the limb, but I suggested delay for
some hours, and the moderate use of stimulants, till the system had
in some degree recovered its equilibrium. Such was the case at five
P.M., and the flap operation was done while the man was under the
full influence of chloroform, (three drachms being required for that
purpose.) When placed in bed, he became conscious, but never rallied,
and died in half an hour.

“Very little blood was lost during the operation, and the impression
on my mind was, that it would have been wiser to have steadily but
carefully continued the use of stimulants during the operation, and
thus have counteracted the shock of the latter following on that of the
injury, from which the system had only partially recovered.”--_Case by
Dr. Dane, Surgeon to the Forces._

Deputy Inspector-General Taylor informs me that “a young muscular man,
of the siege-train, had his left thigh nearly carried off at its middle
by a cannon-shot at Sebastopol. The soft parts on the inside, including
the artery, escaped laceration; the remaining soft parts and large
pieces of bone were entirely carried away, the injury extending above
the middle of the bone. The muscles on the fore part of the other thigh
were extensively laid bare and injured. The prostration was great;
pulse feeble; the man’s spirits were good, and he desired amputation
under chloroform. The left thigh was amputated at the upper third. The
chloroform, administered on a pocket-handkerchief, lightly folded, and
held over the nose and mouth, speedily took effect. I am under the
impression that the chloroform not only caused insensibility to pain,
but supported the system during the operation, although the man died an
hour after its completion. Nevertheless, I think the chloroform enabled
the man to bear the operation better than he would have done without
it.”

This case does not quite meet my proposition as to the effect of
chloroform when the thigh has been carried off nearer the hip-joint,
with rupture of the principal artery; cases which have hitherto been
usually lost, whether amputation is performed or not.

50. While some persons, under the loss of a thigh high up, are reduced
to a state of syncope, or nearly approaching to it, which renders them
almost or even entirely speechless, others are said to suffer extreme
pain, and earnestly entreat assistance, under which circumstances
amputation should be performed forthwith. In the former, the
administration of stimulants may render the operation less immediately
dangerous. In the latter, they will be beneficial, and may save life.

51. Chloroform, or other similar medicaments, may produce an effect in
such cases as yet unknown. Its careful administration may not destroy
the ebbing powers of life, and may render an amputation practicable,
which could not otherwise be performed without the greatest danger. It
may be otherwise; the point, however, is to be ascertained, although in
all cases of great suffering its use should be unhesitatingly adopted.

Much difference of opinion having taken place on the subject of
chloroform, I requested Dr. Snow, who has superintended its use in many
of our hospitals, and in almost all the cases of serious operation in
private life, to draw up his observations and opinions in the most
compendious form possible, which he has been so good as to do, in the
following terms:--

“Chloroform may be given with safety and advantage to every patient
who requires, and is in a condition to undergo, a surgical operation.
A state of great depression, from injury or disease, does not
contra-indicate the use of chloroform. This agent acts as a stimulant
in the first instance, increasing the strength of the pulse, and
enabling the patient, in a state of exhaustion, to go through an
operation much better than if he were conscious.

“Persons who have died from the effects of chloroform had disease of
the heart, or of some other vital organ, but the majority had a sound
state of constitution; and it seems probable that the average health
of persons who have been the subject of accident has been at least as
good as that of those who have taken chloroform without ill effects.
From these and other considerations I am of opinion that accidents from
chloroform are to be prevented by care in its administration, and not
by the selection or rejection of cases for its employment.

“When animals are made to breathe air containing not more than four
or five per cent. of the vapor of chloroform till death ensues, the
breathing ceases very gradually, being first rendered laborious and
then feeble, and the heart continues to beat for a minute or two after
respiration has ceased. During this interval, while the heart is still
beating, the animal can be easily restored by artificial respiration.
This mode of death from chloroform might undoubtedly take place in
the human subject, if a person were to go on giving it regardless of
the symptoms; but a careful examination of all the recorded cases of
death from this agent shows that it has not occurred in this manner.
On the contrary, the symptoms of danger have in every instance come on
suddenly, and the action of the heart has been arrested at the same
moment as the breathing, or even before it. This is precisely the way
in which the lower animals die when they are compelled to breathe air
containing eight or ten per cent. of the vapor of chloroform. It is
therefore evident that the cause of death is the inhalation of the
vapor of chloroform not sufficiently diluted with common air.

“It requires more chloroform to suspend the functions of the ganglionic
nerves, which preside over the contractions of the heart, than to
suspend the functions of the medulla oblongata and the nerves of
respiration; but the action of the heart may be arrested by the direct
effect of this agent. Chloroform, when inhaled, is absorbed by the
blood in the lungs, passes at once to the left cavities of the heart,
and is immediately sent through the coronary arteries to every part of
that organ, in less time, probably, than it can reach the brain; or,
supposing the respiration to be suddenly arrested by the action of the
chloroform on the brain, the vapor, not being sufficiently diluted,
is present in large quantities in the lungs at the moment when the
breathing ceases; and becoming absorbed, in addition to that which was
already in the blood, has the effect of paralyzing the heart.

“Twenty-five minims of chloroform produce only twenty-six cubic inches
of vapor, and as one hundred cubic inches of air, at 60° Fahr., will
take up fourteen cubic inches of vapor, and at 70° will take up
twenty-four cubic inches, if fully saturated, it is quite possible
that the air during inhalation may contain ten per cent. of the vapor,
if means be not taken to prevent it. Under these circumstances,
each hundred cubic inches of air would contain nearly ten minims
of chloroform, and this might be taken into the lungs at once by a
rather deep inspiration. The average quantity of chloroform present
in the blood of an adult, when sufficiently insensible for a surgical
operation, is eighteen minims, while twenty-four minims are as much as
can be present in the system at one time with safety. The absorption
of a little more than thirty minims would have the effect of causing
death, even if it were equally diffused throughout the circulation. It
must be evident, therefore, that to take ten minims of chloroform into
the lungs at one inspiration, when insensibility is almost complete,
must be attended with danger.

“Robust persons, accustomed to hard work or violent exercise, are very
apt to become affected with rigidity of the muscles and struggling,
when nearly insensible from chloroform; and they often hold the breath
for a time, and then draw a deep inspiration. It is under these
circumstances that several of the accidents from chloroform have taken
place, and extreme care is required to give the chloroform more than
usually diluted with air, when this state of unconscious struggling and
rigidity occurs.

“The most important point to attend to, in the exhibition of
chloroform, is to insure that the vapor shall be sufficiently diluted
with air during the whole process of inhalation. This may be effected
with a suitable apparatus and proper attention, or if an inhaler be
not at hand, the chloroform should be diluted with one or two parts
by measure of rectified alcohol. One or two drachms of this may be
placed on a hollow sponge, and repeated when required. The spirit
has the effect of limiting the quantity of chloroform which rises in
vapor, while very little of the diluent is inhaled, since, from its
lower volatility, the greater part of it remains on the sponge or
handkerchief employed to exhibit the chloroform.

“When the chloroform vapor is so diluted that it does not constitute
more than four or five per cent. of the respired air, its effects
become developed very gradually and regularly. The suspension of the
sensibility of the conjunctiva at the border of the eyelids is the best
sign that the patient will bear the operation without flinching, and
the inhalation should immediately be left off if the breathing become
stertorous. The pulse is not a very important guide in the exhibition
of chloroform, for the two following reasons: 1st, if the vapor be
sufficiently diluted with air, the pulse cannot be seriously affected
by it; and 2d, if it be not so diluted, the pulse may cease suddenly,
without previous warning of danger.

“If the vapor of chloroform be sufficiently diluted with air, it is
practically impossible that any accident, really due to this agent,
should occur. In case of accident, however, artificial respiration,
very promptly and efficiently performed, is the only means which
affords a prospect of restoring the patient--at all events, this is
the only means found to restore animals when it was obvious they would
not recover spontaneously. The prospect of success from artificial
respiration will depend on the greater or less extent to which the
heart is affected by the direct action of the chloroform.”

Mr. Syme, in his “Clinical Observations,” delivered in the Royal
Infirmary in Edinburgh, recommends, in cases of approaching death
from the use of chloroform, that the tongue should be drawn forward
by means of a pair of artery forceps, by which it is presumed the
epiglottis is raised, and a greater facility afforded for the admission
of atmospheric air, the inconvenience resulting from two small holes in
the tip of the tongue being amply compensated by the preservation of
life.

Nevertheless, I am of opinion that attention should be paid to the
pulse, and whenever it begins to fail or flutter, the inhalation of
chloroform should be arrested; for respiration and the pulse often
cease almost simultaneously, and in some instances have done so
irrecoverably.

I formerly said that chloroform might be used with advantage in all
cases of injury requiring amputation, save one, and in that one
experience was wanting to decide the point. It is when a thigh has
been carried off by a cannon-ball, or destroyed at its upper part by
any other means, such as the wheels of a railway carriage or other
weighty machine. When the thigh is carried off by a cannon-shot, the
artery being torn across, there is so great a shock and so great a
loss of blood at the moment, followed by fainting, or such faintness
as leads to the belief that the sufferer is dying, and some do
actually die without an effort at recovery. In such a case, or in one
somewhat similar, Dr. Snow and others think chloroform would act as a
stimulus, and that it would enable the patient to bear the operation
of amputation with success, which he otherwise might not have done. It
may be so; but, as I believe nothing in surgery until fairly tried and
found to answer, I refrain, for the present, from expressing a positive
opinion, save that the trials should be made with great caution,
inasmuch as the observations which have been made in the Crimea have
not been sufficiently numerous or so decisive as to settle the point
in favor of the chloroform, although they confirm all the others to
which allusion has been made. In these cases a tourniquet cannot be
applied, and the sudden loss of blood saves the life of the sufferer
for the time, by suppressing the bleeding; which suppression, I have
long since pointed out, is effected in the artery at the groin, by the
formation of a coagulum, and not by the contraction and retraction of
the vessel into the shape of the neck of a claret bottle, which would
take place at the lower third of the same artery in the thigh under
a similar injury; in which case, also, the bleeding would cease by
the unassisted efforts of nature. If the artery, there or elsewhere,
should, on the contrary, be only partially divided, the person would
bleed to death, unless surgery of some kind should come to his aid.

52. When the sufferer is brought to the surgeon at the end of half an
hour, having lost a limb below the thigh or shoulder by a cannon-shot,
he will often be found in a state of such great depression as to be
likely to be destroyed by the infliction of a serious and painful
operation like amputation, unless chloroform should relieve it. This
has occurred to me so often as to induce me formerly to recommend delay
for four, six, or even eight hours, if the unfortunate person did not
suffer much, and appeared likely to be revived by the proper use of
stimulants. If he should be in great pain, the limb should be removed
under chloroform.

53. This recommendation originated from the fact that, as one seriously
wounded man has as much claim as another to the attention of the
surgeon, all could not be attended to at the same time; and the
success following the deferred cases of amputation was as great, if
not greater, than in those on which the operation was more immediately
performed.

54. The advantageous results of _primary_ amputations, or those done
within the first twenty-four, or at most forty-eight hours, over
_secondary_ amputations, or those done at the end of several days, or
of three or four weeks, have been so firmly and fully established as no
longer to admit of dispute.

55. When an amputation is deferred to the secondary period, a joint is
often lost. A leg which might have been cut off below the knee in the
first instance is frequently obliged to be removed above the knee when
done in the second.

56. In the secondary period after great injuries, the areolar and
muscular textures near the part injured are often unhealthy, the
bones are in many instances inflamed internally, and their periosteal
membranes deposit on the surrounding parts so much new ossific matter
as frequently to envelop in a few days the ligatures on the vessels,
and render them immovable, necrosis of the extremity of the bone
following as a necessary consequence, thus protracting the cure for
months.

57. Sloughing of the stump, accompanied by inflammation of the vein
or veins leading to the cava, frequently takes place. This state of
stump is often followed by purulent deposits in and upon the different
viscera, and principally in the cavities of the chest. Where febrile
diseases are endemic, they often prevail; the constitutional irritation
is great; the stumps do not unite, or, if apparently united, open out
and slough, and frequently after a few days implicate the veins.

58. In the first edition of my work on Gunshot Wounds, and on the
great operations of Amputation, published in 1815, I said, alluding
to secondary operations: “In the most favorable state of the stump,
the diseased parts do not extend very deep; yet inflammation is
frequently communicated along the vein, which is found to contain
pus, even as far as the vena cava.” “When I have met with this
appearance, I have always considered the vessels as participating
in (not originating) the disease, which had existed some days, and
thereby more quickly destroying the patient.” I further said that
after secondary amputations, the febrile irritation, allayed by the
operation, sometimes returns, and more or less rapidly cuts off the
patient by an affection of some particular internal part or viscus,
especially of the lungs. “If it be the lungs, and they are most usually
affected, the breathing becomes uneasy; there is little pain when the
disease is compared with pneumonia or pleuritis; the cough is dry and
not very troublesome; the pulse having been frequent, there is but
little alteration; the attention of the surgeon is not sufficiently
drawn by the symptoms to the state of the organ, and in a very short
time all the symptoms are deteriorated: blisters are employed, perhaps
blood-letting, but generally in vain; and the patient dies in a few
hours, as in the last stage of inflammation of the lungs, in which
effusion or suppuration has taken place.” “My attention was drawn to
it after losing several cases in this way, as a circumstance of more
than common accident, from its having happened to a young officer to
whom I was paying considerable attention, (at Salamanca.) Since that I
had one well-marked case at Santander, of a sudden and fatal affection
of the lungs after amputation of the thigh, which was under the
immediate care of Dr. Irwin,” and of myself as the principal medical
officer. The late Mr. Rose, of the Guards, communicated a case, after
amputation of the arm, to Sir James M’Grigor, who forwarded it to me;
and my old friend, the late Mr. Boutflower, who served frequently
under me during the latter part of that war, and aided me in all my
labors and views, forwarded to me, at the same time, two cases from
Fuenterabia, which terminated fatally after amputation of the arm,
from the deposition of a considerable quantity of pus in the cavity of
the thorax. “So insidious,” he said, “was the approach of the disease,
that, except a difficulty of breathing which supervened a few hours
before death, there were no symptoms indicating the existence of such a
morbid affection.” No further notice was taken of this disease by any
one in any of the hospitals on entering France in 1813, neither at St.
Jean de Luz, nor Bayonne, nor Pau, St. Sever, Tarbès, or Orthez, until
after the battle of Toulouse, where the following cases occurred, which
I published previously to any one else in 1815.

A soldier suffered amputation of the thigh five weeks after the injury,
in consequence of a gunshot fracture at Toulouse, he being in a very
reduced state, the discharge profuse, the pain great, hectic fever
severe. The third day after the operation, from which he scarcely
rallied, he complained of difficulty in swallowing, and pain in the
situation of the thyroid gland, which was found next morning to be
inflamed. In spite of the means employed, he died on the fourth day of
this attack, or the seventh after the amputation, in a state of great
emaciation. On dissection, the whole substance of the thyroid gland was
destroyed, a deposit of good pus occupying its place, which descended
by the sides of the trachea and œsophagus to the sternum, and had all
but found its way into the larynx, between the cricoid and thyroid
cartilages on the right side.

Daniel Lynch, wounded through the knee-joint at the battle of
Toulouse, on the 12th of April, 1814, had his thigh amputated by
the late Mr. Boutflower, on the 8th of May. The night succeeding
the operation he passed comfortably. Next day, the 9th, the febrile
symptoms were augmented. On the 10th he was worse; pulse 150. On the
11th he was better. On the 16th he was considered to be in a state
of convalescence, and went on improving until the 22d, when fever
recurred. On the 28th his stomach became very irritable; the stump
appeared to be nearly healed, the discharge being small, and of good
quality; one ligature remained. 30th: Pulse 110; tongue of a brownish
hue. During the 31st and 1st of June he got worse, and died. The stump
appeared to have united externally, except where the ligatures came
out; but, on cutting through the line of adhesion, the muscular parts
within were evidently unhealthy; the bone was surrounded for some
distance by a case of osseous matter, including the remaining ligature,
which could not be removed by any force short of breaking it. The femur
was bare, and showed marked signs of absorption having commenced; three
inches of it must have come away if the man had lived. The extremity of
the vein was in a sloughing state.

Having dissected the other extremity for a clinical lecture I
was occasionally in the habit of giving on particular cases, a
semi-transparent membranous bag, containing good pus, was found
accidentally on the tibialis posticus muscle. The blood in the perineal
vein outside of it was coagulated; there were little or no marks of
inflammation, and the matter appeared to have been deposited without
any. The inner side of the soleus muscle seemed simply to be discolored.

The first edition, containing these facts, which were before unknown,
and which furnish another laurel to the surgery of the Peninsular war,
having been published before the battle of Waterloo, the opinions
and facts stated therein became matters for public discussion, and
the reports made by my friends from Brussels, Antwerp, Yarmouth, and
Colchester, confirmed all the facts, and, I may add, all the opinions
of the slightest importance. They were published in the second edition
in 1820, and again more pointedly in the third, published June 18, 1827.

59. Forty years have passed away since I stated my opinion, that
inflammation of the veins is of two kinds--the adhesive or healthy,
from which the sufferers usually recover, as in the cases of women
laboring under the disease called phlegmasia dolens, and the
irritating or unhealthy, occurring after operations; the disease being
communicated by continuity to the vein, rather perhaps than originating
in it. I then said I did not believe that pus is carried from the
inside of the vein to the general circulation, the office of the vein
as a carrier of blood ceasing on the inflammation taking place in
its internal tissue, although I admit that the blood in a vitiated
state, from the commencing disease in the stump, or in the system, may
have for some time passed along it into the general circulation. The
inflammation thus commencing may extend upward and downward, and across
to the opposite side of the body, as I first demonstrated in 1825, in
the case of Jane Strangemore, p. 47. I never saw it actually in the
heart, the sufferers dying by the time it had reached as high as the
diaphragm, and in general before it had got so far.

60. When a person, after undergoing amputation, is about to suffer
from unhealthy inflammation of the veins, the pulse quickens, and
continues above 90, usually rising from 100 to 130. The stomach
becomes irritable; there are frequent attacks of vomiting, generally
of a bilious character, accompanied by the usual symptoms of fever. A
few days after the commencement of the complaint, there is usually a
well-marked rigor, followed perhaps by others, but exacerbations and
remissions of fever are common. The skin gradually assumes a yellowish
tinge, the perspiration is excessive, the bowels irregular, the pulse
becomes weaker and more irritable, the emaciation is considerable, and
the patient gradually sinks; or the febrile symptoms may subside, with
the exception of the frequency of the pulse, the patient rallies a
little, but while he says he is better, and the appetite even returns,
the deterioration in appearance becomes more marked, more deathlike,
even while eating, and an accession of fever rapidly closes the scene.
The stump is often not more painful than under ordinary circumstances,
neither is there any remarkable pain or tenderness in the course of the
vessels.

61. The practical points are, to draw blood with caution, on the
_accession_ of fever, provided a remittent or typhoid form does not
prevail; to open out the stump as soon as possible, even by a division
of the external adhesions, the inner parts being usually unsound; to
envelop it in a large warm poultice; to apply cold above, even ice if
procurable, in the course of the great vessels, and to soothe the
system by calomel, opium, and saline diaphoretic remedies, followed by
stimulants, cordials, quinine, and acids.

Private A. Clarke, 79th Regiment, had his thigh broken by a musket-ball
a little above the knee-joint, at Waterloo, and was admitted into the
clinical ward of the York Hospital, in London, in November, 1816. The
bone being in a state of necrosis, Mr. Guthrie amputated the thigh high
up, on the 20th of January, 1817. Pulse before and after the operation
104. On the 25th, pulse 120; skin cool; tongue moist; appeared weak
and irritable. During the 26th and 27th, symptoms of low fever came
on. 28th, suffered severely from vomiting, general fever, greater
prostration of strength; stump had not united, but discharged good pus.
30th, skin assumed a yellow tinge.

On the 1st of February, had a rigor resembling a fit of ague, and Mr.
Guthrie declared his suspicion of the formation of matter, probably in
the liver, and of inflammation of the veins of the stump. The symptoms
gradually assumed the character of typhus gravior, and on the 8th he
died. On dissection the liver was found enlarged, and weighing six
pounds; the other viscera were sound. On examining the stump an abscess
containing four ounces of good pus was found in the under part, near
the bone. The femoral vein and those going to that part of the stump
were inflamed, and contained coagulated blood, lymph, and purulent
matter, the disease extending from the femoral to the vena cava. The
rigors on the 1st February marked the formation of matter, the typhoid
symptoms its continuance, and the inflammation of the veins. Union was
discouraged from the first dressing.

The following case is so highly instructive on all points, that it is
transcribed from the _London Medical and Physical Journal_ for 1826:--

Jane Strangemore, aged twenty-eight, was admitted into the Westminster
Hospital, September 24, 1823, with an elastic swelling of the whole
of the knee-joint, measuring twenty-seven inches and a half in
circumference. The thigh was amputated by Mr. Guthrie on Saturday,
the 27th, the bone being sawn through just below the trochanter. She
suffered a good deal from pain after the operation. An opiate was
administered and repeated, and she passed a good night.

28th.--The pulse, which previous to the operation was 80, has increased
to 100; there is, however, little heat of skin, and she appears easy.
Some aperient medicine, and saline draughts to be given every four
hours. Toward the evening, she vomited a quantity of bilious matter;
pulse 120. Three grains of calomel and one of opium, followed by the
common aperient mixture, were ordered, and an enema. Equal parts of
ether and laudanum to be applied to the region of the stomach, to which
part pain was referred.

October 1st.--Better in all respects, but looking irritable and ill; no
pain anywhere; no sickness; appetite good; pulse still quick.

8th.--Two ligatures have come away; the wound looks well; the edges
have nearly healed; eats meat, and with a good appetite.

9th.--Not so well; pulse 120; skin hot; feels ill; complains of pain in
the other leg and thigh, which disturbed her rest. Was well purged, and
the leg fomented; the pain was principally felt in the calf and in the
heel.

10th.--Pulse 130; tongue furred; vomiting again of bile; the pain in
the thigh, extending upward to the groin and downward to the heel,
is intolerable, particularly in the latter part; the thigh and leg
much swelled, and tender to the touch, although without redness; the
swelling elastic, yet yielding to the pressure of the finger, but
not in any manner like an œdematous limb. Mr. Guthrie pronounced the
disease this morning to be inflammation of the veins, extending from
the opposite side; but after a careful examination, and on pressure,
no pain was felt in the course of the iliac vessels of that side, and
the stump looked well, save at one small point corresponding to the
termination of the femoral vein.

17th.--The symptoms continued nearly the same during the week, the
sickness of stomach and purging of bilious matter abating at intervals.

20th.--Less pain in the limb, which is swollen and tender to the touch,
the superficial veins being all very much enlarged. The groin more
swollen and tender; sickness gone, and her appetite returning; she is
allowed good nourishing simple diet. The stump has been poulticed since
the 9th, to promote suppuration.

25th.--During these five days it was interesting to see the patient
eat, and desire solid food, and, in her extremely emaciated state,
seem to enjoy it. The bowels occasionally deranged. Pulse always from
125 to 136. Is slightly jaundiced in color, but declares that she is
better, and will get well.

27th.--Gradually sank in the evening, and died; the limb having
everywhere diminished in size, except at the groin, where the swelling
was more circumscribed, resembling the appearance of a chronic abscess
approaching the surface. On examination after death, the termination
of the vein on the face of the stump was open, and in a sloughy
state; above that, for the distance of four inches, and as high as
Poupart’s ligament, the inside of the vein bore marks of having been
inflamed, but the inflammation seemed to have been of an adhesive
character; above that point, the inflammation appeared to have been
of an irritative or erysipelatous kind, had gone on to suppuration,
and the vein was filled with purulent matter, lymph, and blood, partly
coagulated and partly broken down. These appearances extended up the
cava as high as the diaphragm, and traces of inflammation could be
distinctly observed almost in the auricle. The disease had passed along
the right external iliac and its branches; it had descended along the
left iliac vein and its branches in the pelvis to the uterus, and along
the limb to the sole of the foot. At the left groin the iliac vein,
becoming femoral, was greatly distended with pus, apparently of good
quality, and, if the patient had lived a day or two longer, it would
have been discharged by a natural effort, as in chronic abscess; the
viscera were healthy.

During the last days of this woman’s life, no blood was returned from
the lower half of the body, unless by the superficial veins; yet she
was comparatively easy, although of a yellow hue, emaciated to the
utmost, so as to represent a living skeleton; in this state, with a
pulse at 130, craving for and eating a whole mutton-chop and more at a
time, with the most deathlike countenance it is possible to conceive.

These two cases mark the course, the symptoms, and the termination of
inflammation of the veins after amputation, in as clear (if not a more
clear) and distinct manner as any which have since been published,
and which they preceded; nevertheless, most authors of more modern
date overlook the first, and some appear to avoid as much as possible
noticing the second.

62. After the battle of Waterloo, the wounded of the same regiment were
sent indiscriminately, some to Brussels, others to Antwerp. Those who
remained at Brussels suffered principally from inflammatory fever after
amputation; those at Antwerp, from the epidemic fever prevailing at the
time, beginning us an intermittent and ending often in typhus; facts of
great importance to recollect, as showing the influence of malaria. The
following are instances of endemic fever after secondary amputation,
ending in subacute inflammation of the lungs and effusion into the
chest:--

Charles Brown, 92d Regiment, forty years of age, at that time a healthy
man, was wounded on the 18th June by two musket-balls in the right hand
and wrist; he was admitted into the hospital at Antwerp on the 25th
June. On the 5th July, the arm was swollen above the elbow; discharge
profuse and fetid; countenance sallow and dejected; fever. 8th: Arm
amputated above the elbow. 9th, 10th, 11th: A little increase of
fever. 12th: A paroxysm of intermittent, to which he had been subject
occasionally since he had been at Walcheren. On removing the dressing,
the edges of the stump were retorted; discharge copious and fetid;
respiration hurried; thirst; skin hot and yellowish; pulse 90. 14th:
Intermittent returned; head affected in consequence of long continuance
in the hot bath. 15th: Complains to-day of fullness and pain in the
left side; pulse 100; skin of a deeper tinge of yellow; a sense of
suffocation when in the horizontal position. A blister was applied to
the whole of the side of the chest. 16th: Was delirious during the
night; vomited frequently; became insensible at the hour when the
paroxysm of intermittent fever was expected to return; and died in the
evening. On opening the chest, the lungs were found adhering to the
pleuræ costales in several places, and were hepatized; a quantity of
serum and lymph was contained in the left pleura, so as to compress
the lung, in which there was a small abscess. The liver was twice the
natural size.

J. Lomax, of the Guards, was wounded at Waterloo, suffered amputation
of the right arm on the 23d August, and arrived at the General
Hospital, Colchester, on the 27th, in a state of high fever, and unable
to give any distinct account of himself. He had had the ague, he said,
for many days, which left him for a short time, but returned when on
board ship; on the 25th he was attacked by pain in the side, which
was very severe on the 26th, on which day a blister was applied, which
greatly relieved him. The stump had an unhealthy appearance, the edges
of the wound evincing a disposition to separate. On the 28th he was
free from pain; fever unabated, with a tendency to delirium. He sank
rapidly on the 30th, and died on the 31st, notwithstanding the use of
the most powerful stimuli. A quantity of serum was found on dissection
in the left side of the chest, and the pleura pulmonalis on each side
was covered with a thick layer of coagulable lymph. The pericardium was
distended with fluid. The liver was enormously enlarged, pushing up the
diaphragm, and displacing the lung, having in its substance a large
abscess containing at least a quart of pus. The stump did not exhibit
any peculiar appearance.

O. Sweeney, 90th Regiment, aged nineteen, was wounded in the hand on
the 18th of June, 1815, and taken to Brussels. On the 5th of July he
left for England, and arrived at Colchester on the 14th. The wound
shortly after assumed an unhealthy appearance; hemorrhage took place,
and the arm was amputated on the 30th. The day after, he had severe
rigors for fifteen minutes, followed by fever. The next day he was
better, and appeared to be doing well until the 6th of August, when
fever recurred. Stump quite healthy in appearance. On the 7th, he was
attacked by vomiting and purging, which lasted several hours, and
reduced him much, returning at intervals until the evening of the 8th.
Small quantities of wine and opium agreed best, and a blister was
applied to the scrobiculus cordis. On the 9th, he complained of pain
and tenderness in the abdomen, which were relieved by fomentations and
an enema. The stump looked well, and discharged healthy pus in small
quantity; the ligature on the brachial artery came away. On the 10th,
his strength failed, and the tongue and teeth were covered with a dark
sordes. The adhesions of the stump appeared disposed to separate. At
night he was restless, with low delirium; and on the 11th died, with
the complete facies Hippocratica. On raising the sternum, the pleura of
the left lung was found adhering to that of the ribs, and covered by a
thick layer of coagulable lymph. The lung was highly inflamed; and on
cutting into its substance, a number of small tubercles was observed.
The pericardium and left cavity of the thorax contained more than the
usual quantity of fluid. During the progress of this case, eleven
days from the amputation no one symptom existed which could induce a
suspicion of inflammation going on in the thorax. The stump was in a
sloughing state, but the disease did not extend along the brachial
veins.

Thomas Haynes, 23d Light Dragoons, aged nineteen, was wounded by a
spear on the back of the left forearm, at Waterloo; the wound appeared
to do well until he left Brussels for England, when it assumed an
unfavorable appearance, and on his arrival at Colchester, on the 14th
of July, it was in a sloughing state. The pain was excessive, and the
tenderness around the whole circumference of the sore was so great that
he could not suffer the slightest pressure with the finger. He was
largely bled, and a solution of sulphuric acid, one drachm to twelve
ounces of water, was applied twice a day to the whole surface, and the
whole kept wet with cold water; this treatment was continued until
the 21st, during which period he was bled five times, to about twenty
ounces each time. The acid solution was increased in strength from one
drachm to an ounce, and care was taken that the sloughing portions
only were touched with it. His health was considerably amended, and
on the whole a favorable result was expected. At two on the 22d,
however, a sudden hemorrhage took place, to the amount of three pints;
a second ensuing on the 23d, the arm was amputated. The pulse continued
quick; in other respects he was doing well, until the 25th, when some
accession of fever took place, and increased. He was bled to ten
ounces, and purged. On the 26th, the line of incision in the stump
appeared to be healed; and with the exception of the pulse at 140, he
had no unpleasant symptom on the 27th, and was free from pain of every
kind. On removing the center strap, which had been allowed to remain,
a large collection of matter of good quality issued. On the 28th, he
was much the same. On the 29th, the countenance had assumed a deathlike
paleness; pulse 120, intermitting every fifth pulsation; breathing
short and laborious, with some pain in the chest, and every symptom of
effusion having taken place. He died at two P.M., six days after the
amputation.

The only morbid appearance found on dissection was a large quantity of
serous fluid in the pericardium, which was distended by it, and on both
sides of the chest. The heart and lungs, with their membranes, were
quite sound. On examining the stump, the sanative process was found
to have been entirely confined to the integuments. No appearance of
granulation could be perceived on the muscular surface.

This last case is worthy of especial observation, on account of the
manner in which sulphuric acid was used for the sloughing state, from
one drachm to one ounce of the acid to twelve ounces of water, not
as something new, but as an ordinary application; and I am doubtful
whether there is any case on record of such use, anterior to it. Is the
external use of strong acids in sloughing cases also due to the war in
the Peninsula? Delpech says Yes,--a testimony I shall confirm in its
proper place.

I have departed, in some degree, in the foregoing observations, from
the aphorismal form I had prescribed for myself in the commencement
of these Commentaries. I have done so as an act of justice to those
officers who served at Toulouse, Brussels, Antwerp, and Colchester, in
1814 and 1815, who are all now no more, and who labored hard in the
then early investigation of these different states of disease, and have
not received the reward they merited of public acknowledgment. I have
endeavored, as the late Chancellor of the Exchequer says in his life of
Lord George Bentinck, to preserve for them the chastity of their honor.

63. Mr. Hunter, in 1793, described the appearances and the fatal
results of inflammation of the veins, as a consequence of injuries
inflicted on the surrounding parts, but I apprehend I was the first
person to point out the prevalence of this complaint after secondary
amputation, and its intimate connection with certain low inflammatory
attacks, attended by destructive purulent depositions, particularly in
the chest, and their more chronic deposit in other parts. Mr. Rose,
of the Guards, published some observations in the fourteenth volume
of the _Medical and Chirurgical Transactions_, in 1828, confirming
the remarks made by me in print thirteen years before, but without
referring to them. Mr. Arnott has an able paper on that subject in the
fifteenth volume. M. Sedillot thinks he has detected globules of pus
in different parts of the circulating system in persons who had died
of this disease. Mr. Henry Lee, 1850, one of the last English writers
on the subject, professedly doubts the accuracy of the observation;
this point remains among others for further investigation. He admits,
however, that in cases where, from long-continued disease, there have
been repeated introductions of vitiated fluids into the circulation,
the blood loses much of its coagulating power, which prevents the
admission of purulent matter by the veins, by forming coagula with it
in them, thus constituting he thinks the essential disease. When the
coagulating power of the blood is thus lost, he thinks it possible that
pus-globules may then be found circulating in it. Other late writers,
and lastly Dr. Hughes Bennett, think these diseases are dependent on
the introduction of a peculiar animal poison. Attention should be
paid by the medical officers of the public service, whenever there
is a war, to the state of the blood, and to the inner lining of the
diseased veins under the microscope;[2] and all those gentlemen, when
in London, should study its use, under Mr. Quekett, at the College of
Surgeons, to whose lectures they have the right of admission, and to
whose kindness they will all soon feel greatly indebted. I am not aware
that the writers referred to have added anything to the practical facts
I had related so long before, which is much to be regretted. It is of
little use, although it is a step in the right direction, to describe a
disease, or even to show why and wherefore it destroys, unless a means
of prevention or of cure can also be indicated.

[Footnote 2: The India Company have supplied the principal hospital of
each presidency with one good microscope at least; one of these, with a
person who understands its use, should be attached (but is not) to the
principal hospitals during the present war in the East.]

64. In the irritable and sloughing state of stump alluded to,
hemorrhages frequently take place from the small branches, or from the
main trunks of the arteries, in consequence of ulceration; and it is
not always easy to discover the bleeding vessel, or, when discovered,
to secure it on the face of the stump; for as the ulcerative process
has not ceased, and the end of the artery which is to be secured is not
sound, no healthy action can take place; the ligature very soon cuts
its way through, and the hemorrhage returns as violently as before, or
some other branch gives way; and under this succession of ligatures and
hemorrhages the patient dies.

Some surgeons have, in such cases, preferred cutting down upon the
principal artery of the limb, in preference to performing another
amputation, even when it is practicable; and they have sometimes
succeeded in restraining the hemorrhage for a sufficient length
of time to allow the stump to resume a more healthy action. This
operation, although successful in some cases, will generally fail,
and particularly if absolute rest cannot be obtained, when amputation
will become necessary. The same objection of want of success may be
made to amputation; on a due comparison of the whole of the attending
circumstances, the operation of tying the artery in most cases is to be
preferred in the first instance, and if that prove unsuccessful, then
recourse is to be had to amputation; but this practice is by no means
to be followed indiscriminately. The artery ought to be secured with
reference to the mode of operating, as in aneurism, but the doctrines
of this disease are not to be applied to it, because it is still a
wounded vessel with an external opening.

To obviate all doubts, the part from which the bleeding comes should
be well studied, and the shortest distance from the stump at which
compression on the artery commands the bleeding carefully noted; at
this spot the ligature should be applied, provided it be not within the
sphere of the inflammation of the stump. In case the hemorrhage should
only be restrained by pressure above the origin of the profunda, and
repeated attempts to secure the vessel on the surface of the stump have
failed, amputation is preferable to tying the artery in the groin, when
the strength of the patient will bear it.

When hemorrhage takes place after amputation at or below the
shoulder-joint, it is a dangerous occurrence. An incision should then
be made through the integuments and _across_ the great pectoral muscle,
when the artery may be readily exposed, and a ligature placed upon it
without difficulty anywhere below the clavicle.

If the state of the stump in any of these cases should appear to depend
upon the bad air of the hospital, the patient had better be exposed to
the inclemency of the weather than be allowed to remain in it.

In crowded hospitals, hemorrhages from the face of an irritable stump
are not unfrequent, and often cause a great deal of trouble and
distress. It is not a direct bleeding from a vessel of sufficient size
to be discovered and secured by ligature, but an oozing from some
part of the exposed granulations, which are soft, pale, and flaccid.
On making pressure on them the hemorrhage ceases, but shortly after
reappears, and even becomes dangerous. This hemorrhage is usually
preceded by pain, heat, and throbbing in the surface from which it
proceeds. There is irritation of the habit generally, and a tendency to
direct debility. The proper treatment consists in the removal of the
patient to the open air, with an antiphlogistic regimen in the first
instance, followed by the use of quinine and acids; cold to the stump,
in the shape of pounded ice or iced water. Escharotic and stimulating
applications should be used with caution. If any of the styptics which
are sometimes announced as infallible could be relied upon, their
application in these cases would be most advantageous. The solution of
the perchloride of iron is the best.



LECTURE IV.

APHORISMS FOR AMPUTATIONS, ETC.


65. Amputation of a limb is the last resource and the opprobrium
of surgery, as death is of the practice of physic; it being,
notwithstanding, impossible to do impossibilities, and save a limb or
a life which can no longer be preserved. Art and science at that point
cease to be useful.

66. At the commencement of the war in the Peninsula, all surgeons
believed it to be impossible to compress in an effective manner the
artery of the thigh against the bone, as it passes over the edge of the
pubes, and that the loss of blood on its division must be so formidable
as to be murderous. This was merely a surgical delusion, which
maintained its ground in London until the end of 1815, when the French
soldier, whose thigh I had successfully taken off at the hip-joint,
after the battle of Waterloo, without first tying the femoral artery,
was shown to all disbelievers. It was the great point in advance in
English and European surgery, and one great result of the practice of
that war.

67. This great, indeed most important fact, having been established,
the surgery of amputation was deprived of nearly all its terrors.
Confidence, and with it coolness, were obtained; and many young
surgeons diligently sought for an operation on the hip-joint as the
_ne plus ultra_ of operative boldness and dexterity, much after the
fashion of the young lady _pianistes_, who do not consider themselves
in any way advanced on the road to perfection until they can play at
least the overture to _Guillaume Tell_, if not the _Galop Chromatique_
of Listz, nearly as well as the composer himself.

68. As a tourniquet cannot be applied in this amputation, nor even at
that of the shoulder-joint, without doing harm, its inutility in the
greatest operations is proved; and recourse should not be had to it in
the smaller or less dangerous ones, provided sufficient assistance can
be obtained. When the surgeon has only one assistant, he should apply
a tourniquet, or even if he should have several bad ones on whom he
cannot depend.

69. There is always more blood lost, and particularly in secondary
amputations, when a tourniquet is used than when the principal artery
is compressed by one assistant, and two others are ready to press on
the outside of the flaps, or upon the divided vessels, with the ends
of their fingers; the force necessary to prevent the passage of blood
through the common femoral, or the axillary artery, being merely that
of the finger and thumb, applied in a very gentle manner, or even of
the end of the forefinger of a competent person. I have rarely applied
a tourniquet since 1812, and few persons have done more formidable
operations under more difficult circumstances. The ancient illusion
with regard to the necessity for tourniquets in amputation must be
given up, except by incompetent persons, or by those who are fearful
and superstitious, and do not like to depart from the ways of their
forefathers.

70. A tourniquet is useful when loosely applied after an operation,
and the attendant should be taught how to turn it, so as to suppress
any serious bleeding which may take place until the surgeon can be
procured. It may be, although it rarely is, necessary on the field of
battle. The surgeon need not, therefore, load himself or his assistant,
as formerly, with a sackful, for a thoroughly useful tourniquet can be
made in a moment with a pebble and a pocket-handkerchief, or a roller.
The great point is to know where and how to apply it. When gentlemen
called surgeons by warrant are sent to an army, as many were to that in
Spain and France, with only the knowledge of a druggist, having been
refused a commission on account of their ignorance, it is necessary
this instruction should be especially given to them; and this horrible
fact is recorded with the hope it may be useful in preventing any such
atrocious proceedings in future. Peace or humane societies, if they
cannot prevent a war, may interfere with advantage on this point, to
divest it of some of its horrors. At the battle of Inkerman, a young
officer, the son of a friend of mine, was wounded in the leg by a
musket-ball, which caused much loss of blood. A tourniquet was applied,
instead of the required operation being performed, and he was sent on
board a transport from Balaklava. The leg mortified, as a matter of
course, and was amputated. He died, an eternal disgrace to British
surgery, or rather to the nation which will not pay sufficiently able
men, and therefore employs ignorant ones--the best they can get for the
money.

71. When circular operations were performed in the olden time,
particularly on the thigh, the skin, when divided, was dissected, and
turned up like the cuff of a coat--a painful proceeding, as unnecessary
as it was barbarous. Forty years have elapsed since I demonstrated
its absurdity, and showed that the first incision in the thigh should
include the fascia lata, any deep attachments it might have should
follow, when the parts thus divided ought to be retracted as a whole,
to form a proper covering for the stump.

It was at the same time shown that, in whatever way, and however
clumsily and tediously, the muscles might be divided, it did not
prevent the successful result of the operation, provided the bone was
cut short, so as to form a cone, with an elongated or depressed point.

72. The nicking of the periosteum, and pushing it upward and downward,
so as to leave a space for the saw, was at the same time forbidden, as
leading to necrosis of the part of the bone thus denuded, if unremoved
by the saw. The saw was also directed to be held perpendicularly to,
and not across, the bone, nor even diagonally to it--an apparently
trivial, but yet great improvement. The last part divided is an outer
and thin layer of hard bone, which does not so readily splinter on the
side as on the under part, by the weight of the leg.

73. The limb to be amputated is not to be held by the assistant in the
manner described and usually shown in books: one hand ought not to be
above the knee, but below and by the side of it, the other grasping
the calf, so that the limb may be duly supported, and drawn inward or
outward, in the opposite direction to the saw, as it divides the last
layers of the bone.

74. The common integuments of the stump should be drawn together,
in primary amputations, by sutures formed of flexible leaden wires;
by threads of silk, if leaden wires be not attainable. The vessels
which bleed should be carefully secured by single yet fine threads
of dentists’ or other strong silk, one end to be cut off in primary
amputations. In secondary amputations, when the parts are not always
sound, both ends of the ligature should be cut off, and in such cases
the edges of the wound should be brought in contact only, with a layer
of fine linen between them, without the expectation of, or the desire
for, union taking place.

75. The removal of a limb should not occupy two minutes, but the
securing the blood-vessels should be done without reference to time;
when carefully effected, there is little fear of secondary bleeding,
and the stump should be closed at once. It has been lately recommended
not to close the stump for four, six, or eight hours after the
operation; but this is not advisable, unless the depressed state of the
patient, or other causes, should have rendered it impossible to secure,
in a proper manner, all the vessels which are likely to bleed. It will
be less painful and dangerous to delay, in such cases, than to have to
reopen the stump.

76. When the edges of the incision have been brought together by the
hands of the assistants, and by the sutures indicated, strips of
some kind of agglutinative plaster without resin should be applied
between them, and a little wet lint over the incision, retained by two
cross-pieces of rollers, the ends of which are maintained in their
situation by another roller applied round the body and over the upper
part of the thigh, including the extremities of the two cross-pieces;
but this roller is not to be applied over the end of the stump. When
the war came well in, stump-caps, as they were called, went out, being
worse than useless. The stump should be supported on a soft pillow, so
as to be as comfortable as possible, and protected by a cradle from
accidental injury.

If inflammation, accompanied by pain, should take place, cold or iced
water should be applied, particularly in primary amputations. In
secondary ones, warm fomentations or light warm poultices will be more
advantageous, all constriction by sutures or plasters being removed,
the parts being simply approximated to each other. Attention should be
paid to the directions in aphorism 61.


AMPUTATION AT THE HIP-JOINT.

77. This amputation essentially owes its existence to the wars of the
French Revolution. M. Bourgery says Blandin performed it three times
in 1794; once successfully. Baron Larrey did it seven times during his
different campaigns, and he says one or two persons who had survived
were seen during their cure by an officer in Russian Poland, but they
never reached France. Nevertheless, I always assume that one at least
did recover, whether he was really seen or not, being a compliment and
a reward justly due to the zeal and ability of my old friend the Baron,
to whom the surgery of France is so much indebted. This operation was
first done in Spain by the late Mr. Brownrigg, at Elvas, in 1811, and
by myself after the siege of Ciudad Rodrigo, but none of our patients
ultimately recovered. I operated on a French soldier at Brussels soon
after the receipt of the injury at Waterloo; he survived; and he was
the first and the _only man_ seen for a long time afterward in either
London or Paris. The biographer of Baron Larrey says he was present
at, and advised the operation to be done; but that is an error, as the
Baron did not visit Brussels until after I had left it for Antwerp;
neither had I any knowledge of the Baron’s writings in 1811 or 1812,
when my first operation was done in Portugal. Eighteen or twenty ways
have been suggested for doing this operation, and twenty persons are
believed to have survived its performance, several of whom may be
living at the present time.

A very extensive destruction of the soft parts, the femur remaining
entire, does not authorize the removal of the limb in the first
instance, unless the main artery be also injured. Captain Flack, of the
88th Regiment, was struck by a large cannon-shot at Ciudad Rodrigo,
on the outside and anterior part of the left thigh, which tore up and
carried away nearly all the soft parts from the groin, or bend of the
thigh, below Poupart’s ligament, to within a hand’s-breadth of the
knee. It was an awful affair. He was supposed to be dying, was returned
dead, and his commission was given to another. Left to die in the field
hospital after the town was stormed, and finding himself thus deserted
by his own friends, he claimed my aid as a stranger. I took him five
leagues to my hospital at Aldea del Obispo. The femoral artery lay bare
for the space of nearly four inches, in a channel at the bottom of the
wound; the whole, however, gradually closed in, and he recovered.

If the injury is on the back part, a flap should be made in amputation
from the fore part. If the wound should be on the outside, the flap
is to be made from the inside, and _vice versa_, the object being to
make the stump as long as possible. A wound of the artery, accompanied
by a fracture of the femur, requires amputation, for although many
would survive either injury alone, none would, it may be apprehended,
surmount both united.

If after a fracture in course of treatment, the principal artery should
be wounded by some accidental motion of the bone, amputation should in
general be resorted to. A ligature on the artery higher up would fail,
and the operation of seeking for both ends of the injured vessel would
cause so much mischief in an unsound part that the consequences would
in all probability be fatal.

78. When the femur is suffering from a malignant disease, commencing
in the periosteum, or in its cancellated internal structure, I am
reluctantly obliged to say, from experience, that the removal of the
whole bone at the hip-joint offers the best, perhaps the only chance
of success. In such cases, the operator has in general the power of
selecting his mode of proceeding.

It may be laid down as a principle in all cases of accident, whether
from shot, shell, or railway carriages, that no man should suffer
amputation at the hip-joint when the thigh-bone is entire. It should
never be done in cases of injury when the bone can be sawn through
immediately below the trochanter major, and sufficient flaps can be
preserved to close the wound thus made. An injury warranting this
operation should extend to the neck, or head of the bone, and it may
be possible, as I have proposed, even then to avoid it by removing the
broken parts.

79. The principle being established, as a general rule in all cases of
recent injury, that the femur must be broken at least as high as the
trochanter to constitute an imperative case for this operation, the
next point of importance relates to the manner of forming the first
incisions. The instructions and recommendations to be found in books
for the performance of this operation are frequently inapplicable, and
are not to be depended upon; the errors occurring from the operation
having been considered and performed on the dead body and not on the
living; on the normal and not on the injured state of parts. Thus,
for instance, it is recommended that an assistant should rotate the
knee outward or inward, to show the head of the femur; to which
recommendation there is the insuperable objection, that no person
should suffer this operation who has a knee, or half a thigh, or even
a third of one, to move by the rotary process. Pure theorists in
surgery have decided upon having a large flap made on the fore part of
the thigh, and a smaller one behind, regardless of the fact that this
cannot be done in many cases requiring a primary operation from the
nature of the injury; although it may be done in many secondary cases,
in which this severe operation would not have been required if the limb
had been amputated in the first instance. It is the mode recommended by
Mr. Brownrigg, who in his operations, which were secondary ones, had a
choice of integument, and it is, perhaps, under these circumstances,
the best.

Baron Larrey tied the femoral artery in the first instance, and then
made two lateral flaps; but this operation, dependent on the fear of
hemorrhage, was never performed in the British army.

80. My first successful operation, performed in 1815, was done from
without inward, the flaps being anterior and posterior, the artery
being compressed against the pubis.

The patient is to be laid on a low table, or other convenient thing,
in a horizontal position; an assistant, standing behind and leaning
over, compresses the external iliac artery becoming femoral, as it
passes over the edge of the pubis. The surgeon, standing on the inside,
commences his first incision some three or four inches directly below
the anterior spinous process of the ilium, carries it across the
thigh through the integuments, inward and backward, in an oblique
direction, at an equal distance from the tuberosity of the ischium
to nearly opposite the spot where the incision commenced; the end of
this incision is then to be carried upward with a gentle curve behind
the trochanter, until it meets with the commencement of the first;
the second incision being rather less than one-third the length of
the first. The integuments, including the fascia, being retracted,
the three gluteal muscles are to be cut through to the bone. The
knife being then placed close to the retracted integuments, should be
made to cut through everything on the anterior part and inside of the
thigh. The femoral or other large artery should then be drawn out by
a tenaculum or spring forceps, and tied. The capsular ligament being
well opened, and the ligamentum teres divided, the knife should be
passed behind the head of the bone thus dislocated, and made to cut its
way out, care being taken not to have too large a quantity of muscle
on the under part, or the integuments will not cover the wound, under
which circumstance a sufficient portion of muscular fiber must be cut
away. The obturatrix, gluteal, and ischiatic arteries are not to be
feared, being each readily compressed by a finger until they can be
duly secured. The capsular ligament, and as much of the ligamentous
edge of the acetabulum as can be readily cut off, should be removed.
The nerves, if long, are to be cut short. The wound is then to be
carefully cleansed, and brought together by three or more soft leaden
sutures in a line from the spine of the ilium toward the tuberosity of
the ischium. The ligatures are to be brought out between the sutures,
and some adhesive strips of plaster applied to support them. A little
wet lint is to be placed over the wound, and some well-adapted compress
under the lower flap; the whole to be retained by a soft bandage. In my
successful case there was a shot-hole in the under flap, which did good
service; and from having seen its use, I have no objection to a small
perpendicular slit being made in the lower flap, and a strip of linen
introduced to prevent adhesion. The immediate union of the flaps cannot
be expected, nor is it often to be desired.

This mode of proceeding is more certain of making good flaps where
integuments are scarce. Where the integuments will admit of the
anterior flap being made by the sharp-pointed puncturing knife dividing
the parts after it has been passed across from without inward, there
is no objection to this proceeding, and some prefer it. I have had two
such knives added to each of the cases of instruments supplied to the
army for the purpose.

Professor Langenbeck, when lately in London, informed me he had
performed amputation at the hip-joint several times in the Holstein
war, and he believed more than once successfully; making the anterior
flap by the pointed knife, cutting from within outward, but the
posterior one by cutting through the integuments from without inward,
as I have recommended in high amputation below the joint, in order to
make the flap of a more equal and proper thickness. One point to be
attended to is to leave as little as possible of the internal tendinous
structure of the great gluteus muscle, as it does not readily unite
with other parts; a second, not to leave too much muscle on the under
part; and a third, to remove as much as possible of the ligamentous
structure about the joint. The after-treatment will be the same as in
other formidable cases. The shock, however, of the injury, and of the
amputation, will render blood-letting unnecessary. Cordials, in small
quantities, with opiates and a good but light nourishing diet, should
be given. The wound should be wetted with cold water, and the patient
constantly watched, so that hemorrhage may be arrested if it should
take place. In an otherwise successful operation performed by Mr. C. G.
Guthrie, at the Westminster Hospital, the patient was lost on the third
day from this cause.

Mr. Brownrigg’s operation is to be done in the following manner: The
patient is to be placed on a low table and properly secured, with
the nates projecting over its edge, the artery being compressed. The
surgeon enters the pointed knife between the spine of the ilium and
the trochanter major, and carries it across the thigh, as near as may
be to the head and neck of the femur, until the point appears on the
inside, near the scrotum, which should have been previously drawn away.
The knife is to cut slowly downward, to make a flap, under which, and
behind the knife, an assistant inserts his four fingers, in order to be
able to grasp the flap and aid in compressing the principal artery, as
the operator completes the flap, which it is intended should be a large
one, as shown in the diagram, fig. 1.

[Illustration: Fig. 1.

_Amputation of the Hip-joint as performed by_ Mr. Brownrigg.

(Upper figure.)

 _a_ _a_ _a_, anterior flap in dotted lines;
 _c_, thumb compressing the artery on the pubis;
 _d_, fingers introduced under the flap;
 _e_, the straight knife, entrance and exit of.

(Lower figure.)

_Flap Amputation as performed by_ Mr. Luke, _on the lower half of
the thigh_.

 _A_, middle of the outside of the thigh and point of entrance of knife;
 _B_, under part;
 _C_, upper part;
 _A_ to _E_, the under flap;
 _G_ to _F_, dotted line of upper flap, beginning short of commencement
   of under flap.]

The assistant holding up the flap, the surgeon cuts the attachment of
the gluteus medius muscle, from the upper edge of the trochanter, if it
has not been already done, opens the capsular ligament of the joint,
and divides the ligamentum teres. The head of the bone can then be
readily withdrawn from the acetabulum. The knife being placed behind
the head of the bone and the trochanter, should be carried obliquely
downward and backward, so as to form a shorter flap behind than was
made before. The amputations of the hip-joint, performed in the Crimea,
have not, I understand, been as successful as the ability with which
they were performed might have led the operators to expect.

[Illustration: Fig. 2.

MR. GUTHRIE’S OPERATION.

Left side--

 _a_, anterior superior spine of ilium;
 _b_, commencement of anterior incision, continued by the black line;
 _c_, the posterior incision joining the anterior one.

(Second figure.)

 _b_ _c_, line of incision marked by three sutures.]

81. Amputation by the circular incision is to be done in the following
manner: When a tourniquet is used, which it should not be, if the
surgeon can depend on his assistants, the pad should be firm and
narrow, and carefully held directly over the artery, while the ends of
the bandage in which it is contained are pinned together. The strap of
the tourniquet is then to be put round the limb, the instrument itself
being directly over the pad, with the screw entirely free; the strap
is then to be drawn tight and buckled on the outside, so as to prevent
its slipping, and yet not to interfere with the screw. Should the screw
require to be turned more than half its number of turns, the strap is
not sufficiently tight, or the pad has not been well applied. The
patient being placed on a table at a convenient height, the assistants
are carefully to retract the integuments upward, and put them on the
stretch downward, by which means their division is more easily and
regularly accomplished. The surgeon, standing on the outside, passes
his hand under the thigh and round above quite to the outside, and
there he begins his incision with the heel of the knife, and with a
quick, steady movement, carries it round the thigh until the circular
division of the skin, cellular membrane, and fascia has been completed.
The skin cannot be sufficiently retracted unless the fascia be divided,
and as the division of the skin is certainly the most painful part
of the operation, it ought never to be done by two incisions, when
the largest thigh can most readily and speedily be encircled by one.
If the fascia should not be completely divided by the first circular
incision, it is to be cut with the point of the knife, together with
any attachment to the bone or muscles beneath. The amputating knife
is then to be applied close to the retracted fascia and integuments,
and the outermost muscles are to be divided by a circular incision,
with any portion of the fascia that may not have equally retracted.
This incision completed, the knife is immediately to be placed close
to the edge of the muscular fibers which have retracted, and the
remainder of the soft parts divided to the bone in the same manner.
In making these two incisions, care should be taken to cut at least
half an inch on each side of the great artery by one incision, which
should be either the first or second, as may be most convenient. The
muscles attached to the bone are then to be separated with a scalpel
for about three inches in large thighs, by which means the bone will
be fairly imbedded when sawed off. The common linen retractor is next
to be placed on the limb, and the muscles steadily kept back while the
bone is sawed through. The periosteum may or may not be divided by one
circular cut of the scalpel after the retractor has been put on. The
heel of the saw is then to be applied and drawn toward the surgeon,
so as to mark the bone, in which furrow he will continue to cut with
long and steady strokes, the point of the saw slanting downward in a
perpendicular direction until the bone be nearly divided, when the saw
is to be more lightly pressed upon, to avoid splintering it, which this
manner of sawing will also tend to prevent. During this operation
the thigh should be held steadily above, and in such a manner below
that the part to be cut off does not weigh or drag on the bone above;
at the same time it must not be pressed inward or upward, or it will
prevent the motion of the saw or splinter the bone. The retractor is
then to be removed, the great artery to be pulled out by a tenaculum
passed through its sides, separated a little from its attachments, and
firmly tied with a two-threaded, strong ligature, provided dentists’
silk be not used, and the tenaculum is not to be withdrawn until this
has been accomplished; any other vessels that show themselves may be
secured, and compression should for an instant be taken off the main
artery, when others will start. If used, the tourniquet should now be
removed, and the small remaining vessels will be discovered. If the
great vein continue to bleed after some pressure has been made upon
it, a single-threaded ligature should be put over it; but this should
not be done if it can be avoided, and only when the loss of a little
blood might be dangerous. If the cancellated part of the bone bleed
freely, the thumb of the left hand pressed steadily upon it, while the
vessels are tying, will in a short time suppress the hemorrhage. Any
inequality of bone should be removed by forceps. The ligatures should
now be shortened, one end of each thread being cut off; the stump is
to be sponged with cold water and dried, the bandage rolled steadily
down the thigh; the muscles and integuments brought forward and placed
in apposition, horizontally across the face of the stump, and retained
by leaden sutures and adhesive plasters carefully applied, from below
upward, and from above downward; the ligatures being brought out nearly
as straight as possible, in two or three places between the slips of
plaster, unless both ends have been cut short. A compress of lint is to
be placed over and under the wound, supported by two slips of bandage,
in the form of a Maltese cross, vertically and horizontally, and the
whole secured by a few more turns of the bandage. No stump-cap is to be
applied; the stump is to be raised a little on a proper pillow from the
bed, in which the patient lies on his back; and if the bone appear to
press too much against the upper flap, the body may be a little raised,
which will relieve it.

In secondary amputation of the thigh, the integuments may not be sound,
and will not retract, in which case they must be dissected back to an
equal distance all round. If the muscles are much diminished in size,
or flabby, they should be left even longer than may appear necessary
for the formation of a good stump; and this is to be done more
especially on the under part, for the bone will frequently protrude
under these circumstances, when enough has been supposed to have been
preserved. In all these cases the bone should be shorter than usual,
and the skin should, if possible, retain its attachments to the parts
beneath. No inconvenience can ever arise from too much muscle and skin
in a circular stump; but it does sometimes from too much skin alone.

In primary operations there will be from three to seven vessels to be
tied; in secondary ones, from ten to sixteen, and even then there may
be an oozing from the stump. In this case a little delay in searching
for the vessels is necessary; the tourniquet and all tight bandages
should be removed, and the stump well sponged with cold water before
it is dressed. A certain degree of oozing is to be expected from all
stumps, although it does not always occur: but when there is really
any hemorrhage, so that blood distills freely through the dressings,
the stump should be opened, when the bleeding vessel will generally
be discovered readily, though not visible before. A stump under these
circumstances should not be closed in the first instance; the parts
should be merely approximated until all bleeding has ceased.

When the operation is performed near the knee, the gradual thickening
of the thigh prevents the retraction of the integuments, and has an
effect upon the vessels of the stump; both of which evils are avoided
after the circular incision has been completed, by making a cut, an
inch and a half in length, in the integuments through the fascia on
each side, in the horizontal direction in which they are recommended to
be placed, after the operation is finished; but this will very rarely
be necessary.

82. Amputation of the thigh, by the flap operation, is best
accomplished by the method adopted by Mr. Luke, of the London Hospital,
which is as follows: The patient being placed so that the thigh
projects beyond the table, the surgeon stands with his left hand toward
the body, or on the outside when amputating the right, and on the
inside when amputating the left thigh. The knife to be used ought to be
narrow, pointed, and longer by two or three inches than the diameter
of the thigh at the place of amputation. The point of the knife
should be entered _mid_-distance between the anterior and posterior
surfaces of the thigh, which may be effected with accuracy, if the eye
is brought to a level with the thigh, when the middle point is easily
determined. The posterior flap is to be formed first, by carrying the
knife transversely through the thigh, so that its point shall come out
on the opposite side, exactly midway between the anterior and posterior
surfaces. In traversing the thigh, the knife should pass behind the
bone, and will be more or less remote from it in different individuals,
according to the greater or less development of the posterior muscles,
when, by cutting obliquely downward, to the extent of from four to six
inches, according to the thickness of the thigh, a posterior flap is
formed. The anterior flap is effected, not by making a flap, but by
commencing an incision through the integuments and muscles on the side
of the thigh opposite to the surgeon, at a little distance anterior
to the extremity of the posterior flap. This incision is made from
without inward, through the integuments, so as to form an even curve,
and without angular irregularity, over the thigh, to near the base
of the posterior flap on the side on which the surgeon stands. The
length of this flap is determined by that of the posterior. It will
therefore vary from four to six inches, as before stated; and for its
completion will require a second, or perhaps a third, application of
the knife. In the two flaps thus made, the division of almost all the
soft structures is included, a few only immediately surrounding the
bone remaining uncut. These are to be divided by a circular sweep of
the knife, at the part where it is intended to saw the bone; in this
way it is sufficiently denuded for the application of the saw. The
flaps being held back by an assistant, the bone is to be sawn through
in the usual way. In amputations of the lower part of the thigh it
usually happens that the ischiatic nerve lies upon the surface of
the posterior flap, and should be removed. It occasionally occurs,
although not frequently, that the popliteal artery is cut obliquely at
its commencement; but in amputations above the passage of the arterial
trunk through the tendon of the triceps, this does not take place, the
division of the artery being usually included in the circular sweep
made after the formation of the flaps. The divided arteries having been
carefully secured, the flaps are to be brought together and retained by
three sutures passed through the integuments at equal distances from
each other, and from the extremity or base of the flaps. It appears
to be a matter of considerable importance not only that their edges
should be kept in apposition, but that their _whole surfaces_ should
be kept in accurate contact. For this purpose, the following method of
dressing is adopted: The edges, in the intervals between the sutures,
are to be held together by strips of adhesive plaster about one inch in
breadth. A compress of lint is then to be fitted over each flap, that
upon the posterior being the larger. The compresses are to cover the
flaps only, and not to extend over the extremity of the bone, where
their pressure would probably be ill endured. The posterior compress
is made large, that it may serve as a cushion on which the thigh rests
when the patient is placed in bed. The compresses are to be retained in
position by one or two strips of plaster, and supported by a bandage
applied carefully round the stump. If this be properly accomplished,
the whole surfaces of the flaps will be kept accurately in contact
with each other, and complete union may be reasonably expected. By
securing the perfect apposition and support of the entire surfaces in
accurate contact, the disposition to the issue of blood from small
vessels is also obviated to a great extent, and it is even probable
that vessels of a larger diameter than the smallest, which would bleed
if not restrained, are, by the pressure of the opposing surface,
prevented from doing so, and the probability of secondary hemorrhage
is diminished. Experience has demonstrated the fact that primary
union of the flaps is most effectually procured in the great majority
of amputations thus treated. Indeed, non-union of the flaps is the
exception; union, the rule. In the subsequent treatment of the stump,
care must be taken to prevent an accumulation of discharge in the
tracks of the ligatures; and the dressings must be renewed according to
circumstances having reference to the quantity of discharge, and the
uneasiness of the patient. The line of division of the integuments of
the two flaps is situated, at first, in the center of the face of the
stump; but when the flaps have united, a gradual change takes place in
the position of the cicatrix: it recedes, by degrees, to the posterior
aspect of the thigh, and the bone abuts upon the anterior flap, by
which alone it is eventually covered, and the cicatrix is thus removed
from its pressure.

83. A protrusion of bone is a disagreeable occurrence after amputation;
it will sometimes happen after sloughing of the stump, without any
fault of the operator. If, on completing the operation, it is evident
the bone cannot be well covered, a sufficient portion should be at once
sawn off, and the error remedied.

When the bone protrudes at a subsequent period to the extent of an inch
or more, it should be removed by operation, an incision being made on,
and down to, the bone, and the saw applied where it is sound. The chain
saw, when at hand, answers well, and some should be supplied for the
use of the principal hospitals with every army. The protruded end of
bone should be held steadily by pincers, or it may be introduced into a
hollow tube, which fixes it firmly.

When the bone has been badly sawn through, or split in the act of
dividing the last layer, or the periosteum is unduly separated, the
end will often exfoliate with the split, which may extend up for
several inches, giving rise to the formation of abscesses, causing much
suffering, and occupying a great length of time before the ring of bone
and the split portion exfoliate, and the stump becomes quite sound.
A splinter of this kind may even require to be removed at a late or
at a distant period, from the nervous irritation and suffering it may
occasion. This irritation has been often attributed to the extremity
of the principal nerve, which always enlarges, assumes a bulbous form,
and is painful on pressure, when made for the purpose, although not so
under ordinary circumstances. This enlargement never requires removal,
unless it should adhere to the cicatrix, or be the subject of disease
incidentally occasioned in it. The great sciatic nerve became early
thus enlarged in the thigh of the late Marquess of Anglesea, and was
mistaken for disease, for which he was advised to have it removed, it
being painful on pressure, and therefore the supposed cause of the
tic douloureux under which he labored. Consulted on the propriety of
this operation, his leg-maker, Mr. Pott, being present, who had also
lost a leg above the knee, I requested his lordship to squeeze Mr.
Pott’s bulbous nerve, in the same manner as the doctor had squeezed his
lordship. He did so, and Mr. Pott roared and sprang from the floor in a
manner which quite satisfied Lord Anglesea.



LECTURE V.

REMOVAL OF THE HEAD OF THE FEMUR, ETC.


84. The removal of the head of the thigh-bone from its place in
the hip-joint, after it has been separated in a measure from its
attachments by disease of a scrofulous nature, is an operation which
has been several times successfully performed, and life has been
thereby preserved without much suffering or risk to the patient. In
this case, the head of the bone is found lying outside the cavity, from
which it has been drawn by the action of the muscles. A step further
must be taken, and this operation must some day be done in cases
of fracture of the head or neck of this bone caused by an external
wound--cases which have hitherto been invariably fatal, or in which
life has been preserved by amputation at the hip-joint.

The great advance which operative surgery has made within the last
forty years, and the success which has followed the removal of the
head of the humerus, the whole of the elbow, the ankle, and even the
knee-joint, render it imperative on surgeons of ability to endeavor to
save life without the performance of so formidable an operation as that
of the removal of the whole limb, more particularly when the health
is good and the parts sound, with the exception of those immediately
injured.

The cases which seem more particularly favorable for this operation are
those in which the head or neck of the bone is broken by a musket-ball.
Picture to yourselves a man lying with a small hole either before or
behind in the thigh, no bleeding, no pain, nothing but an inability to
move the limb, to stand upon it, and think that he must inevitably die
in a few weeks, worn out by the continued pain and suffering attendant
on the repeated formation of matter burrowing in every direction,
unless his thigh be amputated at the hip-joint, or he be relieved by
the operation which, I insist upon it, ought first to be performed.

85. In order to do this operation with precision, the surgeon should
make himself well acquainted with the anatomy of the parts; and
as the war in the Russian Empire may offer opportunities for its
performance, a recapitulation of the essential points to be noticed
may be useful. Two limbs should be injected so as to show the great
arteries distinctly, and one should be dissected so that every part
may be brought into view at once. That being done, attention should be
directed to two points, the great trochanter and the round head of the
thigh-bone in its socket, which is directly below and a little internal
to the anterior superior spinous process of the ilium.

When the thigh is bent in the dissected limb, the head of the bone
will be seen rolling in the socket very distinctly, and, in order to
lay it bare for removal, the muscles, etc. around it must be divided.
The first, on the anterior and outer part, is the tensor vaginæ
femoris; this should be divided; outside this the gluteus medius
must be cut, going to be inserted into the upper and outer part of
the top of the great trochanter; deeper, and between these two last,
lies the gluteus minimus, winding forward to be inserted into the
anterior portion of the same part. Now, let the great gluteus muscle
be cut through backward in a curve, and the insertions of four muscles
at one part--viz., the pit or fossa immediately behind the great
trochanter--will be brought into view: these are the pyriformis, the
gemelli, reckoned as one muscle, and the obturatores externus and
internus. They should all be cut through within half an inch from
their insertion. The square muscle lying or placed immediately below
them, and running from the ischium to the inter-trochanteric line, is
the quadratus femoris; it must be cut across. The head of the femur
will now be seen to roll in the socket on the least motion being
given to the knee. The surgeon should then open into the exposed
joint with great care, when by a gentle rotation of the knee inward
the head of the thigh-bone will be readily dislocated outward. The
ligamentum teres, or the round ligament, as it is termed, although it
is triangular at its origin, should now be divided, with as much of the
capsular ligament as may be necessary, when everything will be ready
for the application of the saw.

Pause a moment, and view the parts before the saw is applied. Two
strong muscles are inserted into the small trochanter by a common
tendon, the iliacus internus and psoas magnus. This insertion should
remain untouched if the fracture should not extend below the little
trochanter. It is not always necessary to injure them, and they will
be of great use afterward, if the operation should prove successful.
If the neck of the bone be broken through, rotating the thigh as
directed may not assist much in dislocating its head. But then, the
separation of the fractured parts may be readily completed, and the
piece detached, when the remaining part of the head of the bone will be
more easily removed. The sawing may be accomplished with the greatest
ease by a small common saw, or by the improved chain saw, which will do
good service. The arteries to be divided are all of small size. Filled
with red injection, they are so small as scarcely to be seen; and
they could not give any trouble; for the wound is so large as to give
easy access to every part, and readily admit of any bleeding vessel
being tied without difficulty. The round ligament should be cut off
close to its origin in the acetabulum, and any portion of the capsular
ligament and cartilaginous edge of the acetabulum which can be quickly
removed with it, but no time should be unnecessarily lost in trying to
remove the cartilaginous lining of the cavity itself, which will be
gradually absorbed. The sawn end of the femur should now be brought
up into the cavity, and kept there if possible by a supporting splint
and bandage, with the hope that it may become rounded and adhere by a
newly-formed ligamentous structure, in the same manner as the end of
the humerus does to the glenoid cavity of the scapula, when similarly
treated. The edges of the wound are then to be brought in apposition,
and retained so by two or three sutures. The gluteus magnus slides
over the trochanter major, having a bursa between them, and this part
will not readily throw out granulations. The surgeon may therefore be
less solicitous about the accuracy of the apposition of the edges at
the under part, through which the discharge will more easily pass. The
outside must, however, be supported by sticking-plaster and bandage
compress, to prevent any bagging, and to keep all parts in contact.
The saving the periosteum of as much of the femur to be taken away,
as strongly recommended by MM. Flourens and Baudens in the excision
of the head of the humerus, should be attempted, although not easy of
execution. (_Aph. 118._)

86. The surgeon should now do the operation on the undissected limb.
The first cut through the skin, integuments, and fascia lata should
be a curved one, beginning just over the inner edge of the tensor
vaginæ femoris muscle, as shown on the other leg, curving downward
and outward, so as to pass across the bone an inch at least below the
trochanter major, when it should turn upward to the extent of three
inches or more, as the size of the limb may require. This incision or
flap should, when complete, divide, in addition to the integuments,
the fascia lata, the tensor vaginæ femoris, and part of the gluteus
maximus. The flap thus formed must be raised or turned up by an
assistant, to enable the operator to get at and divide the parts below,
in the order before named. It is not necessary to stop to tie any
bleeding vessel until the operation is finished, for little or no blood
will be lost.

Pause again. The surgeon has just done nearly the outer half of the
operation as to cutting, for removing the whole limb at the joint;
and if he should now find that the bone is so much shattered in the
shaft that he cannot hope to save the limb, there is no difficulty
in removing it. To do this, place your long knife inside the bone,
with the middle of its edge resting against the outer edge of the
iliacus and psoas muscles, and at one firm cut of a strong hand let
it cut its way inward, forming an inner flap, your assistant steadily
compressing the femoral artery against the bone above. This artery and
the great profunda will both be divided; seize them with the finger
and thumb of the left hand, and place a ligature, or assist in placing
one, on each branch with the right; or, if the trunk of the profunda
should have been cut very short, tie the main trunk of the femoral.
Let the ligature be a single thread of strong dentists’ silk, with
which I have successfully tied the common iliac, and no fear need be
entertained of its not holding fast if you tie it reasonably tight.
The idea usually entertained that a great artery cannot be closed by
the ordinary process of nature under a ligature, if a branch be given
off near it, is erroneous. I never placed reliance on this opinion
unless in the accidental circumstance of the outside of the orifice of
the branch being in contact with the ligature, the irritation caused
by which outside may not be sufficient to close the orifice within,
and the common iliac artery of one of the two cases in which I tied it
successfully (the patient dying a year afterward) may be seen in the
Museum of the College of Surgeons. It is tied about an inch from the
aorta, and was pervious on each side of the ligature, which has closed
the vessel to no greater extent than its own width, proving all the
facts I have mentioned so frequently on this subject. As to the smaller
vessels, they will give no trouble, being easily commanded, each by the
point of a finger. I have not done this operation of removing the head
and neck of the femur on a healthy living man after an accident, but
it must be done, and I am satisfied it will in the end succeed. It was
done in the 3d Division of the army in the Crimea after the engagement
of the 18th of June. The continuity of the head with the shaft was not
altogether destroyed, the fracture being principally confined to the
great trochanter and the trochanteric ridge. It was at first thought
the operation might be dispensed with, but as great irritation ensued,
with every prospect of considerable mischief, the head, neck, and both
trochanters were excised. On the 6th of July the man was doing well,
but unfortunately he was attacked by cholera three days afterward,
and died. This operation has since been done by Mr. Blenkin, of the
Grenadier Guards; the result will be stated hereafter.

Amputation at the hip-joint should not be performed, unless the head
and neck of the thigh-bone be injured; and it ought not to be done
if they be, unless the shaft of the thigh-bone be extensively broken
also. The operation I have recommended should be its substitute,
and I hope yet to see a man walking with ease and comfort on whom
it has been performed. The recommendation thus given is the result
of the experience of former times, of the whole of the war in the
Peninsula and at Waterloo, matured by that of the last forty years
in London hospitals, and by a due consideration of the state of
surgery throughout all civilized Europe and America. Surgery is never
stationary, and surgeons of the present day must continue to show that
it is as much a science as an art.

87. Wounds of the knee-joint from musket-balls, with fracture of
the bones composing it, require immediate amputation; for although
a limb may be sometimes saved, it cannot be called a recovery, or a
successful result, where the limb is useless, and is a constant source
of irritation and distress after several mouths of acute suffering have
been endured, to obtain even this partial relief from impending death.
For one limb thus saved, ten lives will be lost; and the sufferer is
often glad, after months and years have elapsed, to lose the limb thus
saved, more particularly when the ball has lodged in the articulating
surface of either of the bones. Amputation at a secondary period, in
these cases, does not afford half the chance of success, for many
will not survive the inflammation and the fever which will ensue.
The amputation should therefore be immediate, unless excision can be
substituted for it, and it is a point to be hereafter decided whether
excision may not almost always be so substituted when the wound is made
by a musket-ball, and the popliteal artery and nerve are not injured.

88. Compound fractures of the patella, without injury to the other
bones, admit of delay, provided the bone be not much splintered. If
the ball should have pierced the center of the patella, and passed out
nearly in an opposite direction behind, the limb will not be saved.
If the ball have struck the patella on its edge, and gone through it
transversely, opening into the joint, it will very rarely be saved;
but if it be merely fractured, there is hope under the most rigorous
antiphlogistic treatment, and delay is proper. A ball will occasionally
penetrate the capsular ligament, and lodge in the knee-joint, with
little injury to the bones. If it cannot be extracted without opening
extensively into the cavity of the joint, and the extraction of the
ball is absolutely necessary, amputation or excision had better be
performed at first, for it will be ultimately necessary. The condyles
of the femur and the lower part of the bone being spongy, a ball may
pass through them or between them, and fall into the knee-joint, or
it may make a prominence on the side of the patella, without passing
out, or immediately interrupting the motion of the leg, for the soldier
may walk some distance afterward. The popliteal artery may also be
divided in addition, and either of these cases will render amputation
necessary, for the ball must be taken out on the fore part, and the
general inflammation of the joint will either destroy the patient
in a short time, or, after much distress and hazard, leave him no
alternative but amputation. If a ball lodge in the condyles of the
femur within the capsular ligament, and cannot be easily extracted,
excision or amputation is advisable; for the limb, if preserved, will
not be a useful one. If the ball, on the other hand, lodge without the
capsular ligament, and cannot readily be extracted, the wound should
be healed as soon as possible; and, although it may cause some little
inconvenience to the knee-joint, the limb and life of the patient
may be saved, as I have seen in many instances, when a continuance
of persevering efforts to extract the ball would have exposed both
to great danger. Many cases of wounds in the knee-joint, in which
the capsular ligament has been wounded, and the articulation opened
into without injury to the bones, do well, such as simple incised
wounds made with a clean cutting instrument. The success attending all
wounds of the knee-joint depends entirely upon absolute rest, upon
the antiphlogistic mode of treatment being rigidly enforced, on the
healthy state of the atmosphere, and on the locality being free from
endemic disease. The limb is to be placed in the straight position, a
splint to be put beneath it, in order to prevent any motion, and cold
or iced water to be applied, especially in summer, to diminish the
increasing heat. General bleeding may be had recourse to in sufficient
quantity to keep all general inflammatory action in due bounds; but
it is on local blood-letting that the surgeon must principally rely
for the prevention of inflammation. Cupping can sometimes be performed
with marked effect; but leeches are more serviceable when they can be
procured in sufficient numbers; from twenty to forty, or more, may
be applied at a time; whenever the sensation of heat is felt, and is
accompanied by pain, they should be repeated until these symptoms
subside. The necessity for the local abstraction of blood is so great
that it should never be lost sight of for a moment; for if suppuration
take place throughout the cavity of the joint, it is followed, in most
instances, by ulceration of the cartilages and caries of the bones. By
local and general bleeding, the application of cold, rigid abstinence,
and the straight position, a recovery may sometimes be effected; but
wounds of the knee-joint, however simple, should always be considered
as of a very dangerous nature, infinitely more so than those of the
shoulder, the elbow, or the ankle. When a poultice is applied to a
gunshot wound of this kind, I consider it the precursor of amputation.
Col. Donnellan, of the 48th Regiment, was wounded, at the battle of
Talavera, in the knee-joint, by a musket-ball, which gave him so little
uneasiness that he could scarcely be persuaded to proceed to the rear.
At a little distance from the fire of the enemy, we talked over the
affairs of the moment, when, tossing his leg about on his saddle, he
declared he felt no inconvenience from the wound, and would go back, as
he saw his corps was very much exposed. After he had stayed with me
a couple of hours, I persuaded him to go into the town. This injury,
although at first to all appearance so trifling, proceeded so rapidly
as to prevent any relief at last being obtained from amputation, and
caused his death in a few days.

89. _Excision_ of the knee-joint is an operation formerly attended
with so little success that it has been but rarely performed until
lately. The result will, in all probability, be more favorable in
cases of injury from musket-balls, in which the femur and tibia have
both been much injured, without so much mischief being inflicted on
the soft parts as would have rendered amputation necessary. In such
cases, provided every accommodation, and particularly absolute rest
and good air, can be obtained for the sufferer, excision should be
attempted, in preference to the amputation recommended in 84 and 85.
Some cases of success have lately been published by Mr. Jones, of the
island of Jersey; some by Mr. Syme, Mr. Mackenzie, Dr. Gurdon Buck,
Mr. Fergusson, and others. Mr. Jones’s method of operating is here
transcribed, as sent to me by himself:--

“In my first case, the incisions were in this form ‘H’, two lateral,
one along each side of the joint, and a transverse one immediately over
the middle of the patella. The flaps were then dissected upward and
downward, the patella removed--and I do not see that any advantage can
be gained by keeping it, even if not diseased--the crucial and lateral
ligaments were then divided, and the joint completely opened. The leg
was afterward bent backward on the thigh, and the diseased portion of
the femur was cleared, and removed with an ordinary amputating saw. The
same method was followed with the tibia: the bones were then placed in
juxtaposition, the flaps brought together by means of a few stitches,
and the limb placed in a species of fracture-box. Water-dressing was
applied. In the second case, I followed very nearly the same plan, with
the exception of my first incisions, which were made something in a
horseshoe shape. In the third case, I removed a considerable portion of
integument, and, I conceive, with marked advantage. In the two former
cases, I think the cure was protracted by preserving all the diseased
external parts.”

Dr. Gurdon Buck, of the United States of America, in a case of
anchylosis, with deformity, after a gunshot wound, removed the
knee-joint by a transverse incision from one condyle to the other
across the lower margin of the patella. A longitudinal incision
intersected this, extending four inches above and below it. The flaps
being dissected up, the joint was opened into by an incision across the
ligamentum patellæ at the inferior edge of the bone, and also across
the lateral ligaments. The adhesions of the articular surfaces were
broken up by forced flexion very gradually applied. A slice was then
removed with the common amputating saw from the surface of the condyles
of the femur, including the pulley-like surface, care being taken to
make this section on a plane parallel with the surfaces of support
upon which the condyles rest, when the body is erect. The articular
surface of the tibia was next removed on a level with the upper
extremity of the fibula, after the insertions of the capsular ligament
had been dissected up from the posterior half of the circumference of
the head of the bone. The broad, fresh-cut bony surfaces, which were
very vascular and healthy, admitted of accurate coaptation without
stretching the tendons and other parts in the ham. To secure them in
close contact, and prevent displacement, a flexible iron wire was
passed through both bones on either side, and the two ends twisted and
left out between the flaps of skin. The patella, being disorganized
and softened, was removed, except the superior margin, which affords
insertion to the quadriceps muscle. The flaps of integument having
been trimmed, were brought together by sutures and adhesive plaster,
and the limb placed in a fracture-box. The constitutional fever was
moderate, and disappeared in a fortnight. Suppuration never exceeded
half an ounce daily. At the end of five weeks and a half the wires
became loose, and were removed. No exfoliation followed. At the end
of nine weeks the wound had entirely healed, and the limb could be
raised bodily from the bed. There is no mobility between the bones; the
difference in the length of the limb, as compared with the other, is
one inch and a half, which permits the foot to clear the surface of the
ground, which cannot be done when the limb is of the same length as the
other.

Mr. Jones, since the publication of his original cases, has in a
subsequent one not only preserved the patella, but even the ligamentum
patellæ, which he considers to be a great improvement when it can be
effected; he operated in the following manner: A longitudinal incision
down to the bone, four inches in extent, was made on each side of
the knee-joint, midway between the vasti and the flexors of the leg.
These two cuts were then connected by a transverse one just over the
prominence of the tubercle of the tibia, care being taken not to cut
the ligamentum patellæ. The flap was turned upward; the patella and its
ligament were freed, drawn over the internal condyle, and kept there
by means of a broad, flat, and turned-up spatula. The joint was thus
exposed, the synovial capsule was divided as far as could be seen,
when the leg was forcibly bent, the crucial ligaments, almost breaking
in the act, only required a slight touch of the knife to divide them
completely. The articular surfaces of the bones were now completely
brought into view, when the diseased portions were removed by suitable
saws, the soft parts being kept aside by assistants; the external
condyle had been hollowed out by a large abscess, so that it was
necessary to saw off (obliquely) another portion of the carious bone,
and to gouge out the remainder, until the healthy cancellous structure
was reached. The articular surface of the patella had also to be gouged
until sound bone was attained. The bones were brought into apposition,
and the patella and its ligament replaced, as nearly as possible; at
the end of seven weeks the patient, twelve years old, was able to turn
the limb from side to side, and ultimately recovered.

This little boy I saw walking firmly on his leg, an admirable instance
of conservative surgery. It is, nevertheless, an operation which ought
not to be done on the field of battle, unless perfect quiescence and
every desired accommodation can be obtained, and no endemic disease
prevail.

90. Amputation of the leg is performed in two ways--by the circular
incision and by two flaps, the circular incision being only applicable
to the calf. In either way the stump should, if possible, be seven
inches long, for the more convenient application of an artificial leg,
which is now made with a socket to fit the stump, instead of resting
against the bent knee, unless the stump be too short for its proper
adaptation otherwise.

The operation by the circular incision is performed by necessity in
the thick part of the leg, and the bone is usually sawn through about
four inches from the patella, so that, when the stump has healed, there
may be sufficient length of bone left to support with steadiness the
weight of the body on the knee, and that greater facility may be given
to the motion of the leg, from the preservation of the insertion of
the flexor tendons. The most eligible place for the application of the
tourniquet, when used, is about one-third of the length of the thigh
from the knee, on the inside, where the artery perforates the tendon of
the triceps muscle, and where it can be most conveniently compressed
against the bone by a small firm pad, the instrument being on the
outside, or opposite the pad; or the compress may be placed between the
hamstring tendons, a little distance from the hollow behind the joint,
the instrument itself being on the fore part of the thigh. In this
method the pad must be thicker, and the compression is more painful,
and not more secure. The surgeon should stand on the inside of the leg
to be operated upon, that he may more readily saw the fibula at the
same time as the tibia, by which the chance of splintering the fibula
is diminished; for this bone is held much more steadily under the saw
when the tibia is undivided, whatever pains may otherwise be taken by
the assistants to secure it. The limb should be a little bent, and the
circular incision made with the smaller amputating knife through the
skin and integuments to the bone on the fore part, and to the muscles
on the outside and back part; and as the attachment of the skin to the
bone will not readily allow its retraction, it must be dissected back
all round, and separated from the fascia, the division of which in the
first incision would avail nothing, from its strong attachments to
the parts beneath. The muscles are then to be cut through, nearly on
a level with the first incision, down to the bones. The interosseous
ligament between the tibia and fibula is to be divided with the catlin;
and as several of the muscles cannot retract in consequence of their
attachment to the bones, they are to be separated with the knife;
in the same manner the inter-muscular septa, or expansions running
between them, are to be divided, as they would else prevent their
retraction. The retractor with three slips is now to be put on, the
center slip running between the bones, by which the soft parts may be
pulled back to a sufficient distance, any adhering part being divided
by the point of the knife. The bones are to be sawn through with the
usual precautions, and the retractor removed, when the three principal
arteries should be secured: the anterior tibial, on the fore part of
the interosseous ligament, between the tibia and fibula; the peroneal
artery behind the fibula; and the posterior tibial near it, more
inward and behind the tibia; this artery will frequently, however,
contract very much, and will only show itself on the compression being
taken off the artery above. It in general causes more trouble to secure
it than the others, and I have two or three times seen, even in London
hospitals, the needle dipped round it in despair, when merely pulling
out the artery with the tenaculum, and dissecting a little round it,
would have shown the small retracted bleeding vessels arising from it,
and have prevented, in all probability, a secondary hemorrhage. The
tourniquet, if used, being removed, the smaller vessels tied, and the
stump sponged with cold water and dried, the integuments and muscles
should be brought forward as much as possible, and the strips of
adhesive plaster applied from side to side--that is, the wound is to be
closed vertically or nearly so, that the strips of plaster may not in
any way press upon the fore part of the tibia, by which its protrusion
will be avoided, an occurrence which almost invariably follows when the
line of approximation is horizontal and the strips of plaster press
upon the bone. If the spine of the tibia be sharp, it should be removed
by the saw, whether the operation be done by the circular incision or
by the use of flaps.

91. The flap operation, as performed by Mr. Luke, differs from that
of the thigh in some particulars. There is a greater variety in
the proportion which the soft parts in the posterior flap bear to
those in the anterior, and the distance from the bones at which the
limb is transfixed in the first step of the operation is subject to
such variety that, when the calf is large, the mid-point for the
introduction of the knife lies at some distance from the posterior
aspect of the bones; in a small calf, it is close to it. The course
of the knife through the limb is oblique instead of transverse, for
the purpose of accommodating the line of incision to the plane of the
two bones. The anterior flap is formed in the same way as in the thigh
amputation, but it has proportionately more integuments and is thinner;
yet its base and length are rendered equal to the base and length of
the posterior flap, and may be adjusted evenly with it when the stump
is dressed. In the circular division of the remaining soft parts,
after the formation of the flaps, there is a necessary variation in
the proceedings, from the circumstance of there being two bones united
by interosseous membrane. It may, however, be accomplished by sweeping
the knife around the more distant bone of the two, its point being
afterward carried between the bones through the interosseous membrane.
While the knife is between the bones, its edge may be so turned that
the membrane may be divided longitudinally to any convenient extent for
the easy introduction of a retractor, and the soft parts around the
bone nearest to the operator may subsequently be divided by a sweep of
the knife in a manner similar to that adopted for the division of parts
around the more distant bone. The sawing of the bones and dressing of
the stump are accomplished as in the thigh amputation; but more care is
required to avoid pressure on the acute margin of the tibia, (which,
when very sharp, should be removed,) and to prevent the pendulous state
of the flaps.

[Illustration:

 _A._ The mid-point between _B_ and _C_, at which the knife is
 introduced for carrying it across the limb.

 _A_ to _D_. The course of the incision to form the posterior flap, _E_.

 _F_ to _g_. The course of the incision to form the anterior flap.]

When the nature of the injury renders amputation necessary at or
immediately below the tuberosity of the tibia, the operation may
be done with safety. Baron Larrey recommended the removal of the
head of the fibula in such cases; I have done it with impunity, and
thereby made a better stump than if it had not been done; but as
the articulating surface of the head of the fibula does sometimes
enter into the composition of the knee-joint, and as this cannot be
known beforehand, the removal of this portion of the fibula is not
advisable, neither must the tibia be sawn through above the tuberosity
lest the capsular ligament be implicated. As an operation by which
the knee-joint is saved, it is important; for although the stump is
very short, it forms a solid support for the body, enables the patient
to walk without the aid of a stick, and admits of the adaptation of
an artificial leg. The skin, in these cases, must be saved in every
direction by flaps, to form a covering. When in sufficient quantity,
the operation may be done by the circular incision, as much muscle
as possible being saved to aid in forming a covering on the under
and outer sides. The posterior tibial artery will be found to have
retracted behind the head of the bone, whence it, or others which may
bleed, must be drawn out. The nerves should be cut as short as possible.


EXCISION OF THE ANKLE-JOINT.

[Illustration]

92. This operation should be performed in the following manner: Begin
the incision behind the external malleolus, an inch and a half above
its lower extremity, and carry it downward and then forward across the
front of the ankle-joint, then under the internal malleolus and upward,
close behind this process, to the extent of an inch and a half; this
incision should merely divide the skin, and should not, on any account,
wound the subjacent parts. Raise the flap thus made, and, placing the
leg on its inside, detach and turn aside the peronei tendons from the
groove behind the external malleolus. Cut through the external lateral
ligaments of the ankle-joint, keeping the knife close to the end of the
fibula; then, with the large bone-scissors or nippers, cut through the
fibula from one-half to three-quarters of an inch above its junction
with the tibia, and, after dividing the ligamentous fibers connecting
the two bones, remove the malleolus externus. Turn the leg on to its
outer side, and cut through the internal lateral ligament close to the
tibia, to avoid wounding the posterior tibial artery; this will allow
the foot to be dislocated outward, and the lower end of the tibia
to be brought well out through the wound. An assistant keeping the
foot and tendons out of the way, the lower end of the tibia is to be
removed by a fine saw to the same extent as the fibula, or as high as
the injury or disease requires. The articulating surface, or injured
part of the astragalus, is then to be removed, after which the foot
is to be returned to its proper position, and the cut surfaces of the
tibia and astragalus brought into close approximation, and so kept by
suture, strapping, and bandage. The limb is to be placed on an outside
leg-splint, having a foot-piece to it; and in order to prevent any
matter oozing, an opening should be maintained on the outside of the
joint, with a corresponding hole in the dressing and splint for this
purpose, until the recovery is completed. The shot-hole will sometimes
answer the purpose, when the injury is inflicted by a musket-ball.
There are no vessels to tie, unless wounded accidentally.


REMOVAL OF THE OS CALCIS.

93. If this bone should be much shattered, and the injury nearly
confined to it alone, it may be removed in the following manner: Make
a semilunar incision down to the bone from the posterior angle of the
inner malleolus, across the sole of the foot to the external malleolus,
the convexity of the flap being forward. This flap being turned back,
the tendo Achillis is brought into view, and is to be separated from
its attachment or cut across above it. The point of junction between
the calcis and astragalus having been ascertained, the ligamentous
fibers are to be cut through and the joint between them opened, when
the knife is to be carried from behind forward, in order to divide the
interosseous ligament between them. Some ligamentous fibers passing
between the calcis and cuboid bones are then to be cut through, when
the os calcis may be dissected out without difficulty. The posterior
tibial artery and nerve will be divided.

This bone was first removed for disease of its substance by Mr.
Hancock, and the operation has been done several times since by Mr.
Greenhow and others with success.

94. When the bones of the leg are not injured, although those of
the tarsus are so far destroyed as to render amputation necessary,
the operation introduced by Mr. Syme for removing the foot at the
ankle-joint will be well adapted for this injury, provided the soft
parts have not been so much destroyed as to prevent the formation of
the covering flap or flaps. His directions are:--

“Pressure should be made on the tibial arteries by the finger of an
assistant or a tourniquet applied above the ankle. The only instruments
required are a knife, the blade of which should not exceed four inches
in length, and a saw. The foot being held at a right angle to the leg,
the point of the knife is introduced immediately below the malleolar
projection of the fibula, rather nearer its posterior than anterior
edge, and then carried straight across the bone to the inner side of
the ankle, where it terminates at the point _exactly opposite_ its
commencement. The extremities of the incision thus formed are then
joined by another passing in front of the joint.

[Illustration]

“The operator next proceeds to detach the flap from the foot bone,
and for this purpose, having placed the fingers of his left hand over
the prominence of the os calcis, and inserted the point of his thumb
between the edges of the plantar incision, guides the knife between
the bone and nail of the thumb, taking great care to cut parallel with
the bone and to avoid scoring or laceration of the integuments. He
then opens the joint in front, carries his knife outward and downward
on each side of the astragalus so as to divide the lateral ligaments,
and thus completes the disarticulation. Lastly, the knife is carried
round the extremities of the tibia and fibula so as to afford room
for applying the saw, by means of which the articular projections are
removed, together with the thin connecting slice of bone covered by
cartilage. The vessels being then tied, and the edges of the wound
stitched together, a piece of wet lint is applied lightly over the
stump, without any bandage, so as to avoid the risk of undue pressure
in the event of the cavity becoming distended with blood, which would
be apt to occasion sloughing of the flap. When recovery is completed,
the stump has a bulbous form, from the thick cushion of dense textures
that cover the heel, and readily admits of being fitted with a boot.

“The advantages which I originally anticipated from this operation
were--_first_, the formation of a more useful support for the body
than could be obtained from any form of amputation of the leg; and,
_secondly_, the diminution of risk to the patient’s life, from the
smaller amount of mutilation, the cutting of arterial branches
instead of trunks, the leaving entire the medullary hollow and
membrane, and the exposure of cancellated bone, which is not liable to
exfoliate like the dense osseous substance of the shaft. From my own
experience, amounting to upwards of fifty cases, and that of many other
practitioners who have adopted amputation at the ankle, I now feel
warranted to state that these favorable expectations have been fully
realized, and that, in addition to its other advantages, this operation
may be regarded as almost entirely free from danger to life.”

This operation has not answered, in some of the hospitals in London,
the expectations entertained of it from its success in Edinburgh, the
flap formed from the under part, or heel, having frequently sloughed.
This, Mr. Syme declares, is the fault of the operators, and not of the
operation, sufficient attention not having been paid to make the flap
of a proper length, and no more, and to preserve the posterior tibial
artery intact, until it has divided into its plantar branches. He
insists, with reason, that the operation should be done exactly as he
has described it in the following explanation:--

“A transverse incision should be carried across the sole of the foot,
from the tip of the external malleolus, or a little posterior to it,
(rather nearer the posterior than the anterior margin of the bone,)
to the opposite point on the inner side, which will be rather below
the tip of the internal malleolus, but can be readily determined by
placing the thumb and finger at opposite sides of the heel. If the
incision be carried farther forward, a considerable inconvenience is
experienced from the greater length of the flap; and I believe a great
deal of the difficulty that has been attributed to the operation has
arisen from this source--the operator getting into the hollow of the os
calcis, cuts and haggles, in striving to clear the prominence of the
bone, with the desperate energy of an unfortunate mariner embayed on
a lee shore in a gale of wind. Another incision is then to be carried
across the instep, joining the ends of the former. The next point to be
attended to is, that in separating the flap of skin from the os calcis
you must cut parallel to the bone. This is of the greatest importance,
since when the flap is detached from the bone, its only supply of
nourishment must be the branches which run through it parallel to the
surface; and if, instead of keeping parallel to the surface, you cut
on the flap as a butcher does when he skins a sheep--you will, by
scoring it in this way, necessarily cut across these branches. I have
reason to believe--nay, to know--that the sloughing which has occurred
in some cases has been due to these defects in the performance of the
operation; the flap having been cut too long, difficulty has been
experienced in separating it from the calcaneum, and this has led to
the scoring of the flap, which has been inevitably followed by death of
a portion or the whole of it.”

Domestic surgery, or that of civil life, has in these operations of
excision of the ankle-joint, and of amputation at that part, repaid
her Amazonian sister of military warfare for the improvements she has
introduced into the great art and science of surgery; and a degree of
generous emulation will be excited and maintained between them, which,
it may be hoped, will, during the present war in the East, add much to
its scientific and preservative character.

95. A musket-ball will seldom pass through the foot without injuring
a joint of some kind, or wounding a tendon or nerve; and the injury
to the fascia, which is very strong on the sole of the foot, and
frequently covered by much thickened integument, is always attended
with inconvenience. The extraction of balls, of splinters of bone, of
pieces of cloth, and the discharge of matter become more difficult, and
often cause so much disease as ultimately to render amputation of the
foot necessary. Tetanus is a frequent consequence of these injuries,
and is a disease, in its _acute_ form, certainly irremediable by any
operation or medicine at present known. Amputation has always failed
in my hands, although it was strongly recommended by Baron Larrey. The
operative surgery of the foot should be done as soon after the injury
as it can be conveniently accomplished; for a large, clean, incised
wound is a safe one, compared with a torn surface of much less extent,
and a splintered bone with extraneous substances; as a ball lodged in
the foot is always very dangerous, great attention should be paid in
the examination of even slight wounds. A cannon-shot can seldom strike
the foot without destroying it altogether; it may, however, strike
the heel and destroy a considerable part of the os calcis, without
rendering amputation necessary, if the ankle-joint be untouched; for by
due attention in removing the spicula of bone at first, and by making
free openings for the discharge of matter in every direction in which
it may appear inclined to insinuate itself, the limb may be preserved
in a useful state.

The following case, from the surgeon of the 44th Regiment, in the
Crimea, is an instance of the removal of the foot after the manner
recommended by the late M. Roux, every effort having previously been
made to save it: “Chloroform having been administered, an incision was
commenced immediately in front of and below the internal malleolus;
this was carried downward and forward until it reached the center of
the sole of the foot. From the extremity of this a second incision was
made nearly at right angles, extending backward along the sole and
upward over the attachment of the tendo Achillis to the os calcis.
A third incision was carried from this round and below the external
malleolus to meet the first at its commencement. Disarticulation of the
ankle-joint was made from the outside, the soft parts put well on the
stretch by forcibly depressing the foot, when, by successive sweeps of
the scalpel, care being taken to keep the edge close to the bone, the
os calcis was separated from its connection with the soft parts. The
plantar arteries were divided at the very extremity of the flap. The
operation was completed by sawing off the two malleoli and the thin
scale of the articulating surface of the tibia. The anterior tibial
and the two plantar arteries each required a ligature. Sutures were
inserted, and the flap supported by strips of wet lint. The operation
was performed on the 4th of July. The stump was dressed the second
day after the operation. There had been no hemorrhage; the flap was
partially adherent; on the outer side the skin was red, tense, and
shining; the sutures were very tight; they were removed from this part;
no appearance of sloughing.

“July 26th.--The ligatures came away upon the sixth day; no sloughing
of the flap occurred; a small abscess formed both on the outside and
inside of the leg, just where the malleoli were sawn off. These were
opened; the redness of the skin rapidly disappeared after this. The
line of incision is now entirely healed at the outer part; the inner is
not so far advanced, but is doing well. The flap is becoming a firm,
round cushion; and the pressure, when he walks, will fall upon the skin
taken from the sole of the foot. The advantages which this operation
appears to possess are, that the flap is not so large and baggy as in
the early stage after Syme’s amputation; it is performed with greater
facility and rapidity, and there is less chance of wounding the
posterior tibial artery.”

The accompanying sketch is of the astragalus and calcis of the right
foot, with a ball lodged on the inside, where it joins the smaller
apophysis of the os calcis. The round spot (No. 3) represents the ball,
and the tendons of the anterior tibial and of the common flexor muscles
of the toes must have been divided by it; the proper flexor of the
great toe is at some little distance below, and unhurt; the posterior
tibial nerve and the artery, about to divide into the two plantars,
are still farther distant. In this case the ball might and ought
to have been removed by the gouge, the small chisel, the screw, or
other instrument supplied for this purpose, as soon as possible after
the injury. Nothing was done, however; inflammation and ulceration
extended into the ankle-joint, and the amputation of the foot by the
flap operation at the joint was performed and failed. The leg became
affected; and the case ended in amputation of the thigh, from which the
man recovered, and was sent to England. I know not his name, nor the
regiment he belonged to, nor the surgeon who attended him, nor any more
of the case, as the bone only has been sent to me from Scutari as a
personal attention.

[Illustration:

  1. Astragalus.
  2. Os calcis.
  3. The ball.
  4. Ligament descending from the tibia, torn by the ball.
  5. Tendons of tibialis anticus and flexor communis cut across by the
     ball.
  6. The other end of the same tendons.
  7. The posterior tibial artery dividing into two branches.
  8. The posterior tibial nerve.
  9. The tendon of the flexor proprius pollicis.]

If the ball had entered to a greater depth, the proper operation would
have been to remove the bone altogether, which is a difficult and
disagreeable operation, even when done in cases in which this bone has
been dislocated, and is projecting under the skin. It is much more
so when in its proper place; less so when the ends of the tibia and
fibula are also removed for disease of these parts, in which case,
the bone being softened, it yields readily to the scissors, by which
it should be divided, and to which it opposes, when sound, a great
resistance from its solidity. The removal of the astragalus alone has
been successfully performed for disease in children, in two instances,
by Mr. Statham, of University College Hospital, and has been strongly
recommended by Dr. Buchanan, of Glasgow, and others. The operation,
according to Mr. Statham’s method, is to be done as follows: An
incision, four and a half inches long, is to be commenced within the
anterior edge of the fibula, and carried down in a straight line beyond
the anterior end of the metatarsal bone of the little toe; a second
incision, about an inch in length, should then be made from the center
of the wound downward toward the sole of the foot, for the purpose
of giving room. The integuments are then to be raised from the bone,
from the upper edge of the first incision, carrying with them the
extensor tendons toward the inside of the foot, to give more room for
ulterior proceedings, without injuring them. The under joint of a pair
of short, strong scissors, such as are supplied in the capital cases of
instruments, ought then to be pushed under the neck of the astragalus,
at the hollow, where it is attached by a strong interosseous ligament
to the os calcis. The upper blade being then closed upon the bone, it
may be divided, but not without considerable force. The articulating
end of the astragalus with the os naviculare can then be easily removed
by a strong pair of forceps, its ligamentous attachments being first
divided by the knife. In order to extract the remaining portion of
bone, the under blade of the strong scissors must be again pushed
under it from before backward, and made to cut it in two. The outer
part being now separated from the internal end of the fibula, care
being taken not to injure the perpendicular ligament going from that
bone to the os calcis, this piece should be forcibly removed by strong
forceps--an operation which could not be easily borne unless chloroform
were used. The remaining piece or pieces must follow, when an
examination should be made by the finger to ascertain that none remain.
The parts should be brought together, a little lint and cold water
applied, the limb placed on a splint, and interfered with afterward as
little as possible. The wood-cut represents the forceps for extracting
a ball imbedded in the astragalus.

[Illustration]

Many years have elapsed since I stated that muscles might be cut across
without, or with very little, inconvenience resulting from their
division. Mr. Stanley has lately shown that tendons even may be cut
across with little disability following, in a boy who had suffered
an injury to the wrist; inflammation followed, with disease of the
bones; and Mr. Stanley, instead of amputating the hand, made a flap
on the back of it through the tendons. He removed seven of the small
bones--all, indeed, except the trapezium supporting the thumb. The
tendons reunited, and the boy has a remarkably good motion of the hand
and fingers--proving the propriety of an operation which does so much
credit to Mr. Stanley.

The astragalus may be also removed by a similar flap operation dividing
the extensor tendons of the toes, commencing on the outside of the
fibula, and being carried round in front, but not so far as to injure
the tibialis anticus tendon, nor the anterior tibial artery and nerve;
or, when the incision reaches the edge of the outer extensor, the whole
of them are to be separated from the parts beneath, and drawn inward,
when the operation of removing the bone is to be completed, as in
the former instance. But many surgeons believe that when tendons are
forcibly drawn aside, after being separated from their attachments,
they are apt to slough, and that their division would, in most cases,
be less injurious. In neither operation need tendon, artery, vein, or
nerve of any importance be divided.

It may perhaps be stated that less regard is paid generally to gunshot
wounds of the foot in which balls lodge than is desirable; and that
other methods of operating may be devised for removing the astragalus
less difficult in their performance, and more advantageous for the
sufferers. The other bones of the instep and foot should be treated in
a similar manner when balls lodge in them. Their removal may be more
readily effected.

96. Wounds from cannon-shot injuring the fore part of the foot are
better remedied by amputation at the joints of the tarsus with the
metatarsus, than by sawing these bones across; but when the injury
affects only one or two toes, they may be removed separately,
recollecting that it is of greater importance to preserve the great
toe than any other, and that this toe is worth preserving alone,
when any one of the others would be rather troublesome than useful.
Musket-balls seldom commit so much injury as to require amputation as
a primary operation, although they may frequently render it necessary
as a secondary one. The splinters of bone are to be removed, the ball
and extraneous substances are, if possible, to be taken out; and if
the bones, tendons, and blood-vessels are so much injured as to render
the attempt to preserve them useless, amputation is to be performed. If
the preservation of the limb be thought practicable--and it generally
will be so in wounds from musket-balls--the attempt must be made
under the most rigid antiphlogistic treatment, the local application
of leeches and cold water from the first, with free openings for the
subsequent discharge. Musket-balls seldom injure the metatarsal bones
so as to require their removal with their toes, and under the treatment
above mentioned these wounds will in general be healed without further
operation. Wounds from grape-shot occasionally render the removal of
the metatarsal bone of the great toe at the tarsus necessary, although
much should be done to save it. The little and adjacent toes are also
sometimes removed at the tarsus, the middle ones but seldom, as it is
not an easy operation to perform, in consequence of the naturally close
attachment of these bones, and the additional compactness they have
acquired from the pressure of the shoe. Hemorrhage from the arteries
of the foot authorizes amputation in a very slight degree, even when
superadded to other causes; for the incisions necessary to secure the
bleeding vessels will not, in general, add much to the original injury,
unless they be very extensive; while, on the contrary, they render the
wound less complicated and more manageable.

97. Amputation at the tarsus, when it is proposed to save the flap from
the under part of the foot, is performed in the following manner: The
joints of the metatarsus with the tarsus having been well ascertained,
an incision is to be made across the foot, in the direction of the
joints, but from half to three-quarters of an inch nearer the toes,
and the integuments drawn back over the tarsus. From the extremities
of this incision, two others are to be made along the sides of the
great and little toes, for about two inches and a half, according to
the thickness of the foot; the ends of these two incisions are to be
united by a transverse one down to the bone, on the sole of the foot,
the corners being rounded off. The flap thus formed on the under part
is to be dissected back from the metatarsal bones, including as much
of the muscular parts as possible, as far as the under part of the
joints of the tarsus. The metatarsal bones are now to be removed by
cutting into and dislocating each joint from the side, commencing on
the outside, by placing the edge of the knife immediately above, but
close to the projection made by the posterior part of the metatarsal
bone supporting the little toe, which prominence is always readily
perceived. The arteries are to be secured, any long tendons and loose
capsular ligament to be removed with the knife or scissors, and the
under flap, formed from the sole of the foot, is to be raised up so as
to make a neat stump when brought in contact with the upper portion of
integuments that was first turned back; the whole to be retained in
this position by sutures, adhesive plaster, and bandage. When the skin
of the under part of the foot is much torn, which is not uncommon in a
wound made by a fragment of a shell, the flap cannot be formed from it;
in this case it must in a great measure be saved from the upper part;
but the integuments being here so much thinner, the flap is not so good
a defense against external violence, and will be more readily affected
by cold. The metatarsal bones may be sawn across in a straight line, in
preference to removing them at the joint; and although the whole may be
sawn across at once with more ease than any one of them individually,
except the outer ones, yet the stump is never so much protected from
external violence as when the operation is performed at the joints of
the tarsus.

98. Amputation of the foot, leaving the astragalus and calcis, may,
in certain cases of injury anterior to these bones, be performed with
advantage, care being taken to make the under flap so large that the
line of cicatrization may be on the upper and anterior edge of the
stump, rather than transversely across the face of it, in order to
render it firmer, and better able to resist and sustain any pressure
which may be applied to it.

The limb being placed on the table, and held by an assistant, the
surgeon ascertains the situation of the joint formed by the junction
of the astragalus with the scaphoides, which will be indicated by the
prominence on the inside of the tarsus, discoverable by passing the
finger forward from the malleolus internus toward the side of the great
toe. The joint of the os cuboides with the os calcis on the outside
is always to be found about half an inch behind the projection formed
by the posterior part of the metatarsal bone of the little toe. The
under part of the foot being firmly held in the palm of the surgeon’s
hand, he places the point of the thumb on the external joint, and that
of the forefinger over the internal one; these indicate a transverse
oblique line for the first incision, which should commence near the
thumb, and be continued with a semilunar sweep, the convexity toward
the toes, until it terminates at the side of the foot where the
forefinger was placed. The joint between the astragalus and scaphoides
is now to be opened, by directing the knife from within obliquely
outward toward the projection of the metatarsal bone of the little
toe. These bones are then to be dislocated by pressure, and the
ligaments retaining them divided. The joint between the os cuboides
and the os calcis is next to be opened from without inward, and the
bones dislocated. The strong inter-articular ligament being cut, and
the joint largely opened, the knife is to be passed between the under
surfaces of the scaphoides and cuboides, and the soft parts adhering to
them, and a flap cut from behind forward sufficiently large to cover
the wound, which is then to be dressed in the usual manner.

99. Mr. Wakley, jun., has lately performed a successful operation for
the removal of the astragalus and calcis, deserving of imitation in
peculiar cases. It is done as follows:--

“The patient being under chloroform, the diseased foot (the left)
having been drawn forward, so as to be free from the table, an incision
was made from malleolus to malleolus, directly across the heel. A
second incision was next carried along the edge of the sole, from
the middle of the first to a point opposite the astragalo-scaphoid
articulation, and another on the opposite side of the foot, from the
vertical incision to the situation of the calcaneo-cuboid joint. These
latter incisions enabled the operator to make a flap about two inches
in length from the integument of the sole. In the next place a circular
flap of integument was formed between the two malleoli posteriorly,
the lower border of the flap reaching to the insertion of the tendo
Achillis. This flap being turned upward, the tendon was cut through,
and the os calcis, having been disarticulated from the astragalus and
cuboid bones, was removed, together with the integument of the heel
included between the two incisions. The lateral ligaments connecting
the astragalus with the tibia and fibula were next divided, and the
knife was carried into the joint on each side, extreme care being
observed to avoid wounding the anterior tibial artery, which was in
view. The astragalus was then detached from the soft parts in front
of the joint and from its articulation with the scaphoid bone, and the
malleoli were removed with the bone-nippers. The only artery requiring
ligature was the posterior tibial. During the few minutes the
operation lasted, the patient did not manifest the slightest symptoms
of pain or uneasiness. On bringing the edges of the flaps together,
they were found to fit with accuracy, and were secured by twelve
interrupted sutures. The wounds were covered by several folds of lint,
and supported by a light bandage. The patient, who had lost but very
little blood, was then removed to his bed.

[Illustration: The incisions above described are here marked out on a
healthy foot.]

[Illustration: The skeleton of the foot will at the same time show the
amount of bone removed.]

[Illustration: These drawings exhibit the present condition of both
sides of the foot--the amount of deformity is less than might have been
expected.]

“On the 21st of February he was discharged the hospital, exactly two
months after the operation, to go into the country, the foot being
well, with the exception of a small opening. He came again up to town
on the 15th of April, and has become stout. The sinus on the left side
of the foot had closed, but a slight collection of matter had formed
a little above the instep; this was discharged by means of a puncture
with the lancet, and he was directed to return to the country, and dash
cold water over the foot two or three times daily. On the 10th of June
he returned to town to his employment. There was then not the vestige
of a wound, the last opening having completely closed. He was ordered
to wear a high-heeled boot. He is now a healthy-looking man, and walks
very well.”

As the posterior tibial must be divided, the preservation of the
anterior artery is essentially necessary; the success of the operation
depends upon it. This artery, accompanied by its vein and nerve, lies
close upon the astragalus; the artery may be said to be even attached
to it, a point requiring the greatest attention in dissecting out the
bone without injuring this vessel, which is seen under the scalpel.

100. Amputation of a single metatarsal bone, on the outside or inside
of the foot, is to be done by an incision round the root of the toe,
terminating in a line on the outside of the foot, which is continued
down to the joint of the tarsus. The integuments are turned back above
and below from the metatarsal bone, which is to be dissected out,
with the toe attached to it, and the flaps brought together so as to
leave but one line of incision. In military surgery, there is always a
wound; and when the removal of the bone is necessary, it is in general
an extensive one, with loss of substance, so that a covering cannot
be saved in this way, especially on the upper part of the foot, when
struck by a ball or piece of shell. The surgeon, therefore, must be
prepared to look for his covering on the under part, where he will
occasionally not be able to procure it in sufficient quantity, and it
must not be forgotten that the neighboring parts will often be injured.
The object must then be to save the integuments from such parts as
are uninjured, so as to cover in the wound as nearly as possible when
the bone has been removed. In doing this, the first incision should
commence at the upper part and inside of the toe, and be carried round
so as to separate the toe from its attachment to its fellow. If the
injury be entirely on the upper part, the continuation of this incision
must be so regulated as to form the whole of the flap from below, and
its commencement above must be continued round the injured part so
as to meet the lower end near the articulation of the bone with the
tarsus, and _vice versa_. If the ball have gone directly through,
destroying the integuments above and below, the incisions must surround
the injured part in such a manner, on the upper and under side of the
foot, as to allow the flaps to be formed in every other part, except
where the injury was inflicted, from which granulations must arise. By
saving skin everywhere else, the wound will be much diminished in size,
will heal sooner, will be less liable to suffer from external violence
and less obnoxious to the subsequent pain which generally at intervals
attends wounds of this kind.

[Illustration: _Amputation above Knee._

  _a_, wooden bucket for stump;
  _b_, pin to attach foot;
  _c_, the rolling foot;
  _d_, straps of attachment to body.]

[Illustration: _Amputation below Knee, No. 1._

  _a_, wooden shape to receive knee;
  _b_, pin;
  _c_, rolling foot;
  _d_, _e_, straps of attachment.]

[Illustration: _Amputation below Knee, No. 2._

  _a_, wooden bucket to receive the whole of stump;
  _b_, fixture to foot;
  _c_, rolling foot;
  _d_, straps for knee.]

101. M. de Beaufoy has invented a foot for the wooden pin used by the
soldiers in the Invalides, at Paris, who had suffered amputation above
or below the knee; this, Mr. Bigg, of Leicester Square, has tried on
some old soldiers at Chelsea Hospital; one of them reports that he has
not only found his step to be steadier, but that he could walk twice
the distance in the same time that he could with his ordinary pin-leg.

The advantage of the invention is, that whereas a common wooden pin
only gives one point of support, and consequently the body is obliged
to raise itself so as to describe an arc, of which the end of the
wooden pin is the center, the curved foot acts like a _series of
levers_, each successive point of it being a _fulcrum_. The precaution
should be taken to have the aperture at _a_, fig. 2, for the insertion
of the pin, made square, to prevent its turning when in use.



LECTURE VI.

PRIMARY AMPUTATION, ETC.


102. An upper extremity should not be amputated for almost any accident
which can happen to it from musket-shot; and there is scarcely an
injury of the soft parts likely to occur which would authorize
amputation as a primary operation.

103. If the head or articulating extremity of the bone entering into
the composition of the shoulder-joint be merely or slightly injured
by musket-shot, the arm ought to be saved with some defect of motion
in the joint. The wound should be enlarged in the first instance, to
allow of a sufficient examination with the point of the finger, and
any loose pieces of bone should be removed. Inflammation is to be
restrained within due bounds until suppuration has been established,
when, if a clear depending opening should not exist for the discharge
of the matter poured out, it should be made, and any loose portions of
bone removed. The principal points to attend to are, the prevention
of sinuses around the joint, by the formation of dependent openings,
position, perfect quietude, due support, the methodical application of
bandages, and occasional mild stimulating injections into the wound. A
simple incised wound penetrating the joint, and even injuring the bone,
does not call for any immediate operation. An attempt should be made
to effect a cure by the first intention, which can only be managed by
means of proper position and support.

104. If the head of the bone be much splintered, or if a ball have gone
through it, that portion should be sawn off; for a part thus injured
has often been a source of great inconvenience and suffering for many
years afterward--during, in fact, the remainder of the life of the
sufferer; which misery would have been avoided by the excision of the
head of the bone in the first instance--an operation which ought in
fact to be done even at a later period, if it had not been performed
at the time when the injury was received. Secondary operations of this
kind are never so successful as primary ones, and great discrimination
should be exercised in attempting to save the head of the bone, or, in
other words, to avoid the operation for its removal.

105. When the splinters extend far into the shaft of the humerus,
it may be proper to amputate the whole extremity, especially if the
great artery be also wounded; but the shaft is seldom broken in such
accidents to any great extent, and amputation should be confined almost
to injuries from cannon-shot or shells, or heavy machinery, destructive
of the soft parts as well as of the bone.

106. When the injury done to the upper arm is so extensive that it
cannot be saved, although the head of the humerus be not injured, the
amputation should take place immediately below the tuberosities, and
not at the joint, which latter operation always renders the shoulder
flatter, and the appearance of the person more unseemly, than when the
head of the bone is left in its place.

107. It will frequently happen that the arm may be irrecoverably
shattered, and the thorax partake in a less degree of the injury, there
being apparent only some slight contusion or grazing of the skin; if
low down, the elasticity of the false ribs may have prevented the
integuments being much injured in appearance, although the blow has
been violent; yet the force of the large shot may have ruptured the
liver or spleen. If higher up, it may perhaps fracture the ribs, in
addition to a more severe contusion of the integuments. When these
accidents occur, the symptoms arising from the wound or contusion
of the trunk of the body are to be first considered. If they do not
indicate a speedy dissolution of the patient, or the prospect of such
an event in two or three days, the operation ought to be performed,
and a chance of recovery given to the sufferer, which he would not
have, the arm being retained, and the injury of the chest remaining
the same. The danger to be apprehended in the more favorable cases is
from inflammation, and this will be rather diminished than increased
by the operation; the danger of deferring which is manifest and
certain, while the injury committed in the thorax or abdomen is not
ascertained, and its effects may be obviated. If the termination should
be unfavorable, it can only be a matter of regret for the sake of the
individual, and not for the non-performance of a duty. If the cavity
of the chest be laid open, or several ribs beaten in, or a stuffing
of the lungs take place from a large ruptured blood-vessel--all of
which circumstances are obvious, and cannot be mistaken--the operation
would, in all probability, be useless. A hemorrhage of short duration,
or the expectoration of blood in moderate quantities, although a
dangerous symptom, is not to be considered as depriving the patient
of a reasonable chance for life, for it frequently follows blows from
more common causes, from which many people recover. If the operation
be delayed to ascertain what injury may have been done to the chest,
from the symptoms that will follow, the danger resulting from both will
be increased; and even when it has been ascertained that there is but
little mischief existing in the thorax, the operation can no longer be
performed with the same propriety, in consequence of the inflammation
which has supervened; and the patient will probably die, when he would
have recovered under a more decided mode of treatment.

108. A round shot or flat piece of shell may strike the arm, after
rebounding from the ground, or when nearly exhausted in force, without
breaking the skin, or only slightly doing it, yet all the parts within
may be so much injured as not to be able to recover themselves: the
bone may be considerably broken or splintered, the muscles and nerves
greatly contused. The injury may not, perhaps, be quite so extensive.
The bone may be merely fractured, and yet the soft parts will often be
so much destroyed as not to be able to carry on their usual actions.
A ruptured blood-vessel may, with an apparently slight external wound
of this nature, pour out its blood between the muscles, and inject the
arm to nearly double its size, all of which are causes rendering an
operation necessary, and requiring decision, for inflammation will,
and mortification may, ensue in a short time, when the most favorable
moment for operation will have been lost.

109. _Amputation at the shoulder-joint_ is an operation of little
surgical importance. The fear formerly entertained of loss of blood
has passed away, and every surgeon now knows that if he should happen
to cut the axillary artery unintentionally, it can be held between the
forefinger and thumb, without difficulty or danger, until a ligature
can be placed upon it. No accomplished surgeon of the present day
should give himself the least concern about compressing the subclavian
artery. It is, on the contrary, better, when the arm is raised from
the side preparatory to entering or using the knife, that the surgeon
should then feel the pulsation of the artery in the axilla, that he
may the more easily avoid, and subsequently command it. The axillary
artery does not throw out much blood at each pulsation, and a little
pressure with the end of the forefinger will always prevent bleeding,
until the surgeon is prepared to take hold of the vessel with the
tenaculum or forceps. The operator should, in fact, divest himself of
all fear of hemorrhage. When gentlemen are afraid, however, and cannot
help it, (for Henry IV. of France, _ce roy si vaillant_, always felt an
inconvenient intestinal motion when a fight began,) compression may be
made upon the subclavian artery by the thumb of an assistant, the round
handle of a key, or the padded end of the handle of a tourniquet; the
latter forms the best pad, and is usually at hand.

110. The great point to be attended to in performing the operation is
to save skin to cover the stump. The directions, therefore, which are
usually given for doing it after any particular method can only be
occasionally useful; for the surgeon may not always be able to select
the parts to be divided or retained. In cases of malignant disease
of the bone and periosteum of the middle of the arm, my experience
directs the removal of the whole of the bone at the joint, and not the
amputation below the head; although the appearance of the integuments,
and of the bone itself, would seem to encourage the attempt to preserve
the roundness of the shoulder. In such cases, the removal of the
extremity at the joint may be done by any one of the many ways which
have been recommended for its performance. In none should the acromion
or coracoid process be exposed, unless previously injured. Neither is
it necessary to lose time, or to give pain, by depriving the glenoid
cavity of its cartilage; but it should always be borne in mind that if
the nerves be not shortened after the removal of the arm, they may be
included in or adhere to the cicatrix, and cause, during a long life,
much distressing pain to the sufferer.

111. Amputation at the shoulder-joint, performed immediately after
the receipt of an injury, is now a very simple operation, for which
simplicity English surgery is also indebted to the Peninsular war. As
a _secondary_ operation, or done at a later period, when the parts are
all impacted together, it is less so. In both stages it is absolutely
necessary to remember--1st. That, except in cases of disease, and not
of injury, the shaft of the bone must be broken; and that _all_ the
directions usually given for rotation of the arm inward and outward
during the operation are _unnecessary cruelties_ not to be attempted,
and rarely to be effected if attempted, with a broken bone. 2d. That
the arm should always be raised from the side and supported by the
hand of an assistant, who can feel, if he please, at any time of the
operation, the pulsation of the axillary artery; and all operative
methods are hereby condemned in which this precautionary measure is not
the first step.

112. _Operation by two flaps, external and internal._--The
outer--beginning nearly an inch below the acromion process, the hair in
the axilla having been previously removed--is to be carried down with
a gentle curve so deeply as to divide the deltoid muscle, and to show
the long head of the triceps at its under and outer edge. The second
incision is to be carried in a similar direction on the inside, through
the deltoid muscle, but need not divide the insertion of the pectoralis
major, which should be exposed. These flaps being held back, the joint
will be seen and readily opened into at its upper part, by cutting upon
the head of the bone, in doing which the long tendon of the biceps will
be divided, allowing the head of the humerus to drop from the glenoid
cavity sufficiently to admit the forefinger of the left hand, on which
the supra-spinatus, infra-spinatus, and teres minor may be cut through
externally, as they go to be inserted into the great tuberosity,
and the thick tendon of the sub-scapularis muscle internally, where
it is attached to the smaller tuberosity. The head of the bone is
then readily drawn out from the glenoid cavity, when the inner flap,
including the axillary artery, vein, and nerves, may be taken hold
of between the two forefingers and thumb of an assistant, while the
surgeon, with one sweep of the knife, divides all the remaining parts
below. The axillary and the posterior circumflex arteries will have to
be secured; the anterior circumflex, when arising from the posterior,
is frequently cut off with it; the nerves are to be shortened; the
flaps brought together by sutures; and an especial pad placed upon the
pectoralis major, to prevent unnecessary retraction, if possible.

113. _The operation by one_, or nearly one upper flap, is to be
performed when the under soft parts of the arm have been destroyed,
and the bone broken. It may be done by thrusting a small, two-edged
knife through the integuments and under the deltoid muscle, from side
to side, to form a flap; or it may be made by commencing an incision
an inch above the posterior fold of the armpit, and carrying it over
the arm in a curved form, the convexity being downward, to the same
height on the anterior fold; the lowest part of the incision being five
fingers’ breadth from the point of the acromion, the posterior end or
point of it being somewhat higher than the anterior one. The flap being
turned up, and the tendon of the pectoralis major divided, the head of
the bone is to be exposed and separated as before stated, as much as
possible of the integuments being preserved on the under part of the
arm. This will often be best done by dissecting out the head and broken
pieces of bone, and then preserving in succession every piece of sound
integument, before the artery, vein, and nerves are divided.

114. Lisfranc and many French and continental surgeons recommend
the operation to be done with a pointed, double-edged knife, in the
following manner: The arm being approximated to the trunk, in a state
of half pronation, the point of the knife is to be entered at a
small triangular space, which may be perceived on the inside of the
fullness of the shoulder, bounded above by the scapular extremity of
the clavicle and a small part of the acromion; on the inside, by the
coracoid process; and on the outside, by the head of the humerus. The
knife thus entered obliquely is to be passed across to the outside,
opening in its passage into the joint, when, by sliding the knife
forward over the head of the bone, while the deltoid is raised up by
the operator or an assistant, a flap is to be formed, during which
proceeding the arm is to be raised from the side, to facilitate
its performance. If this flap be well made, the upper part of the
capsular ligament, the tendons of the long head of the biceps, and the
supra-spinatus are divided, and the tendons of the infra-spinatus,
teres minor, and sub-scapularis are also cut through in part, if not
entirely. The upper and posterior flap is thus completed.

In the second step of the operation, the surgeon passes the knife
behind the head of the humerus, and makes the under and anterior or
inner flap, by cutting downward and inward, including in it a very
small portion of the deltoid, the pectoralis major, latissimus dorsi,
teres major, the triceps, coraco-brachialis, the short head of the
biceps, and the vessels and nerves, when the limb is separated from
the body. The flaps are nearly of the same size, and are to be brought
together by sutures.

In the secondary operation, or that done several weeks after the
receipt of the injury, in consequence of the attempt to save the arm
having failed, it should be borne in mind that the soft parts will
often be found so altered and impacted together that they will not
yield or separate; and nothing is gained but by each cut of the knife,
causing thereby some little delay, inconvenience, and loss of time.

115. _Amputation of the arm immediately below the tuberosities of the
humerus_ ought to be done in the following manner: The arm being raised
from the side, and an assistant having compressed, or being ready to
compress, the subclavian artery, the surgeon commences his incision
one or two fingers’ breadth beneath the acromion process, and carries
it to the inside of the arm, below the edge of the pectoral muscle,
then under the arm to the outside, where it is to be met by another
incision, begun at the same spot as the first, below the acromion
process. The integuments, thus divided, are to be retracted, and the
muscular parts cut through, until the bone is cleared as high as the
tuberosities. The artery will be seen at the under part, and should be
pulled out by a tenaculum or spring forceps, and secured as soon as
divided. The bone is best sawn, the surgeon standing on the outside;
the nerves should be cut short, and the flaps brought together by two
or three silk or leaden sutures. There are few or no other vessels to
tie, and the cure is completed in the usual time, while the rotundity
of the shoulder is preserved. This operation is similar to that already
recommended for the amputation at the joint, which in many cases it is
intended to supersede.

116. _Excision of the head of the humerus._--The point governing the
modus operandi of this operation is, and ought to be, the fact that,
under the most favorable state of recovery which can take place, the
shoulder-joint usually becomes so stiff that its ordinary motions may
be considered to be lost. Operative processes which have for their
principal object the sparing of the deltoid muscle are unnecessary,
for, if spared, it is as useless as if it had been cut; and it seems to
have been forgotten that, when cut, it reunites, and becomes nearly as
strong as before it was injured. It is the joint that cannot be moved,
not the muscle which has lost its power. I prefer, therefore, in doing
this operation, in cases of some standing, to make a _short_ crescentic
flap by an incision across the anterior part of the shoulder, as in the
operation of amputation, which, on being turned up, leaves the joint
exposed. The edge of the knife being applied to the head of the bone
in a line below, but immediately under the acromion process, divides
the capsular ligament, and with it the long tendon of the biceps, on
which the arm drops from the socket, or glenoid cavity, and allows the
finger to be introduced, when the three muscles inserted into the great
tuberosity may be cut through, and the sub-scapularis inserted into the
small tuberosity will also be divided. The head of the bone is then
readily brought out, and may be easily detached from any surrounding
connections, and sawn off with little or almost no loss of blood. The
elbow is to be supported, so as to bring the end of the sawn bone in
apposition with the glenoid cavity. The flap may be allowed to unite
with the parts below as soon as it will, the shot-holes, if any, being
in general sufficient to allow of such discharge as may be necessary.

In cases of _recent_ injury, considerable aid will be obtained in
keeping the sawn end of the humerus in apposition with the glenoid
cavity, by not dividing the long tendon of the biceps. This must be
done by dissecting it out of its groove in the humerus, between the
tuberosities, and by cutting through the capsular ligament vertically,
so as to follow it up to its attachment to the upper edge of the
glenoid cavity, when it may be easily drawn aside with a blunt hook,
until the operation has been completed--a proceeding difficult of
accomplishment in old cases of disease or injury, and in them not
necessary nor advisable.

The accompanying sketch shows the head of the humerus of the right
arm or side, with a ball lodged in it, a relic from Inkerman, sent to
me as an especial mark of attention by one of the medical officers
at Scutari, but without the name of the man, the regiment he belonged
to, or the surgeon who performed the operation for its removal. The
following account was wrapped round the bone. It commences a day or two
after the operation was done at Scutari, and shows that the man died
from an affection of the lungs, not uncommon, as was first shown during
the late war, after operations following extensive suppurations:--

[Illustration:

 _a._ The head of the humerus sawn off below the tuberosities.
 _b._ The ball.
 _c c._ Fractures of the head of the bone.]

“Pulse soft, 120. He passed a rather restless night, although he had
another opiate at one A.M., and partially removed the dressings. In
the morning he was better; he took some tea and a little wine with
arrow-root, but was very much depressed in spirits. The wound looked
well, there being less discharge, and of a more healthy character;
no increased inflammation around the wound, but no tendency to union
by the first intention on removal of the stitches. He was put upon
farinaceous diet, with four ounces of wine and beef-tea. He continued
to do well till the evening of the 16th, when he complained of
tightness of the chest and slight cough. Harshness of respiratory
murmur and increased vocal resonance, but no crepitation, could be
detected on the right side on auscultation; he complained also of
pain in the hypogastrium and slight diarrhœa. At bedtime he had a
sedative antimonial draught, after which he rested well, but perspired
profusely. On being particularly questioned, he admitted that he had
had diarrhœa several times since landing at Varna, and had had bloody
stools after the battle of Alma, for which, however, he had never been
off duty; he had also frequently been troubled with cough, and two
of his family, he understood, died of consumption. For two days he
continued to improve in spirits, to take his food better, and the wound
assumed a healthy granulating appearance, but a very small portion
of the end of the humerus appeared white, as if going to necrose. On
the evening of the 18th his breathing was more oppressed, and his
countenance flushed and anxious. On examination of the chest, the
lower two-thirds of the right lung were dull on percussion; bronchial
breathing in the lower half, with crepitation above; in the left lung
loud sub-crepitus; diarrhœa had also supervened during the day, but was
checked for the time by an opiate enema. From this date his strength
gradually sank; the diarrhœa returned again and again, in spite of
repeated opiate enemata and small doses of Dover’s powder with hyd. c.
cretâ. The surface of the wound assumed a less healthy appearance; the
respiration became more labored, and he gradually sank till Saturday,
November the 25th, when he died at half-past ten A.M.

“On examination of the head of the bone, after its removal, there was
found an irregular, rugged cavity in the cancellated tissue, about
an inch long, by half an inch broad, extending nearly transversely
from the smaller to the greater tuberosity, and above the latter a
musket-ball was found deeply imbedded, its external convex surface
being on a level with the articular cartilage. From this several small
fissures radiated over the globular head, and from each end of the
cavity a much deeper one extended round the anatomical neck, separating
the articular portion of the bone, in two-thirds of its circumference,
from the shaft.

“At the post-mortem examination, the surface of the wound looked
black and sloughy near the seat of injury, but more healthy in the
direction of the incisions. A small portion of the end of the humerus
was of a pearly white, in progress of necrosing; but around the shaft,
immediately below this, and in the glenoid cavity, the process of
repair had commenced. Both lungs were found engorged with frothy
serum; the lower two-thirds of the right lung hepatized; traces of
old tubercle in apices of both lungs, with miliary tubercle scattered
throughout the whole substance of the left and upper part of the right.
The whole tract of the colon, from the cæcum to the rectum, presented
traces of ulceration, the ulcers being seldom larger than a split pea,
with hardened, elevated edges; the bases in some instances were formed
by the peritoneum only; generally they were scattered irregularly,
but occasionally they were found in rows corresponding to the long
diameter of the gut. In the rectum the ulceration was more extensive,
in some parts the size of a farthing, the edges very irregular, and the
direction more transverse.” These appearances precisely resemble those
observed during the autopsy in cases of death from consumption, and are
not therefore peculiar to the dysentery under which he had suffered.”

117. Professor B. Langenbeck, in order to save the deltoid muscle,
proposed and practiced the operation in the following manner, during
the Danish war in Sleswick-Holstein, with success in several instances:
Begin the incision through the integuments and deltoid muscle
immediately below the anterior border of the acromion, and continue
it directly downward, over the minor tuberosity of the humerus, to
the extent of four inches. Separate the parts, open the sheath of the
long tendon of the biceps muscle, and draw out and hold it on one side
with a blunt hook. Rotate the arm outward, (_if it will rotate_,) to
facilitate the division of the tendon of the sub-scapularis; then
rotate the arm inward, to aid in the division of the tendons of the
supra-spinatus, infra-spinatus, and teres minor muscles, inserted into
the great tuberosity. Complete the division of the capsular ligament,
push the bone through from below, using the arm as a lever if you can,
and saw it off. No arteries of consequence are wounded.

This operation would not be so easy of execution as is supposed, in
cases in which the head and neck of the humerus are broken from the
shaft; it would be very difficult of execution in old cases in which
the soft parts are so hardened and impacted as to admit of little or no
motion.

The extent to which the shaft of the humerus may be removed with the
head cannot be distinctly defined. The greater the distance, the less
will be the chance of the bone uniting to the glenoid cavity, in such
a manner as to render it a useful limb, whether by the formation of
a ginglymoid joint, or by anchylosis. In the present state of our
knowledge the bone should not be sawn lower than the insertion of the
deltoid muscle. If the arm were preserved by an operation below that
part, it is probable that the bone, however supported, would not become
attached to the glenoid cavity. It might however become useful, by some
artificial help, as has occurred in cases of false joint in the middle
arm, after ununited fractures.

118. Excision of the head of the humerus is not to be done in every
instance of compound fracture of that bone, as the following cases will
show:--

Lieutenant Madden, 52d Regiment, was wounded at the assault of Badajos
in 1812, by a musket-ball, which fractured the head of the humerus,
and lodged in it. The broken pieces were from time to time removed
by incisions, together with the ball, and he ultimately preserved a
very serviceable arm. He is now a very zealous member of the Church of
England.

Robert Masters, 40th Regiment, was wounded at the battle of Toulouse,
on the 12th of April, 1814, by a musket-ball in the right shoulder,
which lodged in the head of the bone. Shown to me a few days afterward
as a case for amputation at the shoulder-joint, I directed the excision
of the head of the bone as soon as the parts became more quiescent.
Under venesection, purgatives, leeches, the constant application of
cold, and low diet, the high inflammatory symptoms which had supervened
subsided, and, six weeks after the accident, the ball, and part of
the head of the humerus, were removed, after an incision had been
made through the external parts for the purpose. Three mouths after
the receipt of the injury, the man was sent to England, with no other
inconvenience than that resulting from the loss of motion in the
shoulder, which was stiff. The use of the forearm was preserved, and a
limited one of the upper arm, by moving the shoulder-bone on the trunk.

Private Oxley, 23d Regiment, was wounded at the battle of Toulouse, in
April, 1814, by a musket-ball, which entered at the anterior edge of
the deltoid muscle, passed across the head of the humerus, injuring
it in its course, and went out near the posterior edge of the muscle,
through which, at its middle part, the deficiency in the rotundity of
the head of the humerus could be distinctly felt. Shown to me a few
days afterward as a slight but peculiar wound, it was marked as a case
for excision, if circumstances should render it necessary. No bad
symptoms, however, supervened; the man only complained of the restraint
put upon him, and the lowness of his diet. Some pieces of bone came
away, or were removed, and in July he was sent to England, the wound
being healed and free from pain; the shoulder stiff. The lower arm he
used as before the accident.

General Lord Seaton suffered from a nearly similar wound, at the taking
of Ciudad Rodrigo, and recovered with a good use of his arm.

These cases were fortunate in their results, but such do not always
follow. Major C. was wounded in one of the battles in the Pyrenees,
in 1813, by a musket-ball, which injured the head of the left humerus
from side to side. Thirty years afterward the wounds still discharged,
and gave him great uneasiness. A probe discovered much diseased bone.
I advised the excision of the head of the bone, to which he would not
assent. His courage had been broken by continued suffering.

Ensign Moore, of the Bengal army, was wounded at Sobraon, on the 10th
February, 1846, by a musket-ball, which passed through the anterior
and inner part of the deltoid muscle, one inch and a half below the
inner part of the acromion process, struck and went through the head of
the bone, which it splintered, and made its exit behind, in front of,
but near the inferior angle of the scapula. He remained in camp three
days, and was sent to hospital at Ferozapore, where he suffered much
from inflammation, pain, etc., and after a month was sent to Subaltro
in the Hills, where some pieces of bone came away, during which time
he suffered severely, and was much weakened by it and the discharge.
On the 20th October, 1846, he was removed to Bunda, in Bundeleund;
here more bone came away, accompanied by much discharge. Thence
he proceeded in April, 1847, to Juanpore, where he suffered three
attacks of inflammation, two of them very severe; the constitutional
disturbance was great. The posterior wound was reopened, and a large
quantity of offensive matter discharged. On the 7th of August, 1847,
the suppuration is stated to have been still great, and the strength
very much reduced, on which account he was recommended to proceed to
Europe. On the 9th June, 1848, the wounds were healed, the last piece
of bone having come away about ten days before. The pieces of bone
are from the head and from the part adjoining. The head of the bone
is greatly diminished in size, so much so as to appear to have been
almost entirely removed; the joint is stiff, if not anchylosed, the
shoulder flat, the under use of the arm perfect, that of the upper
part dependent on the motion of the shoulder-blade. The removal of the
head of the bone, immediately after the receipt of the injury, would
have been the best course to have pursued, for the arm when the cure
took place was not in a better state than it would have been in if the
operation had been performed at first, and the patient would have been
spared two years of great suffering, not unattended with considerable
danger.

M. Baudens, in a very able paper, an extract of which, made by himself,
is published in the “Comptes Rendus” of the French Academy of Sciences,
for February, 1855, on the Resection of the Head of the Humerus, seems
to have overlooked, or not to have seen, the foregoing observations,
as he assumes, as a consequence of his own observations on fourteen
primary cases of which one only died, that the resection of the head of
the humerus ought to be the rule in surgery when a ball has broken this
part, and that amputation of the limb should be the exception--a point
long since settled in my surgical works.

He considers that surgical writers in general have supposed that the
bone remains suspended in the middle of the muscles, which does not
accord with his practice, nor with the remarks made by me on this
subject.

He recommends the following mode of operating: The arm being slightly
turned outward and backward, the point of a small, straight amputating
knife is to be entered on the outside of the coracoid process,
immediately over the head of the humerus; lower the hand and carry the
point of the knife in a straight line for ten or twelve centimeters
downward, always applied to the bone, which serves as a guide.

If the incision thus made should not be large enough to expose the head
of the humerus, a transverse subcutaneous one should be made through
the muscular fibers toward the superior angle. If it be sufficiently
large and open, this is not necessary. The long tendon of the biceps
will be seen at the bottom of the incision, and is to be cut across.

Bring opposite the incision, by rotating the arm, first the great
tuberosity, then the smaller one, in order to divide the four
muscles attached to them. The division of these parts will largely
open the joint, when the elbow being carried backward and upward,
the head of the bone will protrude. Detach gently the periosteum,
slip the chain saw behind and below the head of the bone, so as to
leave the periosteum as much uninjured as possible, doing in fact a
sub-periosteal extirpation.

Tie the vessels, cover the upper end of the humerus with the periosteum
thus saved like a hood, and keep it in contact with the glenoid cavity.

He maintains that when a ball has broken the head of the humerus, if
the removal of the head be not effected, one of three things follows:
the operation is performed subsequently, or the patient dies of
purulent deposits, or recovers with a stiff joint, accompanied by
fistulous openings of a disagreeable nature.

He contends that a ginglymoid joint is always formed by his method,
which enables the sufferer to make much greater use of it than if
the operation were performed in any other way; but it will be very
difficult of performance if the bone should be so much injured as to
prevent the tuberosity following the motion to be given to the elbow,
and is not therefore recommended.

119. If, from some complication of injury, the axillary or other artery
should give way during the treatment, the extremity is not to be
amputated. The artery is to be secured by one ligature applied above
the opening in it and by another below it, the surgeon always bearing
in mind the fact that the proper way to get at the axillary artery is
by cutting _across_ the fibers of the pectoral muscle, and not in their
direction, and that it will be better to amputate the arm than to tie
the subclavian artery above the clavicle.

120. _Amputation of the arm_ by the common circular incision should
only be practiced in the space between the lower edge of the insertion
of the pectoralis major and the elbow-joint; and rarely in cases of
injury from musket-balls. No common flesh-wound, made either by cannon
or musket-shot, even including a division of the artery, absolutely
demands this operation, the bone being uninjured. If, in addition to a
destructive flesh-wound, the bone be broken, or if it be mashed with
the muscles by an oblique stroke of a round shot, or the forearm be
carried away or destroyed, it is admissible. It is to be done in the
following manner: An assistant draws up the integuments with both
hands; another does the same downward, if the parts admit of it; the
forearm is to be moderately bent. The integuments are to be divided
by a circular incision, and retracted. The muscles and vessels are
then to be cut through by one sweep of the knife, if it can be done.
The muscles adhering to the bone are next to be separated from it to
the extent of two inches. The retractor is to be applied, and the
periosteum divided by one circle of the knife around the bone, and
in the circle thus cut the saw is to work until the bone is divided;
attention being paid to the directions already given to saw in a
perpendicular, not slanting direction. The artery or arteries are to be
tied, the surface of the stump cleansed with warm and then with cold
water, and dried. Leaden sutures are useful.

121. Mr. Luke performs the operation by two flaps on the same principle
as in the thigh. There is a close resemblance in the manner of
amputating the arm by the double-flap operation to that adopted for
the amputation of the thigh. The first flap is made posteriorly to the
bone, by transfixing the limb, for which purpose the knife is entered
at the mid-point between the anterior and posterior surfaces, carried
transversely across the limb, and made to cut toward the posterior
surface, in an oblique direction, until all the soft structures are
divided. It is necessary, in entering the knife, to bear in mind that
the bone lies opposite to the mid-point, and that, in carrying the
knife across the limb, it would strike against the surface of the
bone, unless means were adopted for its prevention. This is easily
done by grasping the structures which are to form the posterior flap
between the fingers and thumb of the left hand, and by drawing them
backward during the time the knife is entering at the mid-point and
being carried across the limb. Having formed the posterior flap, the
anterior one is formed as in amputation of the thigh, by cutting inward
from the surface toward the bone with a sweep, which will make this
flap equal in length to the posterior. The operation is completed by
dividing the remaining soft parts by means of a cut carried circularly
around the bone, and by sawing the bone in the line of division. The
after-treatment is the same as in the thigh.

122. _Excision of the elbow-joint._--An incised wound of moderate
extent into the elbow-joint, cutting off with it a part of the condyle
of the humerus, or the head of the radius, or a part of the ulna,
demands the removal of the injured piece of bone only. The forearm
should be bent, and the antiphlogistic treatment fully carried out.
A ball fracturing the olecranon, or other portion of a single bone,
although opening into the joint, does not immediately require any
operation.

If a ball should lodge in the lower part of the humerus, or in either
of its condyles, it should be removed as quickly as possible by the
trephine, or other appropriate instrument.

When the articulating ends of the humerus, radius, and ulna are wholly
or in part injured by a musket-ball, it was formerly the custom to
amputate the arm in such instances of great mischief--an operation
which should be superseded by that of excision of the joint, by which
the forearm will be saved, and considerable use of it retained.

To perform this operation, a straight, strong-pointed knife is to
be pushed into the joint behind, immediately above but close to the
olecranon process, and exactly at its inner edge, to avoid the ulnar
nerve, which lies between it and the inner condyle, to which it may
be considered to be affixed. The incision thus begun is to be carried
outwardly to the external part of the humerus, dividing the insertion
of the triceps. At each end of this transverse cut an incision is to
be made upward and downward for about two inches each way, the three
resembling the letter =H=. The flaps thus made being turned up and
down, the olecranon should be sawn across, together with the great
sigmoid cavity and the coronoid process of the ulna, the insertion
of the brachialis internus having been previously separated from the
coronoid process. Before this is done, the ulnar nerve should be
separated with its attachments from the inner condyle, and turned
aside to avoid injury. The joint being now fully exposed, the head
of the radius may be sawn off or cut through with the strong spring
scissors if possible, above the tubercle into which the biceps tendon
is inserted. The extremity of the humerus should next be pushed through
the wound, and the broken end sawn off, a spatula or other thin
solid substance being placed underneath it, to prevent the brachial
artery or median nerve being injured. Any hemorrhage which there may
be having ceased, the forearm is to be bent, the bones are to be
placed in apposition, and the incisions approximated by sutures and
sticking-plaster, duly supported by compress and bandage, so that
union may take place if possible, particularly of the transverse wound
first made. The arm should be supported by a sling, and dressed early,
as the shot-hole or holes must remain open and discharging. Some motion
of the new joint to be formed may be expected under gentle passive
movements; but as a stiff joint cannot always be avoided, the arm
should be kept bent.

123. _Amputation of the elbow-joint_ has been recommended, but not
frequently performed. It may be done in any way by which good covering
can be obtained, and it has been supposed that the long stump thus
made is more useful if the olecranon process be sawn across, and left
with the triceps attached to it, than if it be removed. When the parts
are sound, a flap may be made in front by introducing a straight,
double-edged knife over the outer condyle, and carrying it across and
through the soft parts over the opposite or inner condyle, when by
cutting downward and outward a flap is to be formed of from three to
four fingers’ breadth in length. A shorter flap is to be made behind,
when both are to be raised, and the bleeding vessels previously
secured, the external lateral ligament being divided. The radius is to
be separated from the humerus, when the olecranon may be sawn across,
or, if the arm be bent, separated from the humerus without difficulty.
The flaps are to be brought together and retained in the usual manner.

124. _Amputation of the forearm_ is seldom required after wounds from
musket-balls. The bones can be readily got at, and large pieces removed
with ease. The arteries can be cut down upon and secured without
difficulty, except at the upper part, and even there with some little
sacrifice of muscular parts, which are not to be spared. The fascia
may be divided freely in every direction, and as mortification from
defect of nourishment rarely takes place in the fingers, as it does in
the toes, when the great arteries of the limb have been injured, every
effort should be made to save a forearm, however badly it may at first
appear to be injured.

The flap operation is to be preferred to the circular, particularly
when done a little above the wrist; to which operation Baron Larrey
and the surgeons of France particularly objected during the late war.
Having done it most successfully since 1806, however, it is recommended
as preferable to any other, even when the injury admits of its being
done neat the carpus. When the nature of the injury does not admit of
two equal flaps being formed, it must be done by two unequal ones, or
even by one, it being important for the fixing of an artificial hand or
other help to have a long stump.

The arm being placed and held firmly in the intermediate position
between pronation and supination, with the thumb uppermost, so that the
radius and ulna are in one line, a sharp-pointed straight knife is to
be entered close to the inner edge of the radius, and brought out below
at the inner edge of the ulna. It is then to be carried forward for
half an inch, and made to cut its way out with a gentle inclination, so
as to form a semicircular flap. Re-entered at the same point as before,
a similar flap is to be made on the outside, the position of the bones
being a little altered to admit of its easy execution. The two flaps
are to be turned back; the tendon of the supinator radii longus, and
all other tendinous, muscular, or interosseous fibers, not cut through,
are then to be divided, and the linen retractor run between the bones,
which are to be sawn across at the same time. All pressure being taken
off, the tendons and the vessels, if long, are to be cut short, and the
arteries to be tied, after which the flaps are to be brought together
by sutures, and retained by sticking-plaster, compress, and bandage.

125. When the operation is to be performed above the middle of the arm,
it may be done by the _circular_ incision.

The arm being placed with the thumb uppermost, an assistant should
retract the integuments as much as possible, while the operator makes
a circular incision through them. They are then to be drawn up for
nearly an inch. The muscles on the inside of the arm should be divided
by one slanting cut to the bones; then those on the outside. The bones
are to be cleared by cutting through any muscular fibers attached to
them, when the interosseal ligament should be divided, and the linen
retractor passed between the bones, which may be sawn through at the
same time without difficulty. The stump is to be dressed in the usual
manner. The operation may be done by cutting through the integuments
and muscles at once in an oblique manner, until the flaps thus formed
shall be sufficiently large to make a thick cushion over the ends of
the bones.

126. _Amputation at the wrist_, or the joint of the radius and ulna
with the first row of the bones of the carpus, has been recommended
by some surgeons as preferable to amputation above the ends of the
radius and ulna. The hand being placed midway between pronation and
supination, the soft parts are to be divided by a circular incision
beginning from half an inch to an inch below the ends of the radius and
ulna. The integuments being turned up without the tendons, they are
to be divided, and the joint is to be opened into before the spinous
process of the radius; and, while the hand is pressed down, the knife
should divide all the soft parts, and separate the carpus from the
radius and ulna. The wound is to be closed by sutures in the usual
manner. When a circular incision cannot be made, in consequence of the
nature of the injury, and this operation is still preferred, a covering
for the bones must be obtained wherever it can be procured, by one or
more flaps.

127. _In all injuries of the hand_, the value of a thumb and a finger,
or of two fingers, or even of one, should be borne in mind, and no part
should be removed that can be saved, and appears likely to be of use.
When cannon-shot, large splinters of shells, or grape-shot have struck
the hand, amputation will often be necessary; but the foregoing precept
should never be forgotten.

A musket-ball fairly passing through the hand generally fractures two
metacarpal bones, although a small ball may pass between them without
breaking either. The wounds should be enlarged, and the broken ends of
the bone sawn off, or the splinters removed, and the points of bone
smoothed off, the tendons to be carefully preserved, and vigorous
antiphlogistic measures adopted. The tendency to tetanus or trismus
will be best obviated by such measures, the incisions, when necessary,
being made in the direction of the bones and tendons. Any hemorrhage
which can ensue will be readily commanded by ligature, by torsion of
the vessel, or by a small graduated compress and bandage, when those
are inapplicable. Injuries by musket-balls to the metacarpal bones
rarely take place without implicating one or more flexor or extensor
tendons, and the consequence is that the fingers to which they belong
are often bent inward toward the palm, constituting a defect less
inconvenient, however, than if the finger remained straight and
immovable.

128. When one or more fingers are destroyed, and the metacarpal bones
injured, they are to be sawn or cut off, but not removed at the carpus,
although an opening into the joint of the carpus will generally do
well, if skin can be saved to cover it. In all cases of amputation of
one or more fingers, the metacarpal bones, if injured, should be left
as long as possible, and particularly that of the index finger, when
the thumb remains. In all cases it is better, if possible, to leave
the heads of the metacarpal bones in their places, rather than open
into the joint of the carpus, if it can be avoided. If the articulating
heads must come out, a strong, thin scalpel is to be pushed in between
the bones, the ligaments cut through above, below, and at the sides,
and care should be taken, in removing one or two of these bones, not
to dislocate the others, and the joint should be covered by a flap or
flaps made for the purpose, the sides of the remaining fingers being
covered in a similar manner. This succeeds admirably, when the two
outer bones and fingers only are taken away.

129. _The phalanges_ of the fingers may be removed by making a flap
from the upper or under part, or from both, or from the sides. The
square flap from the upper part of the finger is preferable, when the
joint with the metacarpal bone is to be operated upon, the commencing
points of the flap being united by a transverse incision on the
under part of the joint. It should be recollected, that in all these
excisions the larger end of bone belongs to that which is not removed,
as may be shown by bending the finger; and that the ligamentous
attachment between the metacarpal bones, connecting a middle one to
its fellows on each side, should be cut through, when the joint will
be easily dislocated. Attention should be paid to the division of the
lateral ligaments, in the removal of any of the bones of the fingers.

Professor B. Langenbeck has operated in some instances, and he says
successfully, without the loss of the finger, by sawing off, in his
first case, the articulating ends of the first phalanx and of the
metacarpal bone of the forefinger, in consequence of an injury from
a rotating piece of machinery; in another, the ends of the first and
second phalanges of the middle finger after a severe laceration; and in
a third case, by sawing off the end of the second phalanx, and removing
the whole of the bone of the third of the forefinger from the soft
parts, leaving the nail; the man recovering with a shortened but useful
finger. In all these cases the flexor and extensor tendons were from
the first uninjured.

M. Langenbeck has also removed the metacarpal bone of the thumb in the
following manner: “An incision is to be made along the whole length of
the bone toward the palmar aspect, thus avoiding the tendons. Then free
both articulating extremities, separate the soft parts from the body
of the bone, which is to be drawn outward by a strong pair of forceps,
with two bent points or teeth at each extremity. To prevent the
shortening or drawing inward of the thumb, it is to be kept straight
and duly extended by a splint and other apparatus.” He recommends, with
Flourens, the preservation of as much as possible of the periosteum,
and uses for its detachment a small curved knife with a square end.
Separating the periosteum from the bone is more easily directed than
done. Professor Quekett, at my request, made some trials on the humerus
to ascertain the point, and found that the periosteum could not be
separated from the cartilaginous covering of the head of the bone, in
the manner proposed, although it could be done by scraping half an inch
below the insertion of the capsular ligament, and a sufficient portion
saved to cover the sawn end of the bone, in the manner recommended by
M. Baudens.



LECTURE VII.

SECONDARY AMPUTATIONS, ETC.


130. _Secondary amputations_, or those performed after the lapse of
six or more weeks from the receipt of an injury, when suppuration has
been fully established, are not as successful in military as in civil
hospitals, in which these operations are more commonly performed for
incurable diseases than for injuries. When, however, they are done in
them for injuries, they are not equally successful.

131. In military warfare these amputations are frequently done
from necessity, not choice, after the first forty-eight hours; and
especially after four or five days to the end of six weeks, in
parts which have been lately, or are still affected by some of the
accompaniments of inflammation, or are in a state of irritation. In
these cases the cellular or areolar tissue has become firmer and
more compact than usual; the muscles are not perfectly healthy; the
blood-vessels are larger and more numerous, and ready to assume
actions unusual to them in a state of health. Where the bones have
been diseased, much bony matter may be deposited between the muscles,
and in some cases the vessels even are surrounded by it. After a few
hours’ remission, the constitutional symptoms often return, the wound
sloughs, and secondary hemorrhage is not an infrequent consequence.
The ligatures are a source of irritation, and prevent union, which, in
fact, should not in such cases be attempted, and, if attempted, will as
rarely succeed.

132. In these states of constitutional derangement, inflammation of the
veins and sloughing of the stump are not uncommon, augmented by, if
not dependent in some degree on, the state of the atmosphere, which in
autumn, the season for many military movements, gives rise to endemic
fevers, and even to dysenteries and cholera, which the soldier is often
so unfortunate as to acquire in crowded hospitals. If the man should
escape with life, a joint will frequently be lost which might have been
saved, if the operation had been performed in the first instance below
it. When the injury is in the thigh, this is a most important point for
consideration.

133. If the sufferer should escape these dangers, there remain the
sudden and usually disastrous affections from depositions of matter
in the viscera, alluded to in aphorisms 58, 59, 60, 61, and 62, which
are by no means so common when the patient is in better health; the
connection of these with inflammation of the veins deserves a more
close investigation than has as yet been bestowed upon it by civil or
by military surgeons since attention was first drawn to it by me in
1815.

134. In secondary amputations in parts which have partaken of the
extensive irritation which accompanies the original injury, more of
the soft parts must be preserved, although they cannot be said to be
unsound. In other words, the bone must be cut shorter, or the stump
will be conical and bad, particularly if sinuses containing pus are
found to run up between the muscles, or between them and the bone
itself--a state very likely to give rise subsequently to caries.

In sawing the bone, it may be again stated, the point of the saw should
incline downward, and when two-thirds of the bone have been divided,
it should be made to cut perpendicularly, whereby the _side_ next the
operator is the last part divided; the hazard of splintering the bone
at that moment will then be avoided, particularly if the limb to be
removed be held with great steadiness.

135. In secondary amputations, twice, nay, three times the number of
arteries will often bleed as in primary ones. In the thigh, the femoral
artery should be drawn out with a tenaculum or spring forceps, and tied
firmly with a single thread of dentists’ silk, one of the two ends
being cut off close to the knot. The smaller the vessel, the smaller
the thread required. Torsion or twisting the smaller vessels, so as to
rupture their inner coats, answers very well in cases in which many
small ones bleed. When a nerve is known to accompany an artery, it
should be carefully separated from it.

136. If the bleeding should continue from above the ligature on the
extremity of an artery, it is generally caused by some small branch
given off from it, which has been cut so close to the trunk of the
vessel as not to have been observed. In that case, the artery itself
should be drawn out by the tenaculum or spring forceps until the
bleeding point can be seen, and a ligature placed above it, when the
piece below should be cut off with the first ligature applied. This
inconvenience will be in general avoided by taking care to divide the
principal artery at one stroke of the knife, and with it half an inch
at least of the surrounding tissues, if the operation be done by the
circular incision; if by flaps, the extent of the exposed arteries
should be carefully examined, and the ligatures applied at the highest
point of exposure, when all below should be removed.

137. When a tourniquet is used, and applied too close to the incised
parts, it often prevents, even when loosened, the principal vessel from
being found, from its having pressed on the ends of the muscles. If one
be used, it should be removed as soon as possible after the principal
artery has been secured. The repeated tightening and loosening of the
tourniquet will cause more vessels to bleed in the end, and more blood
to be lost, than if it had not been used; it ought not, therefore, to
be resorted to when good assistance is procurable. In cases of this
kind, in which the stump may not cease to ooze, the circulation being
good, and sponging with cold water not effectual, the wound should
not be finally closed for two, four, or more hours, until the oozing
has ceased, and the parts can be freed from the coagulated blood, and
brought together.

138. In cases in which union is not expected to take place, both
ends of the ligature should be cut off; for union of the external
parts is not to be desired in many instances of secondary amputation,
particularly after serious injuries; the inflammation consequent on
which has in some degree implicated the structures divided in the
operation, rendering them less liable to take on the healthy action of
adhesion. The soft parts should be simply approximated by two or more
sutures, the edges of the wound having a piece of lint or fine linen
between them. This precaution should be particularly attended to after
a great battle, when it is perceived that from the air, the crowded
state of the hospital, or the season of the year, the stumps, although
they may appear to unite in the first instance externally, do not in
reality do so internally.

139. It has been proposed to use ligatures made of cat-gut or other
animal substances, which may be cut short, and left in the wound to
be absorbed. This has taken place in some instances, while in others
little abscesses have followed, allowing their discharge, and not
expediting the cure, so that the practice has not prevailed; it is said
that greater success has attended in America ligatures used in this way
made of very fine shreds of the strong tendons of the large deer of
that country. Ligatures should not be applied on large veins when they
continue to bleed, if it can be avoided, although it has frequently
been done without subsequent inconvenience. A little delay and moderate
pressure will generally suffice to arrest the bleeding.

140. If the surgeon find, after completing the operation, that the bone
cannot be sufficiently covered to make a good stump, a piece should
be sawn off at once, and the error remedied, with little comparative
inconvenience to what would occur afterward, if the bone be too long.
No false shame should prevent its being done. If, however, the error
have occurred, and the end of bone should become uncovered during
the process of healing, it may be allowed to separate of itself, as
it cannot be sawn off at this period without difficulty and much
suffering; for an exposed surface will then remain, from which an
exfoliation will take place before the stump can heal. In cases of
great protrusion, an incision should be made down to the bone, which
should be firmly held by strong forceps, or by a tube in which it
will fit, when it is to be sawn off by the chain saw at a sound part,
above that which has been exposed. The wound, in all cases, should
be well supported by compress and bandage, to secure a good stump;
whence the necessity for the bone being shorter than in those secondary
amputations which are done at the period of election, and which will,
on the contrary, often unite without difficulty. In primary operations,
cold water is most applicable in the first instance; in secondary
amputations, warmth by fomentations, rather than by even the lightest
of poultices.


ON COMPOUND FRACTURES.

141. A fracture of a bone, however _simple_ it may be in its nature,
is said to be _compound_ when accompanied by an external opening in,
or a wound of, the soft parts, communicating with the broken bone--a
complication which usually gives rise to ulcerative inflammation and
suppuration throughout the whole extent of the injury, preventing
thereby those milder processes being effected which, under the more
favorable circumstances of the skin being unbroken, lead to a speedy
union of the broken parts; whence the desire manifested by the surgeon,
in ordinary cases of compound fracture, to close the external wound, if
possible, but which, from the nature of a gunshot wound, it is useless
to attempt. A fracture is said to be _comminuted_ when the bone is
crushed, as by a heavy wheel passing over it. It may still, however,
be a _simple_ fracture, that is, without an external wound; and in
that state it is much less dangerous than a similar injury accompanied
by an external opening, however small, the edges of which cannot be
immediately and permanently reunited.

142. An arm or a leg, as a general rule, is not to be amputated in the
first instance for a compound fracture caused by a musket-ball, unless
the ball be of large size, and the bone much shattered. An effort
should always be made to save it; and, under reasonable circumstances
with regard to the extent of injury, the comfort, climate, and ordinary
good health of the sufferer, the object will frequently be obtained
under good surgical treatment.

143. It is not so with the thigh. After the battle of Toulouse,
forty-three of the best of the fractures of the thigh were attempted
to be saved under my direction, and even selection. Of this number
thirteen died; twelve were amputated at the secondary period, of whom
seven died; and eighteen retained their limbs. Of these eighteen, the
state three months after the battle was: five only could be considered
well, or as using their limbs; two more thought their limbs more
valuable, although not very serviceable, than a wooden leg; and the
remaining eleven wished they had suffered amputation at first. Of the
officers with fracture of the femur, one (having been taken prisoner
during the action) died under the care of the French surgeons, by whom
he was skillfully treated; the other has preserved a limb, which he
rather wishes had been exchanged for a wooden leg.

In the five successful cases, the injury was in all at or below the
middle of the thigh. In the thirteen others who retained their limbs,
the injury was not above the middle third; and of those who died
unamputated, several were near or in the upper third, and either
died before the proper period for secondary amputation, or were
not ultimately in a state to undergo that operation. Of the seven
amputations which died, two were at the little trochanter, by the flap
operation; and the others were for the most part unfavorable cases.
In one case only was the head or neck of the bone fractured. The man
lived for two months, and, from the dreadful sufferings he endured, it
was much regretted that he had not lost his limb at the hip-joint at
first. The operation ought, however, to have been the removal of the
head and neck of the bone; but he was not seen in time by those who
could or would have done this operation, which was then, however, only
contemplated for the first time.

Nearly all the wounded, after this battle, had every possible
assistance and comfort, from the second day after the action. The
hospitals were well supplied with bedsteads--no inconsiderable point
in the treatment of fractures--and several of the surgeons had been in
almost every battle from the commencement of the war. The medicines and
materials for their treatment were in profusion. The sick and wounded
(1359 in number, including 117 officers) were in charge of two deputy
inspectors-general, ten staff-surgeons, six apothecaries, and fifty-one
assistant-surgeons; and the whole worked from morning until evening
with the greatest assiduity. The surgery of the British army was then
at the highest point of perfection it attained during the war; and
this enumeration is given to show the number of medical men required
under the most favorable circumstances for 1500 wounded men, if they
are to have all the aid surgery can give them. Doctors are not the most
ornamental part of an army perhaps, but there are days in a campaign
when many poor fellows find them to be the most useful.

Every broken thigh or leg was in the straight position, and the success
was greater than on any previous occasion. Nevertheless, with all
these advantages, there can be little doubt that if amputation had
been performed in the first instance, on the thirty-six out of the
forty-three who died or only partially recovered, some twenty would
have survived, able, for the most part, to support themselves with a
moderate pension, instead of there being perhaps five, or at most ten,
nearly unable to do anything for themselves. Baron Larrey, with the
_élite_ of the military surgeons of France, as well as of those of
Germany, have maintained this opinion; and the result of the practice
as yet observed in the Crimea essentially confirms it, partly from
the greater extent of mischief done to the bone by the large needle
two-ounce rifle bullets of the Russians, and partly perhaps from the
want of the accommodation and appliances which the circumstances of
the siege of Sebastopol did not admit of. In the present state of
our knowledge, it is perhaps the safest practice, particularly under
doubtful circumstances, in which it cannot be ascertained whether rest,
the best surgical care, and comfort may not be wanting; without all
which a favorable result cannot be expected.

144. War is an agreeable occupation, trade, or professional employment
for the few only, not for the many; and particularly not for the
poor, when they have the misfortune to have their limbs broken by
musket-shot. There are very few men in England who know what are the
first principles of a medico-military movement with an army in the
field; and it will not materially signify whether there should be
even one so instructed, until the nation at large shall be impressed
with the idea that no expense, no trouble, ought to be spared to
obtain for their soldiers so unhappily injured the utmost comfort
and accommodation that can be procured for them, as well as the best
surgical assistance. The first was little attended to in England during
three-fourths of the Peninsular war; and the latter was supposed to be
obtained, when the demand was urgent, by giving a warrant to kill or
cure to persons as dressers who were unable to undergo an examination
with any prospect of success, and prove themselves worthy a commission.
Many a gallant soldier lost his life from the want of that proper
attendance and care alluded to; many a desolate and unhappy mother
mourned the loss of a son she need not have mourned for under happier
circumstances, and who might have been the support, the happiness, of
her declining years. Yet England calls herself the most humane, as
well as the greatest, nation upon earth; she claims to be the most
civilized, and she may be so; but certainly, in the case of those who
have hitherto fallen in her defense, she could not on many occasions
have been more careless or less compassionate. I have endeavored to
impress on the directors of the East India Company in particular the
injustice, the carelessness, of their treatment of the wounded soldiers
of the royal army of Great Britain. My remonstrances have hitherto been
in great part useless. It is to be hoped, however, that the present War
Minister will cause an official public inquiry to be made into this
matter, for that alone can cause this grievance to be redressed. Old
habits are not to be overcome but by public opinion.

145. The peculiar difficulty in treating a gunshot fracture takes place
when the bone is splintered for some distance, as well as broken. In
these cases, inflammation occurs internally in the membranous covering
of the cancellated structure of the bone, ending in the death of the
parts affected; while the periosteum takes on that peculiar action
externally which ends in the deposition of ossific matter around the
splinters which have lost their life, and are enveloped by it. The
bony matter, at first small in quantity, is gradually augmented, and
deposited for some distance in the surrounding parts, so that it has
been known to include the neighboring vessels and nerves in less than
twenty days; at the end of a few weeks the quantity of ossific deposit
is often very remarkable. Each splinter of bone becomes the sequestrum
of a necrosis, in a similar manner as it is known to occur in the bones
of young persons spontaneously affected by that disease, with this
essential difference, that in the idiopathic disease there is only
_one_, as if worm eaten, sequestrum, perhaps the length of the shaft
of the bone, easily removable by one operation, while there may be in
the traumatic disease several dead centers of ossific deposit, each of
which requires to be removed by an operation to effect a cure. This new
bony deposit will often be half an inch and more in thickness, and at
a late period is as hard as the old bone. The repetition of operations
required in such cases is very distressing, particularly in the thigh,
in which the disease often continues for months, and even for years.

The following case, related by Colonel Wilton, is instructive:
“Lieutenant Timbrell, late of my old regiment, the 31st, had both his
thighs broken at the battle of Sobraon; he would not allow amputation,
so the doctor put him in a boarded ‘dooley,’ and his legs in a kind
of trough. As I was also wounded, I used to see him almost daily, and
I never heard him complain except the days when the doctor tried to
extend his legs. Some time after our return to England (perhaps seven
or eight months) I went to visit him, and found him quite recovered,
and able to enjoy a day’s shooting as well as most people. He showed me
many pieces of bone which had come away from his wounds, and appeared
to have lost about three inches of his height; his limbs were rather
bowed. He is now paymaster of the 6th Foot; and when I saw him, a
few days before he embarked for the Cape, he was as active as ever,
although I do not think he could either run or jump.”

146. A musket-ball will often lodge in the less dense parts of
bones, such as the great trochanter or the condyles of the femur,
without fracturing the bone; it will sometimes even pass through the
femur above and between the condyles, merely splitting, but without
separating the bone in parts or pieces. Balls sometimes lodge in the
shaft of the femur without breaking it, and frequently do so in the
tibia, the humerus, the bones of the cranium, and even in others of
less size. Balls thus lodged will sometimes remain for years--nay,
during a long life--without causing much inconvenience. It is, however,
generally the reverse, and they are often the cause of so much
irritation and distress that the sufferers are willing to have them,
and even their limbs, removed at last at any risk. Whenever, then, a
ball can be felt sticking in a bone, although it cannot be brought into
view, it should, if possible, be dislodged and removed by the trephine,
by small chisels, by small, strong-pointed curved elevators, or by any
of the screws invented for the purpose, which have sometimes been found
efficient. An apparently useful instrument of this kind is attached
to the forceps for extracting balls; it is more frequently used in
France than in England. When the ball can be seen as well as felt, the
surgeon must be guided by his own experience and judgment with respect
to the most fitting instruments. It is to be removed if possible,
whatever may be the means used for its abduction, after the wound has
been properly enlarged for the purpose.

147. When a ball merely grazes a bone without breaking it, and
passes through the limb, and no splinters can be felt by the finger,
dilatation is unnecessary in the first instance; although some small
splinters may be cast off subsequently, or a layer of bone may
exfoliate, requiring assistance for their removal.

The bone may be fractured in a case of this kind transversely, and will
require only the simplest treatment in an almost similar manner.

148. If the ball should enter and be flattened against the bone without
breaking it, and lodge against it or in the soft parts, it should be
sought for and removed. When the ball is flattened and the bone broken,
it may lie between the broken extremities, and even lodge in one of
them, rendering the case more complicated, and the necessity for close
investigation more urgent. A leaden ball when striking on the sharp
edge of a long bone, such as the spine of the tibia, has been known to
be divided on it, without the bone being broken. This has happened in
the arm.

149. When a ball strikes the shaft of a bone, such as the femur,
directly and with force, it shatters it often in large, long, and
pointed pieces, retaining their attachment to the muscles inserted into
them. A fracture of this nature in the middle of the thigh will often
extend downward into the condyles, and as high as, although rarely
into, the trochanters. These are cases for immediate amputation.

150. Gunshot fractures of the head and neck of the femur have hitherto
been fatal injuries, unless the whole extremity has been removed. It is
hoped death may be prevented without this most formidable operation,
by the removal of the head and neck of the bone, according to aphorism
85. If the upper third of the femur below the trochanter be badly
fractured, and an attempt be made to save the limb, death generally
occurs after several weeks of intense suffering, more particularly
when the bone is broken by the large two-ounce balls now used by the
Russians in the Crimea.

The least dangerous and the most likely to be saved are fractures of
the lower third, or at most of the lower half, of the thigh-bone. When
they do not communicate with the knee-joint, an attempt ought always
to be made to save the limb.

151. The preservation of a femur fractured by a musket-ball, when
splintered to any extent, ought only to be attempted if the principal
splinters can be removed. When the splinters of the femur are long and
large, it has been supposed that if they retain their attachment to
the soft parts, they may be placed in apposition and preserved. This
may be doubted. It ought, however, only to be attempted under the most
favorable circumstances, and will not often succeed even then. In the
humerus it is different. An examination by the finger in the first
instance is necessary to ascertain the extent of the injury to the
bone, and to enable the surgeon to remove the broken portions, as well
as the ball or any extraneous substances which may be in the wound.
The incisions necessarily required for this purpose in the thigh are
sometimes neglected, or the surgeon refrains from making them from
the great thickness of the muscular parts, and from the wound having
taken place on the inside, near the great vessels, so as to render
incisions of sufficient size or extent in some degree dangerous.
The thickness of the muscular parts is not a sufficient reason for
avoiding an incision, neither is the vicinity of the great vessels
and nerves, although they may not be divided; if the situation of the
bone on the outside of the thigh be attended to, the broken portions
may sometimes be got at at that part, if not on the inside. If this
cannot be done, amputation had better be had recourse to. The object
of the examination of such a wound being to ascertain the state of the
fracture, and to remove the splinters and any extraneous substances,
the extent and number of the incisions must depend on them; the true
principle of what has been called dilatation of wounds. If the ball
should have merely struck and grazed the bone, and passed out, causing
a transverse fracture only, there is no necessity for making incisions
at the moment, although one or more may be subsequently required to
aid in the discharge of an exfoliated piece of bone, or of a splinter
which may have been overlooked. If the ball lodge deeply in the soft
parts, after breaking the bone, it should be removed, if practicable,
by a second or counter-opening, and a free vent should always be made
for the discharge. It may, however, be laid down as a general rule,
that whatever is likely to be required during the first few days had
better be done on the first than on the second or third; for after
inflammation has commenced, any handling or examination of the limb,
however gently made, gives great pain.

152. After the first incisions have been made, and the larger
splinters, which can be felt, have been removed, a secondary danger
occurs from those which are smaller, and may have been overlooked, or
not been discovered. This arises from the enveloping of these splinters
in the new ossific matter described as being formed by the inflamed
periosteum. This evil must be prevented by a careful examination of the
wound when suppuration has been fully established, and the sensibility
of the parts is in some degree diminished; when, if loose splinters
of bone can be felt, they ought to be removed by incisions carefully
and gently made to the extent which may be required. If this be not
done early, the ossific deposit will take place around, and shut them
in, even if the wound should close, which it usually will not. Their
retention is accompanied by a firm thickening of the part, and in due
course of time a spot of inflammation implies the formation of an
abscess, and an ulcerated opening through the new bony deposit. When
this abscess breaks externally, the probe will pass through the hole
in the new bone, and rest on the rough, dead, and now perhaps movable
splinter, the extraction of which can alone afford permanent relief.
The earlier this is done the softer the ossific matter will be; at an
early period, it will cut like Parmesan cheese intermixed with lime. If
deferred until the bony matter is quite hard, it must be cut through
with the chisel, or bone scissors or forceps, the application of which
sometimes requires great force.

153. The successful treatment of a gunshot fracture of the thigh
cannot be effected while the patient is lying on a little straw or
a mat on the ground, and proper bedsteads should always form a part
of the hospital stores of an army in the field. There is one in use
at the Westminster Hospital, and another at the Royal Westminster
Ophthalmic Hospital, which may be taken as models. Each, when complete,
with mattress, etc., costs ten pounds, and, with a second inclined
plane and mattress, might answer for two fractures; six may be easily
carried in any common or spring cart wherever they are wanted. They
would alleviate the sufferings, the horrible torments, many suffer
unnecessarily. There is a very good and even cheaper one in use in
the London Hospital, well worthy attention. An instrument or iron
machine, movable from bed to bed, has been invented by Dr. Thomson,
of Stratford-on-Avon, which lifts a man readily from his bed, and,
after he has been dressed, lays him down again with ease in a similar
manner to the bedstead alluded to. It has, however, the advantage of
being movable, while the apparatus in the bedstead is fixed. Lord
Strafford has sent one to his regiment, the Coldstream Guards, and Dr.
Thomson has sent another. Young backs and young knees only can bend
for consecutive hours over men lying on the ground. Doctors of fifty
years of age cannot do it; they are physically unequal to the labor.
A staff-surgeon half a century old on a field of battle is almost an
absurdity in the art, if not in the science of surgery: he ought to be
promoted to the rank of inspector. The custom of the present day is
to promote men more on account of the length of their services than
because of their value: whereas, to make good physicians and surgeons,
it should be from their value, combined with a due regard to a moderate
yet sufficient length of service, which certainly should never exceed,
even if it amounted to, twenty years; ten or twelve, in time of war,
would be better,--a matter of expense against life and human misery.

154. The position of the patient in a gunshot fracture of the thigh
or leg is of the utmost importance. He should lie on his back, and
the limb should be straight. It is almost impossible to keep a man’s
thigh in the bent position, or on its side, without his turning on
his back, and the union of the bone, if it take place at all, must
then be at an angle. The bent position forward, or on an inclined
plane, is defective, inasmuch as the matter, which must necessarily
be secreted in great quantity, will gravitate backward in spite of
every care to prevent it. When a proper bedstead is used, a slightly
inclined plane will sometimes be advantageous at a later period, when
the body may also be raised, even to the erect position, the principal
object being to take off the action of the two muscles inserted into
the smaller trochanter, which, with the rotators behind, raise and
evert the upper end of the broken bone. This direction outward should
be met by a similar direction of the lower part of the bone, and by
the application, from time to time, of a proper splint, compress, and
bandage on the elevated bone, if they can be borne with perfect ease.

155. Splints are of various kinds, and made of different substances.
The discovery of gutta-percha has enabled some to be made of that
substance, which, when moulded into sheets, of from one to two or three
eighths of an inch in thickness, can be rendered soft and pliable
by the application of hot water, regaining its firmness as it dries.
Splints can thus be made of any size or length, and of any form, with
apertures, if necessary, for the passage of the discharge from the
wounds. Leather tanned without oil, and called splint-leather, is
equally useful; if, when dried, the splints thus made become too hard,
and press unequally, they can be softened by hot water, and removed and
replaced with little comparative inconvenience.

One wooden splint of more than the length of the limb, somewhat similar
to that called Desault’s, is absolutely necessary for the thigh, if it
can be borne, which it rarely can, as a means of extension, or rather
of preserving length. A shorter one on the inside, and one behind, will
sometimes be required to complete the set A short one may be wanting
for occasional use in front.

156. The bones of the leg being more exposed, admit of greater
liberties being taken with them, and of larger portions, or even parts,
being taken away successfully, than ought to be attempted in the thigh.
A leg should, therefore, be seldom amputated for a fracture from a
musket-ball. The splinters should be removed to almost any extent and
number, and irregular portions sawn off from both ends, if they should
be thus implicated. If one bone of the leg remain uninjured, the case
becomes comparatively simple. The position should be straight on the
heel, as a general rule, admitting of few exceptions.

157. The best apparatus for a compound fracture of the leg in either
civil or military surgery, particularly in the latter, is that
contrived by Mr. Luke, which may be seen in use at the London Hospital,
and is supplied by Mr. M’Lellan, 3 Turner Street, Whitechapel Road.
It is a simple iron cradle of small size, such as is used to guard a
limb from the weight of the bedclothes, composed of three bars or large
segments of a circle, united at their middles and ends or sides, as
all cradles are, by a bar of iron of equal thickness. This is placed
on a board a little wider than itself, with a ledge or bar at each
side to prevent the cradle from moving, aided by two buttons or little
pieces of wood on each side, which, being movable, turn over the iron
bars, and thus render the board and cradle one firm piece. In this
the leg is to be slung, to the center bar above, by ordinary tapes. A
splint made of copper, to prevent rust or injury, hollowed to receive
the leg, extending beyond the foot with a footboard, and beyond the
condyles of the femur above, enables the tapes to be passed under the
limb for slinging it; while from the extension of the splint beyond the
condyles, it causes the leg and thigh to move together, in a manner
which will often prevent the pain which follows a sudden motion of
the patient. Solid wooden side splints are still wanting, and these
should have holes cut in them to allow a vent for the discharge and
for the application of dressings; or if a portion of the splint, say
the middle, should require removal altogether for this purpose, the
upper and lower parts may be united by a semicircular bar of iron, at
the pleasure of the surgeon; within this the dressings may be applied,
and by it the splint will be rendered firm.[3] When the leg is thus
slung, the knee will be somewhat bent, the thigh raised, the muscles of
the leg behind relaxed, and the patient can be moved with much greater
facility than with any other apparatus; one great advantage of this
apparatus is, that it can be used with effect even if the patient be
obliged to lie on the ground. It admits of being slung as a whole in
a spring-cart, by additional but strong, elastic straps fastened to
or applied on the under part of the board, and thus a double slinging
motion may be obtained when the sufferer is obliged to be moved.

[Footnote 3: This apparatus has, I think, been improved upon at the
Bristol Hospital by the addition of a bar on each side of the center
one.]

[Illustration]
These splints are so portable that they may be carried into the field
or upon the deck of a ship, to bring the patient to the surgeon.

In using the apparatus, the back of the leg and lower end of the thigh
are to be evenly supported on a pad placed on the leg-rest; a splint is
to be placed on each side of the leg, and the whole secured by straps
carried around near the knee and ankle. The leg is then to be suspended
by two straps from the bar of the cradle placed over the leg as
represented, so as to swing without touching the folding board on which
the cradle is placed. The foot should be secured to the foot-piece by a
bandage.

Solid splints, and a firmly-fixed cradle, under which the leg may hang,
may be said to be the _sine qua non_ of the treatment of a gunshot
fracture of the leg. The French in the Crimea have an apparatus called
a GOUTTIÈRE, to be hereafter noticed.

158. Half-a-dozen pairs of long poles made light and of tough wood,
which might always be replaced without difficulty, and a good thick
ticking for each pair, having a case or pipe on each side in which the
poles might run, ought to be a part of the surgical stores of every
regiment on service in time of war. Two short irons, having at each
end a ring through which the poles may run, will keep the ticking or
sacking extended, and the patient flat and immovable unless shaken by
accident. The sacking will roll up into little compass, if the poles
should not be forthcoming or are not wanted, and, when the ground is
damp, will make an excellent bedstead as well as a covering for the
doctor. If four legs be added to each bearer, a great facility will
be obtained on halting when the carriers are tired, the sufferer
being raised from the ground, which in muddy or boggy places is very
desirable.

159. The _arm_, when fractured by musket-shot, admits even of more
strenuous efforts being made to save it; from its smaller size, and
the more ready exposure of the bone or bones when badly broken, the
danger is less. If an artery should yield by ulceration, it should be
laid bare by operation, and a ligature placed on each bleeding end.
An additional or second wound in the forearm only complicates the
case, and the loss of a finger or two does not augment the danger. In
fact, amputation should rarely take place in the first instance, and
only in the second when mortification has commenced, or the strength
and health of the patient will no longer bear the drain upon them.
The head of the bone should be removed, with as much of the shaft as
may be injured; the elbow-joint should be excised, if the condyles
are destroyed and the joint injured; if the middle of the bone should
be destroyed, the upper and lower ends of it should be approximated.
A great advantage is derived from the facility with which the upper
extremity can be supported as compared with the lower, and the aid to
the general health which may be obtained from the locomotion sufferers
with broken arms are capable of undergoing.

160. In making incisions for the removal of splinters of bone, both
at an early and at a late period, particularly in the latter, when
the soft parts are all impacted together, and _nothing is gained
beyond what is cut_, the course of the trunks of nerves, as well as
of the great arteries, should be carefully attended to, and those
parts avoided; for a successful cure of the fracture will be much
deteriorated in value, if accompanied by a loss of motion or of
sensation in the hand or fingers.

161. Splints for the arm should be made of solid materials, although
light; some a little hollowed, and at a right angle, to correspond with
the bend of the arm, and to admit of a little motion of the radius
and of the forearm and hand, which relieves the position, is more
comfortable for the sufferer, and tends to prevent stiffness of the
elbow. The pads of lining for the splints should be made of cleaned or
carded wool, rather than of tow or old linen, protected by some one or
other of the modern modifications of caoutchouc or gutta-percha.

162. The medical treatment of compound fractures should be directed
to allay pain and to prevent as far as possible any excess of general
irritation and fever; to sustain, at a subsequent period, the strength
of the sufferer by appropriate medicines, good and sufficient diet, and
a free circulation of air, without all which little can be expected, to
say nothing of absolute rest and those ordinary attentions and comforts
so necessary for the restoration of health.

163. The following returns are illustrative of the principles
recommended with reference to primary and secondary amputations. The
first two show the seats of injury in 1359 persons wounded and admitted
into hospital after the battle of Toulouse. The fifth return should be
considered rather as an approximation to the truth than as the exact
truth, as it does not include those who died on the field of Waterloo,
but those only who reached Brussels, and does not include those who
were sent to Antwerp.

 No. 1.--RETURN OF SURGICAL CASES _treated and_ CAPITAL OPERATIONS
 _performed in the General Hospital at Toulouse, from April 10th to
 June 28th, 1814._

 +-----------------+--------+-----+--------+-----------+----------------+
 |DISEASES AND     | Total  |Died.|  Dis-  |Transferred|Proportion of   |
 |STATE OF WOUNDS. |treated.|     |charged |    to     |death to the    |
 |                 |        |     |to duty.|Bourdeaux. |number treated. |
 +-----------------+--------+-----+--------+-----------+----------------+
 |Head             |    95  |  17 |    25  |       53  |1 in   5-10/17  |
 |Chest            |    96  |  35 |    14  |       47  |1 in   2-35/96  |
 |Abdomen          |   104  |  24 |    21  |       59  |1 in   4-1/3    |
 |Super’r extrem’s |   304  |   3 |    96  |      205  |1 in 101        |
 |Inferior ditto   |   498  |  21 |   150  |      327  |1 in  23-5/7    |
 |Comp’d fractures |    78  |  29 |   ...  |       49  |1 in   2-20/29  |
 |Wounds of spine  |     3  |   3 |   ...  |      ...  |1 in   1        |
 |Wounds of joints |    16  |   4 |   ...  |       12  |1 in   4        |
 |                 |        |     |        |           |                |
 |Amputations--    |        |     |        |           |                |
 |                 |        |     |        |           |                |
 |Arm            7}|        |     |        |           |                |
 |Leg and thigh 41}|    48  |  10 |   ...  |       38  |1 in   5-1/3    |
 |                 +--------+-----+--------+-----------+----------------+
 |    Total        |  1242  | 146 |   306  |      790  |1 in   8-128/145|
 +-----------------+--------+-----+--------+-----------+----------------+

Wounded officers 117, not included, making a total of 1359, among whom
thirteen cases of tetanus occurred, all of which proved fatal.

 No. 2.--OFFICERS.

 +-----------------+---------+------------+---------+-----+----------+
 |NATURE Of        |Admitted.|Discharged. |Sent to  |Died.|Remaining.|
 |WOUNDS.          |         |            |Bordeaux.|     |          |
 +-----------------+---------+------------+---------+-----+----------+
 |Head             |     6   |     4      |     1   |  ...|     1    |
 |Chest            |    10   |     2      |     2   |  ...|     6    |
 |Abdomen          |     1   |   ...      |   ...   |  ...|     1    |
 |Sup’r extremities|    33   |     9      |    15   |  ...|     9    |
 |Inferior ditto   |    49   |    12      |    21   |    1|    15    |
 |Comp’d fractures |     7   |   ...      |     1   |    2|     4    |
 |Slight wounds    |    11   |     7      |     2   |  ...|     2    |
 |                 +---------+------------+---------+-----+----------+
 |  Total          |   117   |    34      |    42   |    3|    38    |
 +-----------------+---------+------------+---------+-----+----------+

One secondary amputation of the arm occurred, and recovered; four
of the inferior extremities, of which one died from tetanus. The
thirty-eight remaining eventually went to Bordeaux, and thence to
England.

 No. 3.--RETURN _of_ CAPITAL OPERATIONS _performed at the Hospital
 Stations of the Army in Spain, between the 21st of June and 24th of
 December, 1813, including the battles of Vittoria, the Pyrenees, and
 San Sebastian, to the entrance into France._

 +---------+-----------+--------+-----+-------+-------+------------+
 |STATIONS.|OPERATIONS.|No.     |Died.|Dis-   |Under  |  REMARKS.  |
 |         |           |operated|     |charged|treat- |            |
 |         |           |upon.   |     |cured. |ment.  |            |
 +---------+-----------+--------+-----+-------+-------+------------+
 |Vittoria |Shoulder-  |        |     |       |       |            |
 |         |joint      |      13|  10 |     2 |    1  |            |
 |         |Upper      |        |     |       |       |            |
 |         |extremities|     108|  58 |    40 |   10  |            |
 |         |Lower ditto|     148|  95 |    38 |   15  |            |
 |         |Trepan     |       3|   3 |       |       |            |
 |         |           |        |     |       |       |            |
 |Santander|Upper      |        |     |       |       |            |
 |         |extremities|      22|   5 |     8 |    9  |            |
 |         |Lower ditto|      23|   9 |     6 |    8  |            |
 |         |           |        |     |       |       |            |
 |Bilbao   |Shoulder-  |        |     |       |       |{The great  |
 |         |joint      |       5|   5 |       |       |{number of  |
 |         |Upper      |        |     |       |       |{amputations|
 |         |extremities|     146|  48 |    46 |    52 |{at this    |
 |         |Lower ditto|      68|  36 |    16 |    16 |{station was|
 |         |Aneurism   |       1|   1 |       |       |{in part    |
 |         |           |        |     |       |       |{occasioned |
 |         |           |        |     |       |       |{by hospital|
 |         |           |        |     |       |       |{gangrene.  |
 |         |           |        |     |       |       |            |
 |Passages |Shoulder-  |        |     |       |       |            |
 |         |joint      |       1| ... |   ... |     1 |            |
 |         |Upper      |        |     |       |       |            |
 |         |extremities|      11|   1 |     3 |     7 |            |
 |         |Lower ditto|      14|   6 |     3 |     5 |            |
 |         |Trepan     |       3|   2 |     1 |       |            |
 |         |Aneurism   |       1|   1 |       |       |            |
 |         |           |        |     |       |       |            |
 |Vera     |Upper      |        |     |       |       |            |
 |         |extremities|      12|   4 |     8 |       |            |
 |         |Lower ditto|       5|   3 |     2 |       |            |
 |         |           +--------+-----+-------+-------+            |
 |         |Total      |     584| 287 |   173 |   124 |            |
 |         +-----------+--------+-----+-------+-------+            |
 |Recapitulation:--    |        |     |       |       |            |
 |         Shoulder-   |        |     |       |       |            |
 |         joint       |      19|  15 |     2 |     2 |            |
 |         Upper       |        |     |       |       |            |
 |         extremities |     299| 116 |   105 |    78 |            |
 |         Lower ditto |     258| 149 |    65 |    44 |            |
 |         Trepan      |       6|   5 |     1 |       |            |
 |         Aneurism    |       2|   2 |       |       |            |
 +---------------------+--------+-----+-------+-------+------------+

If one-sixth of the number remaining under treatment be considered
to have died, which is a low calculation, the deaths will stand to
the recoveries as 300 dead to 276 recovered, or a loss of more than
one-half of the secondary operations.

 No. 4.--CAPITAL OPERATIONS _performed in the Field with Divisions of
 the Army during the same period_.

 |DIVISIONS.
 |        |OPERATIONS.
 |        |              |Number operated upon.
 |        |              |     |Died.
 |        |              |     |     |Discharged cured.
 |        |              |     |     |     |Under treatment.
 |        |              |     |     |     |     |Tetanus occurred.
 |        |              |     |     |     |     |     | REMARKS.
 +--------+--------------+-----+-----+-----+-----+-----+--------------+
 |Cavalry |Upper         |     |     |     |     |     |              |
 |        |extremities   |   3 |   1 |   2 |     |     |              |
 |        |Lower ditto   |   3 |   2 |   1 |     |     |              |
 |First   |Shoulder-joint|   3 | ... |   2 | ... | ... | 1}Sent       |
 |division|Upper         |     |     |     |     |     |  }to         |
 |        |extremities   |  14 |   1 |   3 |   5 | ... | 5}General    |
 |        |Lower ditto   |  10 |   2 | ... |   1 |   1 | 6}Hospital.  |
 |        |Trepan        |   2 |   2 |     |     |     |              |
 |Second  |Shoulder-joint|   1 | ... |   1 |     |     |              |
 |        |Upper         |     |     |     |     |     | 5}Sent to    |
 |        |extremities   |  16 | ... |   5 |   6 | ... |  }General    |
 |        |Lower ditto   |  21 |   3 |   6 |   7 | ... | 5}Hospital.  |
 |        |Aneurism      |   1 | ... | ... |   1 |     |              |
 |Third   |Shoulder-joint|   1 | ... | ... |   1 |     |              |
 |        |Upper         |     |     |     |     |     |              |
 |        |extremities   |  17 |   2 | ... |  15 |     |              |
 |        |Lower ditto   |  10 | ... |   2 |   8 |     |              |
 |Fourth  |Upper         |     |     |     |     |     |              |
 |        |extremities   |  10 | ... |  10 |     |     |              |
 |        |Lower ditto   |  20 | ... |  20 |     |     |              |
 |Fifth   |Shoulder-joint|  12 | ... |   8 |   2 | ... | 2}Sent       |
 |        |Upper         |     |     |     |     |     |  }to         |
 |        |extremities   |  57 |   1 |  36 |   2 | ... |18}General    |
 |        |Lower ditto   |  41 |  10 |  13 |   2 | ... |16} Hospital. |
 |Sixth   |Shoulder-joint|   1 |   1 |     |     |     |              |
 |        |Upper         |     |     |     |     |     | 2}Sent to    |
 |        |extremities   |   7 | ... |   5 | ... | ... |  }General    |
 |        |Lower ditto   |   6 |   1 |   1 |   3 | ... | 1}Hospital.  |
 |Seventh |Upper         |     |     |     |     |     |14}Sent to    |
 |        |extremities   |  18 | ... |   3 |   1 | ... |  }General    |
 |        |Lower ditto   |   9 |   1 | ... |   1 | ... | 7}Hospital.  |
 |        |              |     |     |     |     |     |}The whole    |
 |Light   |Shoulder-joint|   1 | ... | ... | ... | ... |}of these     |
 |division|Upper         |  21 | ... | ... | ... | ... |}cases sent to|
 |        |extremities   |     |     |     |     |     |}the General  |
 |        |Lower ditto   |   8 | ... | ... | ... | ... |}Hospital;    |
 |        |Trepan        |   4 | ... | ... | ... | ... |}results not  |
 |        |              |     |     |     |     |     |}known at     |
 |        |              |     |     |     |     |     |}the division.|
 |        |              +-----+-----+-----+-----+-----+              |
 |        |  Total       | 317 |  27 | 118 |  55 |   1 |              |
 |        +--------------+-----+-----+-----+-----+-----+              |
 |Recapitulation:--      |     |     |     |     |     |              |
 |         Shoulder-joint|  19 |   1 |  11 |   3 | ... | 4}Sent       |
 |         Upper         |     |     |     |     |     |  }to         |
 |         extremities   | 163 |   5 |  64 |  29 | ... |65}General    |
 |         Lower ditto   | 128 |  19 |  43 |  22 | ... |44}Hospital.  |
 |         Trepan        |   6 |   2 | ... | ... | ... | 4}           |
 |         Aneurism      |   1 | ... | ... |   1 | ... |              |
 +-----------------------+-----+-----+-----+-----+-----+--------------+

Of 310 amputations 25 died, 172 recovered in the field, and 113 were
sent to the rear, of whom one-sixth may be considered to have died,
making a total of 45 deaths in 310 cases--the proportion of upper
extremities to lower in the 310 being as 182 to 128, thus greatly
influencing the result, which is consequently much more favorable
than if the numbers had been reversed. The proportion of upper to
lower extremities in the secondary amputations, as by return No. 3,
is equally in favor of the upper, and can only be accounted for, when
compared with Return No. 4, by the army being constantly in motion and
the hospitals at a distance. The difference of results at the several
stations is also remarkable; it is so with the divisions in the field.
The 3d and 4th divisions, under Staff-Surgeons Lindsey and Boutflower,
kept their amputations with them in bivouac, and their success is
remarkable; that of the 4th division has no parallel. The light
division, on outpost duty, could not keep their amputations. These two
returns include 886 amputations.

The labors of the surgeons of the army may be judged of by the fact
that, during the last three months of the year to which these returns
refer--viz., from September 25th to December 24th, 1813--the number of
sick and wounded amounted to 37,144, a number nearly equal to that of
the whole army.

 No. 5.--RETURN _of_ CAPITAL OPERATIONS, _Primary and Secondary,
 performed in the British General Hospitals, Brussels, or brought in
 from the Field between 16th June and 31st July, 1815_.

 |OPERATIONS.
 |         |General total.
 |         |   |Primary operations.
 |         |   |   |Died.
 |         |   |   |   |Remaining.
 |         |   |   |   |   |Proportion of deaths
 |         |   |   |   |   |to operations.
 |         |   |   |   |   |       |Secondary operations.
 |         |   |   |   |   |       |   |Died.
 |         |   |   |   |   |       |   |   |Remaining.
 |         |   |   |   |   |       |   |   |   |Proportion of deaths
 |         |   |   |   |   |       |   |   |   |to operations.
 |         |   |   |   |   |       |   |   |   |      |Total remaining.
 |         |   |   |   |   |       |   |   |   |      |   |Of these
 |         |   |   |   |   |       |   |   |   |      |   |doubtful.
 |         |   |   |   |   |       |   |   |   |      |   |  |Transferred
 |         |   |   |   |   |       |   |   |   |      |   |  |to Antwerp.
 |         |   |   |   |   |       |   |   |   |      |   |  |  |REMARKS.
 +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+
 |Shoulder-|   |   |   |   |       |   |   |   |      |   |  |  |        |
 |  joint  |  8|  6|  1|  5|1 to  6| 12|  6|  6|1 to 2| 11|  |  |        |
 |Hip-joint|  1|...|...|...|... ...|  1|...|  1|......|  1|..|..|A French|
 |         |   |   |   |   |       |   |   |   |      |   |  |  |soldier,|
 |         |   |   |   |   |       |   |   |   |      |   |  |  |who     |
 |         |   |   |   |   |       |   |   |   |      |   |  |  |recover-|
 |         |   |   |   |   |       |   |   |   |      |   |  |  | ed.    |
 |Thigh    |148| 54| 19| 35|1 to  3| 94| 43| 51|1 to 2| 86| 9| 4|        |
 |Leg      | 93| 43|  7| 26|1 to  6| 50| 16| 34|1 to 3| 60|..| 4|        |
 |Arm      | 72| 21|  4| 17|1 to  5| 51| 13| 38|1 to 4| 55|..| 6|        |
 |Forearm  | 39| 22|  1| 21|1 to 22| 17|  5| 12|1 to 3| 33|..| 3|        |
 |Carotid  |   |   |   |   |       |   |   |   |      |   |  |  |        |
 |  artery |   |   |   |   |       |   |   |   |      |   |  |  |        |
 |  tied   |  1|...|...|...|... ...|  1|...|  1|......|  1|..|..|        |
 |Trephine |  2|...|...|...|... ...|  2|  1|  1|1 to 2|  1|..| 1|        |
 |         +---+---+---+---+-------+---+---+---+------+---+--+--+        |
 |Total    |374|146| 32|104|... ...|228| 84|144|......|248| 9|18|        |
 +---------+---+---+---+---+-------+---+---+---+------+---+--+--+--------+



LECTURE VIII.

CHARACTERS OF HOSPITAL GANGRENE.


164. This most destructive disease owes its names of hospital gangrene,
phagedena, gangrenosa, _pourriture d’hôpital_, sloughing ulcer,
etc. etc. to the different appearances the affected parts assume
on different occasions, according to the intensity of the morbid
poison applied, and possibly also to the state of constitution of the
individual attacked. The peculiar nature of this poison has not yet
been ascertained. Professor Brugmans says that in 1797, in Holland,
charpie composed of linen threads cut of different lengths, which, on
inquiry, it was found had been already used in the great hospitals in
France, and had been subsequently washed and bleached, caused every
ulcer to which it was applied to be affected by hospital gangrene; and
the fact that this disease was readily communicated by the application
of instruments, lint, or bandages which had been in contact with
infected parts, was too firmly established by the experience of every
one in Portugal and Spain to be a matter of doubt. Its character as a
thoroughly contagious disease is indisputable. Its capability of being
conveyed through the medium of the atmosphere to an ulcerated surface
is also admitted, although some have thought that the infection was
not always applied to the sore, but affected it secondarily, through
the medium of the constitution. Brugmans says that hospital gangrene
prevailed in one of the low wards at Leyden in 1798, while the ward or
garret above it was free. The surgeon made an opening in the ceiling
between the two, in order to ventilate the lower or affected ward,
and in thirty hours three patients who lay next the opening were
attacked by the disease, which soon spread through the whole ward. Our
experience in Portugal and Spain confirmed this fact, and left no doubt
on the mind of any one who had frequent opportunities of seeing the
disease, that one case of hospital gangrene was capable of infecting
not only every ulcer in the ward, but in every ward near it, and
ultimately throughout the hospital, however large. The disease, as long
as it remains unaltered by destructive applications, may be considered
to be infectious as well as contagious.

This infection can penetrate the dressings so as to affect the ulcer
through them, although requiring a difference of time in different
parts of the body. Ulcers on the lower extremity experienced the
influence of the morbid poison in general at an earlier period than
those on the upper extremity; and a wound might be seen in a healthy
state on the arm, while one on the leg had been evidently suffering
from this disease for some days, if the complaint had become mild, or
somewhat chronic. If the morbid poison were in its active state, then
the deterioration of the ulcers on the arm was almost if not quite
contemporaneous with that on the leg.

165. Mr. Blackadder has given the following account of the disease from
inoculation in his own person, which is, therefore, more to be relied
upon than any other:--

“While engaged in examining the stump of a patient who had died from
this disease, I accidentally wounded one of my fingers with the
point of a double-edged scalpel, but so slightly that not a drop of
blood made its appearance, and on this account I did not consider
any particular precautionary means necessary. In the course of about
sixty hours, however, the wound had become inflamed, and I was
attracted to it by an occasional smart, stinging sensation, which
ultimately extended a considerable way up the arm. On the fourth day
the inflammation had increased, and the stinging sensation was almost
constant. Headache, nausea, and general indisposition followed, with
frequent chills, which increased very much toward evening; but which,
with the other symptoms, were considerably relieved by the use of
neutral salts, the pediluvium, and warm diluents. A vesicle, having
a depression in its center, and containing a watery fluid of a livid
color, was now forming upon a hard and elevated base; the surrounding
integuments became tumefied, of an anserine appearance, and extremely
sensitive to the touch; at about the distance of the fourth of an inch
from the base of the tumor, a very distinct areola, of a bluish-red
color, made its appearance, and remained visible for several days. At
this period, circumstances rendered it necessary for me to be exposed
to wet, to undergo considerable fatigue, and immediately afterward to
travel to a considerable distance. The inflammation, however, gradually
subsided, but the stinging, accompanied by a burning sensation, still
continued, and the sore had no disposition to heal; yet it did not
enlarge externally, but was disposed to burrow under the integuments.
This phagedenic disposition was ultimately got the better of by laying
open the sore, and by repeated applications of caustic; but it was
two months before a complete cicatrix had formed. The new cuticle
remained for a length of time extremely sensitive to the touch; and
it was upwards of six months before it had acquired the color of the
surrounding integuments.”

166. M. Delpech was disposed to consider that the misfortunes and
sufferings of the French army had a great depressing influence on the
soldiers, from which at other times they would have been exempted, and
that this aided the propagation of the malady; but many soldiers of the
British army, free from these particular depressing causes, suffered in
a similar manner. Dr. Tice, at Coimbra, says:--

“An uncommon depressing affection of the mind often exists among
persons suffering from this disease, painful to witness--a morbid
dejection, or apathy, which could scarcely be removed, and on which,
in very bad cases, no impression could be made. In others, the humane
solicitations of the medical officers have failed against the influence
of oppressive gloom, amounting to despair. Expectation and hope seemed
to be exiled from their minds by the dominion of painful despondency,
which, prevailing in melancholy disorder, seemed uncontrolled or
checked by the intrusive importunities of the present, or the
consciousness of a future existence.”

A wound attacked by hospital gangrene in its most concentrated and
active form presents a horrible aspect after the first forty-eight
hours. The whole surface has become of a dark-red color, of a ragged
appearance, with blood, partly coagulated, and apparently half putrid,
adhering at every point. The edges are everted, the cuticle separating
from half to three-quarters of an inch around, with a concentric
circle of inflammation extending an inch or two beyond it; the limb is
usually swollen for some distance, of a shining white color, and not
peculiarly sensible, except in spots, the whole of it being perhaps
edematous or pasty. The pain is burning, and unbearable in the part
itself, while the extension of the disease, generally in a circular
direction, may be marked from hour to hour; so that in from another
twenty-four to forty-eight hours, nearly the whole of the calf of a
leg, or the muscles of a buttock, or even of the wall of the abdomen,
may disappear, leaving a deep, great hollow, or hiatus, of the most
destructive character, exhaling a peculiar stench, which can never be
mistaken, and spreading with a rapidity quite awful to contemplate.
The great nerves and arteries appear to resist its influence longer
than the muscular structures, but these at last yield; the largest
nerves are destroyed, and the arteries give way, frequently closing the
scene, after repeated hemorrhages, by one which proves the last solace
of the unfortunate sufferer. I have seen all the largest arteries of
the extremities give way in succession, and until the progress of the
disease was arrested by proper means, the application of a ligature was
useless. The joints offer little resistance; the capsular and synovial
membranes are soon invaded, and the ends of the bones laid bare. The
extension of this disease is, in the first instance, through the medium
of the cellular structure of the body. The skin is undermined, and
falls in; or a painful red, and soon black patch, or spot, is perceived
at some distance from the original mischief, preparatory to the whole
becoming one mass of putridity, while the sufferings of the patient
are extreme. A complaint of this kind cannot be local, even if a local
origin be admitted; the accompanying fever is usually dependent on the
previous state and general constitution of the patient, modified by the
season of the year, or the prevailing type of febrile disease.

This gangrenous disease does not always prevail in this, its most
concentrated form; the destroying process assumes more of a sloughing
than of a gangrenous character, whence Delpech has denominated it
pulpous, rather than gangrenous. It is in its nature almost equally
destructive, although not quite so formidable in appearance. It
may attack the whole surface of an ulcer at once, or in distinct
points, all, however, rapidly extending toward each other, until
they constitute one whole. The red of the granulations becomes of a
more violet color, and the change is accompanied by burning, a pain
not usually felt in the part, while a layer of ash-colored matter is
soon seen covering them, which adheres so firmly as not to be readily
removed; or, if separated, shows that it is a substance formed upon the
surface, and constituting a part of the granulations themselves, which
are ultimately confounded with it.

About the end of the first week, and sometimes much later, this kind
of ulcer becomes more painful, the edges or the circumference of the
wound assume a browner hue, and the parts become somewhat pasty, the
whitish color of the part particularly affected being opaque, gray, and
soft. It may be said that the false membrane, having become very thick,
has lost the little vitality it possessed, and become putrid; the
discharge, which had been partly suppressed, now reappears, not as pus,
but as a fetid ichor, exhaling the peculiarly offensive stench of this
disease. This pulpy, yellowish, putrid substance becomes thicker, and
extends deeply; it invades the whole substance of a muscle, under which
a probe may be passed, and the instrument brought out through it, with
the loss, perhaps, of some striæ of blood, from parts which are not yet
actually destroyed; the mass is, however, adherent, although its extent
diminishes by the putrefaction and wasting away of its surface.

There are two characters always peculiar to this disease, in which it
differs from all other gangrenous ulcers from ordinary causes; these
are, the circular form it assumes after a very few days, even in its
slighter varieties, and its peculiar odor or stench.

167. If this disease were entirely a local complaint, caused by the
application of a morbid poison, giving rise to the destructive changes
described on the surface of an ulcer, it should be followed by febrile
or constitutional symptoms at the end of several days only; and
Delpech is disposed to think that in such cases these constitutional
symptoms take place from and after the sixth day. If it were entirely
a constitutional disease, giving rise to the destructive changes
described as taking place on the surface of an ulcer, the febrile
symptoms should precede the changes in the ulcerated surface. That
the febrile symptoms do seem to follow the appearance of the local
alteration, is in many cases indisputable; that they precede or
accompany the local symptoms in many other cases, is indubitable;
and that the disease in a mild state, although yet capable of
committing much mischief, is neither preceded nor followed by febrile
or constitutional symptoms, cannot be doubted. The febrile symptoms
themselves differ essentially from each other when they do occur,
generally partaking the character of the endemic fever prevailing in
the country at the season at which they appear. The fever is sometimes
inflammatory, sometimes typhoid, and occasionally resembles the
bilious remittent of the summer and autumn in hot climates, and ends in
typhus. It is probable that a want of attention to these circumstances
decided the opinions entertained by different individuals as to the
general character of the febrile symptoms, and of the treatment to be
pursued for their removal. That this disease was generally considered
a constitutional complaint, until nearly the end of 1813, must be
admitted; and it was the very indifferent success which attended its
treatment by constitutional means and simple detergent applications,
which caused the surgeons of the British army to view it more as
a local disease, capable of giving rise to severe constitutional
symptoms--a change of opinion which was materially influenced by the
knowledge that the French surgeons more generally considered, with
Pouteau, that it was local in the first instance, and treated it by
the actual cautery. In my hands, constitutional treatment, and every
kind of simple mild detergent applications, always failed, unless
accompanied by absolute separation, the utmost possible extent of
ventilation, and the greatest possible attention to cleanliness; and
not even then without great loss of parts in many instances. This
induced me, at Santander, in November and December, 1813, to try the
mineral acids, not as then generally used as stimulants or detersives,
but as caustics. This proceeding was always, however, accompanied by
a constitutional treatment, regulated by the nature of the symptoms,
which at that station were never benefited by bleeding, although it had
proved so effectual, without the local remedies, at the neighboring
sea-port of Bilbao.

168. Dr. Boggie, the great advocate for constitutional treatment, says
that under him, at Bilbao, in 1813, where caustic applications were not
used, or only as detersives, the disease was arrested by blood-letting
to the amount of one or two pounds, and, in some cases, to the extent
of three or four. He admits, however, that bleeding must be resorted
to with the greatest caution in persons of less robust constitutions,
who may have lingered long in hospital, or suffered much from ill
health; and that in some cases it is altogether inadmissible--an
acknowledgment which is decisive, in my mind, that constitutional
treatment is only auxiliary. He says he never saw the puncture made by
the lancet affected by this disease; a convincing proof to me, who have
seen it, that the virulence of the complaint, as an infectious disease,
was subsiding at Bilbao when the treatment he introduced proved so
effectual.

In one case at Santander, in which hospital gangrene in the hand and
arm and tetanus existed together, they were both cured by venesection,
which failed as signally in doing the least good in a case in the next
bed, under nearly similar circumstances.

Dr. Boggie admits that “in that form of gangrene named phagedena, a
very great destruction of parts may sometimes take place without the
constitution being much affected by it. Now, if blood-letting be used
in such a case, or even in the advanced stage of the true inflammatory
gangrene, when disorganization has taken place, and the system is
sinking under the consequent debility, the vital powers being nearly
exhausted, the result must be obvious; but when it is used with
caution, and in cases where it is really applicable, it will be found
to be a most valuable remedy.” In all cases, Dr. Boggie, like every
one else, had recourse to emetics, purgatives, and such other general
treatment as the febrile symptoms appeared to indicate. As local
applications, he recommends cold water, alone or mixed with a small
portion of acetic acid, constantly applied and frequently renewed.
Poultices and warm applications he objects to; and after the sloughs
separate, he approves of dry lint and weak solutions of sulphate of
zinc. Should the sloughs adhere after the inflammation has abated,
warm, stimulating ointments, and sometimes weak solutions of the
nitrate of silver or of the mineral and vegetable acids, may be had
recourse to.

169. To Mr. Blackadder must be attributed the introduction of the use
of Fowler’s solution of arsenic as an escharotic, in November, 1813,
while he was at Passages; it answered remarkably well in arresting
the progress of the disease, and was afterward found to be equally
efficient in the hospitals at Antwerp. The only objection to its
use that I am aware of is, that it caused in some few cases slight
symptoms of its poisonous effect having taken place on the bowels,
apparently from absorption,--an inconvenience which might become a
serious evil, and which caused a preference to be given to the mineral
acids, which act equally well without incurring a similar risk of
evil. Mr. Blackadder, stationed on the same coast, within about forty
miles of Dr. Boggie at Bilbao, took a diametrically opposite view
of this complaint to the doctor; and believing the disease to be
purely local in the first instance, considered venesection as almost
always unnecessary, although he admitted that cases may occur in
which the abstraction “of a small quantity of blood would be likely
to be attended with more good than harm; but certainly,” he adds,
“blood-letting is an operation which ought to be avoided as much as
possible in gangrenous phagedena, particularly when the previous injury
has been extensive, such as that of a penetrating gunshot wound.”

Dr. Walker, who served at Bilbao at the same time, concludes an able
report in the following terms:--

“Lately, however, the disease put on a milder form, and the sloughing
did not proceed with that rapidity that it did at first, nor was the
fever so violent. And more lately still, since the setting in of the
cold weather, the type of the fever seems to have changed entirely,
and to have put on the inflammatory type, so as to require strong
evacuants, and even bleeding, which has been used with the greatest
success by Staff-Surgeon Boggie, who has for a considerable time had
the more immediate care of the patients of this description at the
Cordeleria Hospital.”

170. “When this disease does not proceed rapidly, and is confined to
the ulcerative form,” Delpech says, “it may be removed by stimulant
applications, such as vinegar, the vegetable and mineral acids, the
Egyptian ointment, etc.” Of these he prefers vinegar applied on lint,
after having rubbed or scraped off any false or pulpy membrane which
appears to conceal the surface of the ulcer. “Some good effect,” he
adds, “has been observed from the careful application of powdered
charcoal to the whole surface of the sore, which,” he says, “ought
not to be in the gangrenous, or pulpy, or putrid state, but merely
ulcerative or phagedenic; and not even then, when this peculiar
ulceration assumes a deeply hollowed-out form, rapidly filled with
an abundant and tenacious discharge.” Of constitutional treatment
he evidently thinks little; and, while he admits the propriety and
necessity of treating every accompanying state of fever, whether it be
inflammatory, catarrhal, bilious, remittent, etc., by its appropriate
means, he does not seem to think they have much influence on the local
disease, although he firmly believes that the suppression of the local
disease materially assists in arresting, in a great measure, such
constitutional symptoms as may be dependent on it, unless influenced
by some peculiarity of constitution. His principal local remedy was the
hot iron or actual cautery applied to every part.

He says (page 86) some surgeons of the Anglo-Portuguese army of Lord
Wellington had assured him that the mineral acids, the hydrochloric,
nitric, and sulphuric, had been frequently employed in the British
hospitals in Spain with success; and he particularly mentions M.
Guthrie, _Inspecteur au Service de Santé_, as the person from whom he
especially received his information; thus establishing the fact that
the use of the mineral acids in a dilute and concentrated state was
known to, and had been essentially introduced into practice by, the
surgeons of the British army during the war in Spain--a fact which
admits of no dispute as to the origin of its use.

171. In India, Mr. Taylor, late surgeon 29th Regiment, now a deputy
inspector-general in the medical department in the Crimea, reports:--

“Hospital gangrene appeared among the wounded of the 29th Regiment a
little later than in the hospitals of other corps. The disease declared
itself, on the 18th of January, in a stump case; and between that date
and the 26th of the same month fifteen cases had come under treatment.
At first I could tell, by the peculiar dark, florid countenance of the
patient, that his wound had taken on the gangrenous affection; yet I
cannot say that there was, in these cases, any marked inflammatory
fever. Subsequently, in the prevalence of the disease, this dark-red
color of the face was neither well marked nor by any means so constant.
In many cases the disease seemed purely local; but in the great
majority there was certainly much feverish constitutional disturbance
accompanying the local affection, and often preceding it. My experience
of the disease, as it occurred among the wounded at Ferozepore, does
not enable me to determine, satisfactorily to myself, whether it be
essentially a local or a constitutional affection. I am inclined to
place it in the former category; and there is no doubt whatever in my
mind that the essential means of treatment are local.

“In the treatment of this disease, I proceeded regularly on one plan,
and found that so efficacious that I was not inclined to try any other.
The plan adopted was, the application of the strong nitric acid, so as
completely to cut off the diseased from the sound part, or part so far
sound as only to be affected with inflammation. The acid, however,
required to be rubbed in with the blunt end of the probe, so that it
not only destroyed the cuticle, but killed the cutis vera, and probably
the cellular membrane underneath. The narrow yellow ring of dead skin
thus formed separated like a piece of leather, generally carrying with
it the whole slough, and leaving a clean, healthy surface, as well as
edges to the wound. I never attempted to apply the acid to the surface
underneath the slough, neither is such an application necessary; the
vital seat of the disease is in its circumference, however large
the area. I must admit that the disease sometimes crossed the acid
boundary, and a second, and even a third application of the remedy
was required; but this was rare. Neither was constitutional treatment
neglected, but this varied according to the state of the patient;
emetics, purgatives, saline medicines, and low diet being sometimes
required; while in other instances ether, ammonia, laudanum, and
generous diet were administered.

“When speaking of the symptoms of this disease, I should have mentioned
that a burning, gnawing sensation was sometimes loudly complained of.
The application of the acid soon removed that pain, and the acid itself
did not often seem to produce much suffering. In one instance, deemed
a favorable one, I tried venesection, and I fear did mischief. Calomel
and antimonials were useful. I did not try the arsenical solution.
The change of air, which the march of the wounded, on their return to
Kussowlee, occasioned, certainly had a very beneficial effect on all
the gangrenous and sloughing sores.

“At the same time that hospital gangrene was prevalent at Ferozepore,
some wounds took on a malignant fungous affection, which spread
over the healthy surface like the hospital gangrene. The dirty,
fibrous-looking, fungous growth rose considerably above the edges of
the wound, partially overlapping them; these edges were inflamed, but
not livid and vesicated as in the cases of gangrene; but here also the
disease took the circular or oval form. The affection here noticed I
observed only in wounds of the forearm and hand; Colonel Barr’s wound,
which was of the forearm near the wrist, took on this disease. The
application of nitric acid in the same way as for hospital gangrene
eventually checked its progress.

“In no case that came under my observation did the gangrene directly
prove fatal, though in many cases it contributed largely in bringing
about an unfavorable termination.”

172. _Conclusions._ First.--Hospital gangrene never occurs in isolated
cases of wounds.

Second.--It originates only in badly-ventilated hospitals, crowded with
wounded men, among and around whom cleanliness has not been too well
observed.

Third.--It is a morbid poison, remarkably contagious, and is infectious
through the medium of the atmosphere applied to the wound or ulcer.

Fourth.--It is possibly infectious, acting constitutionally, and
producing great derangement of the system at large, although it has not
been satisfactorily proved that the constitutional affection is capable
of giving rise to local disease, such as an ulcer; but if an ulcer
should occur from accidental or constitutional causes, it is always
influenced by it when in its concentrated form.

Fifth.--The application of the contagious matter gives rise to a
similar local disease, resembling and capable of propagating itself,
and is generally followed by constitutional symptoms.

Sixth.--In crowded hospitals the constitutional symptoms have been
sometimes observed to precede, and frequently to accompany, the
appearance of the local disease.

Seventh.--The local disease attacks the cellular membrane principally,
and is readily propagated along it, laying bare the muscular, arterial,
nervous, and other structures, which soon yield to its destructive
properties.

Eighth.--The sloughing of the arteries is rarely attended by healthy
inflammation, filling up their canals by fibrin, or by that gangrenous
inflammation which attends on mortification from ordinary causes, and
alike obliterates their cavities. The separation of the dead parts is,
therefore, accompanied by hemorrhage, which, when from large arteries,
is usually fatal.

Ninth.--The operation of placing a ligature on the artery at a
distance, or near the seat of mischief, does not succeed, because the
incision is soon attacked with the disease, unless it has been arrested
in the individual part first affected, and the patient has been
separated from all others suffering from it.

Tenth.--The local disease is to be arrested by the application of the
actual or potential cautery: an iron heated red hot, or the mineral
acids pure, or a solution of arsenic, or of the chloride of zinc, or
of some other caustic which shall penetrate the sloughing parts, and
destroy a thin layer of the unaffected part beneath them. If a sinus
or sinuses have formed under the skin or between the muscles, from the
extension of disease in the cellular or areolar structure, they must be
laid open, and the cautery applied; for if any part affected be left
untouched or undestroyed by the acid, the disease will recommence and
spread from that point. The parts touched by the acids or cautery may
be defended by cloths or other material, wetted with hot or cold water
according to the feelings of the sufferers, and poultices of various
kinds may be had recourse to, if unavoidable.

Eleventh.--After the diseased parts have been destroyed by the actual
or potential cautery, they cease in a great measure to be contagious,
and there is less chance of the disease being propagated to persons
having open wounds or ulcerated surfaces. A number of wounded thus
treated are less likely to disseminate the disease than one person on
whom constitutional treatment alone has been tried.

Twelfth.--The pain and constitutional symptoms occasioned by the
disease, considered as distinct from the symptoms which may be
dependent on disease endemic in the country, are all relieved, and
sometimes entirely removed, by the destruction of the diseased surface,
which must, however, be carefully and accurately followed, to whatever
distance and into whatever parts it may extend, if the salutary effect
of the remedies is to be obtained.

Thirteenth.--On the separation of the sloughs, the ulcerated surfaces
are to be treated according to the ordinary principles of surgery.
They cease to eliminate the contagious principle, and do not require a
specific treatment.

Fourteenth.--The constitutional or febrile symptoms, whenever or at
whatever time they occur, are to be treated according to the nature of
the fever they are supposed to represent, and especially by emetics,
purgatives, and the early abstraction of blood if the fever be purely
inflammatory, and by less vigorous means if the fever prevailing in
the country be of a different character. Pain should be alleviated by
opium, which should be freely administered.

Fifteenth.--The essential preventive measures are separation,
cleanliness, and exposure to the open air,--the first steps toward
that cure which cauterization will afterward in general accomplish.

Sixteenth.--If the sufferer be very young, or of a weakly habit, his
strength will frequently require to be supported in the most efficient
manner by a due administration of cinchona bark, wine, and a generous
diet,--means often found essentially necessary after all severe attacks
of debilitating diseases.

The formidable nature of this terrible disease, before the local
application of caustic remedies was fully adopted, will be best
understood by the following document.

 RETURN _of the_ NUMBER OF CASES _of_ HOSPITAL GANGRENE _which have
 appeared at the Hospital Stations in the Peninsula between 21st June
 and 24th December, 1813_.

 +---------+---------+-------+-----+----------+--------+------------+
 |         |No.      |Dis-   |Died.|Under     |No.     |            |
 |STATIONS.|of cases |charged|     |treatment.|operated|REMARKS.    |
 |         |occurred.|cured. |     |          |upon.   |            |
 +---------+---------+-------+-----+----------+--------+------------+
 |Santander|   160   |    72 |  85 |    53    |   25   |Most of     |
 |Bilbao   |   972   |   557 | 387 |    28    |  183   |these cases |
 |         |         |       |     |          |        |were sent   |
 |         |         |       |     |          |        |from        |
 |         |         |       |     |          |        |Vittoria.   |
 |         |         |       |     |          |        |            |
 |         |         |       |     |          |        |            |
 |Vittoria |   441   |   349 |  88 |     4    |   74   |            |
 |Passages |    41   |     2 |   2 |          |        |Thirty-seven|
 |         |         |       |     |          |        |transferred |
 |         |         |       |     |          |        |to          |
 |         |         |       |     |          |        |Santander.  |
 |         |         |       |     |          |        |            |
 |         |         |       |     |          |        |            |
 |Vera     |         |       |     |          |        |Vera, being |
 |         |         |       |     |          |        |almost on   |
 |         |         |       |     |          |        |the field of|
 |         |         |       |     |          |        |battle, had |
 |         |         |       |     |          |        |no case.    |
 |         |         |       |     |          |        |            |
 |         |         |       |     |          |        |            |
 |         |         |       |     |          |        |            |
 |         +---------+-------+-----+----------+--------+            |
 |         |  1614   |   980 | 512 |    85    |  282   |            |
 +---------+---------+-------+-----+----------+--------+------------+



LECTURE IX.

ON WOUNDS OF ARTERIES, ETC.


[Illustration]

173. The efforts resorted to by nature for the suppression of serious
hemorrhages depend on the capabilities of the arteries as resulting
from their structure, into which it becomes an object of importance
minutely to inquire. With this view, the old division of an artery
into three coats may be continued, the difference between ancient and
modern anatomy being in their subdivision into different textures or
layers. The annexed diagram shows the edge of a large artery, which
has been divided circularly, and magnified so as to exhibit six layers
in a distinct manner; each of the three ancient coats is divided into
two. The _inner_ or old serous coat is shown to be separable into
_two_: the epithelial, marked 1, and the fenestrated, marked 2. The
_middle_ coat is also separated into _two_: the inner, or _muscular_,
marked 3, and the outer, or _elastic_, marked 4. The _outer_ coat is
divisible also into two layers, the _inner_, marked 5, and the _outer_,
marked 6; number 5 being composed more of elastic fibers: number 6 more
of areolar fibers, by which tissue, in a less condensed state, the
arteries of the extremities are attached to their sheaths. Such may
be considered to be the general composition of a large artery, each
particular structure remaining to be examined.

[Illustration: No. 1.

  OLD.      MIDDLE.      YOUNG.]

174. If a small portion of the inner coat of an artery be gently
scraped with a knife, or if the inside of the cheek be treated in a
similar manner, a little white soft substance is brought away on it,
called _epithelium_, a name given to it by Ruysch, from the delicate
layer of epidermis investing the female nipple, έπι, upon, θηλή,
_a nipple_. The epithelium of the human body is divided into three
kinds by microscopists--the _tesselated_, _pavement_, or _scaly_; the
_cylindrical_, or _conical_; and the _spheroidal_, or _glandular_. The
tesselated, as it exists in arteries, is represented in diagram No.
1, in three different stages--in the young person, in middle age, and
in the very old person; one stage gradually degenerating or changing
into the other, at each different period of life. It is composed of a
single layer of nucleated cells, of a flat, oval, round, hexagonal, or
polygonal form, and about 1/1400 of an inch in diameter, the nucleus
in each cell containing within itself one or more nucleoli, and even
several paler granules. The epithelium has a thickness proportioned
to the friction or pressure to which it is exposed, particularly when
covering the skin. In the arteries of the young, and in the mammalia
generally, the epithelium is strongly marked; in older persons, all
traces both of cells and nuclei have disappeared. It lines not only
the internal surface of the arteries and veins, but the mouth with its
mucous glands; the _conjunctiva_ of the eye; the pharynx and œsophagus;
the vagina and cervix uteri; the entrance of the female urethra, and
the serous membranes.

The _conical_ or cylindrical is composed of cells closely set together,
of a conical, cylindrical, or pyramidal form, about 1/1200 of an inch
long, each cell inclosing a flat nucleus, with nucleoli. It lines the
urethra in the female, from the entrance where the tesselated ends,
and extends inward to the urinary tubules of the kidneys; the greater
part of the male organs in a similar manner; the digestive canal and
gland-ducts, from the cardia to the anus.

The _spheroidal_ or _glandular_ epithelium consists of cells, more or
less circular or spherical in figure, each having a large nucleus in
its center. The epithelium is met with in all glandular organs, such as
the liver, kidney, lachrymal, and salivary glands, and in these cells
the proper secretion of the gland is developed. The tesselated and
cylindrical kinds are, on the contrary, more or less protective.

The two first kinds are sometimes ciliated, by the addition, at
their free extremities, of several fine, pellucid, blunt, and pliant
hairlike processes or cilia, about 1/5000 of an inch long, which are,
during life, in constant motion. This kind of epithelium, known as the
ciliary, lines the whole respiratory track of mucous membrane; the
_palpebral_ conjunctiva, as opposed to the tesselated on the eyeball;
the ventricles of the brain; the posterior half of the uterus, and the
Fallopian tubes.

The epithelium is placed upon the second layer of the internal coat,
which, from certain appearances of apertures or windows, has been
called the _perforated_ or _fenestrated_ layer. (See diagram No. 2.)
It can be peeled off in small pieces only, and shows under a power
of 250 diameters a series of well-marked fibers running in almost
parallel lines upon a comparatively structureless membrane, resembling
the inner layer of the cornea, as in the left-hand figure of the
diagram, the fibers being arranged in the length of the vessel. They
frequently bifurcate, and almost immediately join again, so that an
oval space, resembling a hole, is perceived. This is not always a hole
or perforation, as it is generally described to be, as may be seen
and proved by the fact that the supposed opening is sometimes filled
up by small bodies, like nuclei, as if the oval space were occupied
by a cell. This fenestrated layer varies in thickness in different
vessels, and is more strongly developed in the lower animals than in
man; by some authorities it is not regarded as a distinct layer, but
as the innermost layer of longitudinal fibers belonging to the middle
coat. When this layer is very thick, the fibers which are yellow do
not all run in the direction of the length of the vessel, for others
crossing at right angles may sometimes be observed, as delineated in
the right-hand figure of diagram No. 2. These two layers compose the
ancient inner coat of an artery, and are frequently the seat of disease.

[Illustration: No. 2.]

The middle coat, as it was termed, forms by much the greatest part
of the thickness of an artery, and, generally speaking, is of a more
or less yellow color. It appears fibrous to the naked eye, and can
be peeled off not unfrequently in a series of circular layers; when
examined microscopically, it is seen to be composed of _two_ sets of
fibers arranged in a circular direction. The inner layer is composed
principally of muscular fibers, of the organic or involuntary kind.
(See line marked 3 on the circular diagram.) The outer layer, marked
line 4 on the same diagram, is made up chiefly of elastic fibers, with
a much smaller amount of the muscular or contractile element. These
conjoined layers form the muscular coat of Mr. Hunter, the fibrous or
contractile coat of later anatomists, who denied its muscularity from
the supposed absence of fibrin--an error fallen into from chemical
science being unequal at that time to its discovery, or rather of its
more elementary part, called _protein_, the principal constituent
both of albumen and fibrin, which two are now found to differ from
each other in the addition only of three per cent, of sulphur. Mülder
says, in his “Animal and Vegetable Chemistry,” (Part II. p. 307:) “The
combinations of sulpho-phospho protein (_fibrin_ and _albumen_) and of
sulpho-protein _casein_ with acids, alkalies, and salts are especially
remarkable. Protein is soluble in weak alkalies. Since, therefore, the
serum of the blood is always slightly alkaline, being a proteate of
soda, with sulphur and phosphorus, it keeps the sulpho-phospho protein
in solution. This property is the cause of the blood remaining in a
liquid state--a chief requisite for animal life.

“If a weak alkaline solution of protein be neutralized by an acid,
the solubility of sulpho-phospho protein is greatly diminished. The
sulphuric and phosphoric acids, by not dissolving protein, stanch
bleeding. Acetic acid, by which protein is dissolved, does not, neither
does the hydrochloric.

“Protein, according to Mülder--although it is doubted by Liebig--is
a complex substance, consisting of several heterogeneous organic
compounds united into one whole, easily acted upon by strong reagents.

“If a protein compound be brought into contact with an alkali, ammonia
is immediately disengaged, and the alkaline solution can hardly be
made weak enough to prevent the disengagement of ammonia. If either
fibrin or coagulated albumen be dissolved in a weak potash lye, ammonia
is always perceptible. Protein, therefore, is always in a state of
decomposition, as serum is alkaline.”

In diagram No. 3, fig. 3, the organic or _involuntary_ muscular fibers
of the intestine are shown, consisting of more or less flattened
bands, the fibers of which are soft, and marked with minute granules,
sometimes exhibiting traces of nuclei. These purely muscular fibers are
most abundant next to the inner coat of the artery, and diminish in
number as they approach the outer layer, their place being occupied by
firmer and more elastic fibers of a yellow color, seen collectively in
the circular diagram, as line 4, and separately in diagram 3, fig. 4,
and in diagram 4.

[Illustration: No. 3.]

[Illustration: No. 4.]

The _involuntary_ muscular fibers of an artery do not always form
a continuous layer; they are often smaller than those found in the
intestines, bladder, and uterus, and occur as fusiform cells, detached
from each other, and having a large, club-shaped nucleus, as shown at
fig. 6 in diagram 3.

The _voluntary_ muscular fibers differ from the _involuntary_, in
having cylindrical fibers of much larger size, with transverse and
longitudinal markings, unlike the flattened fibers of less size of the
involuntary muscles, which have also a faintly granular appearance,
instead of the more determined transverse and longitudinal lines of the
voluntary muscles.

The _outer_ or _elastic_ layer of the ancient _middle_ coat,
represented by line 4 in the circular diagram, contains muscular
fibers, but it is formed principally of strong, elastic fibers
difficult of separation, and, when torn across, have curled
extremities, as shown in the diagram marked 4, differing only in size
from those found in the ligaments of the spine, and in the ligamentum
nuchæ of quadrupeds, as shown in the separate diagram marked 4.

The _external_ coat of an artery, divided also into _two_ layers, is
shown on the circular diagram by lines 5 and 6. These two layers are
composed of the yellow elastic fibers last noticed, and another set
of fibers, _white_ in color and _in_elastic in structure, arranged
in various directions; the _inner_ layer predominating in yellow
elastic, the outer layer in white inelastic fibers, constituting
a firm investment to all the other layers of which the artery is
composed. The white inelastic fibers are shown in diagram No. 3,
fig. 5, with a yellow elastic fiber curling round them. The constant
crossing and recrossing of these two sets of fibers form certain
spaces, which, when not in a compact form, become real spaces, meshes,
or areolæ, constituting what is now called areolar tissue, rather
than the cellular of the older anatomists, from the circumstance that
the areolæ communicate, and that perfect cells in any tissue do not.
These elements of areolar tissue can be readily distinguished by the
action of acetic acid, under which reagent the white fibers will
almost disappear, leaving only a slight trace of fibers containing
oval nuclei, as seen and marked in diagram 3, fig. 5. It is seen when
unraveled in _b_, diagram 5.

[Illustration: No. 5.
  _a._ Yellow elastic fibers.
  _b._ White inelastic fibers.
  _c._ Nuclei.
  _d._ Fiber, with nucleus.]

The inner layer of the middle coat, or muscular coat, as it may be
justly termed, forms, it will be seen, the greatest part of the
thickness of the wall of certain arteries, and in some instances, as in
the anterior tibial artery, constitutes nearly the entire thickness of
the vessel. The _internal_ coat in all is frequently seen puckered in a
longitudinal direction.

175. The arteries are supplied with blood by vessels of small size,
which do not come off immediately from the part of the artery they are
destined to supply, but principally from neighboring vessels. They are
called vasa vasorum. They are arranged precisely in the same manner as
those of the areolar tissue. A few of these vessels penetrate as far as
the middle or muscular coat, but do not reach the inner, which has no
vessels, proximity to the circulating fluid being apparently sufficient
for its nutrition.

Arteries are supplied with nervous influence by branches from the
sympathetic system running in their walls, and through their connection
by ganglions with the organs they supply with blood.

176. The cells, nuclei, and nucleoli alluded to are supposed to be
thus produced. In a shapeless, consistent, sometimes almost gelatinous
mass, to which the name of _cyto_-blastema or _formative substance_
has been given, containing the materials requisite for the production
of cells, small, round grains or nucleoli are perceived in the act of
formation. Around these grains a layer of granular matter is deposited,
which continually increases in thickness, and constitutes the kernel
or nucleus. This is oval shaped or round, almost always opaque, has
a granular surface, and is considered to be a vesicle, a little cell
itself. From the surface of this kernel a small, very thin transparent
vesicle is raised, appearing as a segment of a sphere, which soon
expands, and becomes so large, when full grown, that the kernel lies
as a minute corpuscle upon its interior wall; the material for its
formation being supplied by the cyto-blastema, it is converted into a
vesicle by the kernel which is first formed, its embryo existing in the
formative substance.

The first trace of organization is the production of a small,
perceptible body, or nucleolus, which deposits on the surface a
granular substance from the cyto-blastema, to give rise to a little
producing organ, the kernel or nucleus. This further transforms the
surrounding cyto-blastema into a granular surface, from which the
vesicle is formed, raised, expanded, and filled with a liquid, in which
vesicle thus enlarged the kernel remains inclosed and adhering to a
certain spot of its wall.

If two nucleoli lie close to one another, they coalesce and become one
solid mass, capable of producing one cell only, containing one kernel
and two nucleoli. This view is that of Schleiden and Schwann, supported
by Mülder, but not entirely approved by Henle; inasmuch as no kernel
can be perceived in the cells of many cellular systems while in the
act of formation. In the elementary parts of animals which have long
since lost their cellular form, the remnants of kernels are frequently
found, as has been demonstrated in the preceding diagrams. The manner,
however, in which the elementary first-seen granules are formed in the
cyto-blastema, science has not yet been able to discover. The chemists
have proved that all elementary organic substances consist of carbon,
hydrogen, oxygen, and nitrogen, susceptible of endless modifications
of their respective forces, under which an organic molecule or ovum is
produced, and after that, under certain circumstances, an animal such
as man.

177. When the current of blood through the main trunk of the arteries
of an extremity is cut off, the circulation is carried on by the
collateral branches. This collateral circulation is more perfect, more
active in young persons during the increase or growth of the body,
than it is either at maturity or in the decline of life. The important
point is not, however, alone referable to the time of life at which the
continuity and permeability of the main trunk cease to exist, but to
the nature of the disease or injury which has given rise to it.

When an aneurismal limb has been injected, on which an operation has
not been performed, the collateral vessels have all been found larger
and more fully shown than on the opposite side, although not to the
same extent as in cases of a similar nature in which the operation has
been done.

It is necessary that this enlargement of the collateral branches should
lake place at an early period, because in many cases of aneurism
the artery beyond or below the tumor is obliterated long before any
operation is performed. The main supply of blood has been already cut
off from the extremity, and the operation adds very little to the
derangement of the circulation which has for some time taken place
below the tumor.

When an operation has been successfully performed for aneurism, and
the patient has died some time afterward, dissection has shown various
arteries enlarged, both above and below the part where the trunk was
obliterated by the ligature; and not only an enlargement of arteries,
which, from their regularity have received names, but others have
been developed not usually known to exist, or not of a size to be
conveniently traced. These through their frequent anastomoses bring the
blood at last into several large trunks, by which it is again conveyed
to the original vessel below all and every obstruction which may have
taken place; thus compensating by a circuitous route for the loss of
the direct supply. The principal object of inquiry is, do these vessels
always exist, or at what period of time do they begin to enlarge, so as
to enable them to carry on the circulation, in the manner in which it
is presumed to be done?--for few will assert that the enlargement of
these particular collateral vessels was an accidental play of nature,
and existed previously to the commencement of the disease or injury
for which the operation was performed. On this point, the theory of
the operation for aneurism and its applicability to wounded arteries
appears to hinge; and, what is of more importance, on which the
practice resulting from it depends.

Two distinct kinds of collateral circulation are at present
acknowledged: one by direct large communicating arteries; the other
through the direct medium of the capillary vessels inosculating
with each other. Where direct communicating arteries exist, little
subsequent change beyond enlargement takes place in them. It is
otherwise with the indirect capillary vessels. When the radial or
ulnar artery has been divided in the hand, the blood will not only
flow readily from each end of the divided vessel, but equally red and
arterial from both, the communication being through direct arterial
branches from one vessel to the other. It will also be red and arterial
if the division take place at the wrist, and may be so in the brachial;
but if the femoral in the lower part of the thigh be wounded, the color
of the blood issuing from the lower end of the artery, if any issue at
all, will be _dark or venous_. It is so, because it has been obtained
from the capillary arteries, which in this case being empty received
blood by regurgitation from the veins, the valves of which when present
do not prevent its reflux course. If a limb be injected and carefully
dissected four or five days after a ligature has been placed during
life high up on the principal trunk, the capillary vessels will be
seen to be well injected; but few or none will be found large enough
to admit of their inosculation being traced throughout. If another
limb be injected and dissected, some sixty days after the ligature
has been applied, a difference will be distinctly observed between
the two preparations. In the latter, the capillaries will not appear
to be so fully injected, but several larger and more tortuous vessels
will be found in situations where they were not expected to exist;
and the anastomoses of these one with another, generally by arches,
may be traced to their communication with the principal trunk, both
above and below the obliterated part. If an incision were made in the
nearest pervious portion of the lower part of an artery in the thigh of
a person who had undergone this operation, arterial blood would issue
from it. The communication would have become direct by communicating
branches, and the capillaries would have returned to their accustomed
duties.

178. During the first twenty-four hours after the division of an artery
such as the femoral, or the application of a ligature, the temperature
of the limb is commonly diminished; after that period, and as the
action of increase takes place, the temperature is usually from three
to five degrees higher than in the opposite healthy limb. At the end of
from eighteen to twenty-eight days, in a successful case, it is found
to be equal in both.

It is asserted by some sanguine supporters of the all-powerful
influence of the collateral circulation, that it is sufficient at all
times, and under all natural circumstances, to maintain the life of
the extremity. The practice of the Peninsular war proved the fallacy
of this opinion in too many instances to admit of any doubt of its
inadequacy to do so in the lower extremity after the division of the
femoral artery, under ordinary circumstances. The fact of enlargement
or of a new development of vessels having taken place after the
commencement of disease or the reception of an injury, has been
demonstrated by dissection, and it is through them the life of the limb
is to be preserved; but time is required for their development. When a
limb is lost through mortification, as the consequence of a division
or obstruction of the principal artery, it usually takes place after
the infliction of a sudden injury, in consequence of these collateral
branches not having had time to enlarge.

179. The collateral circulation is therefore not the same, and is not
in the same stage of preparation, in a limb suffering from a divided
or wounded artery, as in one in which an aneurism has for some time
existed; this is the reason why mortification is more common after
wounded arteries than after operations for aneurism.



LECTURE X.

PROPER TREATMENT OF WOUNDED ARTERIES, ETC.


180. The due appreciation of the means adopted by nature and by art
for the suppression of hemorrhage, as well as the proper treatment of
wounded arteries, is owing to the surgery of the war in the Peninsula.
They were suspected after the battles of Roliça, Vimiera, Oporto, and
Talavera, but did not receive their complete development until after
the battle of Albuhera. It was not until after that of Toulouse they
were partially admitted; and it is only of late that they have been
almost everywhere acknowledged, taught, and practiced.

Previously to the time of Mr. Hunter, the diseased or dilated state
of the coats of an artery which constitutes an aneurism was, when it
occurred in the ham, very often fatal. The operation of Anel, first
performed in 1710, of cutting down to the artery, and placing a
ligature upon it immediately above the dilated part, was not approved,
and Mr. Pott, the great contemporary of Mr. Hunter, recommended in bad
cases that amputation should be resorted to in the first instance;
although Desault had succeeded, in 1783, in a case of popliteal
aneurism, in which, after the manner of Anel, he had placed the
ligature on the artery a little above the aneurismal swelling in the
ham. Mr. Hunter’s contemplative mind, aided by his knowledge of anatomy
and of disease, led him to believe that the ligature thus applied on
the artery in the ham failed, because the vessel was unsound at that
part, and was therefore incapable of taking on those healthy actions
necessary for the obliteration of its canal above the ligature,
which are known to take place when the artery is in a normal state.
He concluded that this was sufficient to account for the failures,
without especially taking into consideration the difficulty of applying
the ligature in the ham immediately above the aneurismal sac, and
of the probability of the sac suppurating when thus molested; an
occurrence aiding materially in the necessity for the loss of the limb
by amputation, performed then under circumstances of constitutional
irritation, which would render it less likely to be attended with
success.

From the consideration of these and other circumstances, Mr. Hunter was
induced to propose, in 1785, that the ligature should not be placed on
the artery near the tumor in the ham, but at a greater distance on the
fore part or middle of the thigh, and Scarpa subsequently recommended
it to be placed even higher--a recommendation which has been generally
followed, and the spot now selected for this operation is at the lower
part of the upper third of the thigh. This operation was therefore
performed not only for aneurism, but improperly for a wound of the
artery, not only in the ham, but even in the leg; it consequently
failed in almost every instance of traumatic injury, thus rendering
amputation necessary, which was generally followed by death.

181. The Hunterian theory implies:--

1. That the artery is in general sound at the part in the front of
the thigh selected for operation, while it is usually unsound in the
popliteal space behind, or in the ham, where Desault operated, and
Anel recommended it to be done; that operation is now abandoned on the
continents of Europe and America, as well as in England.

2. That a ligature can readily be placed upon it at a distance from the
disease in the fore part of the thigh, and will usually be followed by
success as far as concerns the obliteration of the artery immediately
below the part on which it is applied.

3. That the artery being aneurismal, the collateral branches had begun
to enlarge, so as to be better able to carry on the circulation, after
the supply of blood to the lower part of the limb by the main trunk had
been cut off.

4. That no branches of importance are usually given off between the
ligature on the artery on the fore part of the thigh and the sac of the
aneurism in the ham.

5. That if such branches were ever given off, and brought the blood
from their collateral communications back into the main artery below
the ligature, and thence into the sac, so as to renew its pulsatory
movements, they would ultimately disappear, from the impelling force
not being sufficient to prevent a gradual coagulation taking place,
which would soon fill up the cavity of the sac, and thus prevent its
further enlargement; at which stationary point a process of removal
by absorption would begin and continue, until the diseased sac with
its contents had diminished, if not entirely disappeared, leaving only
a trace behind of its former existence, the process thus described
being frequently assisted by a commencing obliteration of the artery
immediately below the aneurism. The essential point in this theory,
which has immortalized the name of Hunter in surgery, depends on the
integrity of the aneurismal sac, which ultimately retains, as a general
rule, subject to rare exceptions, any blood which may be brought into
it, either by the collateral branches from above, or from below by what
may be called regurgitation, until it has become coagulated, when the
sac is so filled up that no more blood can pass into it to cause its
further distention, or any ulterior evil.

This theory of Mr. Hunter, then so new, so beautiful in itself, was
eagerly embraced by nearly all the civilized world; and surgeons
were not content with applying it to cases of diseased or aneurismal
arteries, to which it is especially applicable, but they extended it
indiscriminately to cases of wounded arteries, to which the practice of
the war in Spain proved it was inapplicable, and in which I have, since
1811, maintained it could only succeed as a matter of _accident_, not
of principle.

182. The essential features of the theory opposed to Mr. Hunter, with
respect to wounded arteries, and called mine, are:--

1st. That the artery at the wounded part is free from previous disease,
and may be expected to take on those healthy actions which, after the
application of a ligature, lead to the obliteration of its canal, and
the consequent suppression of hemorrhage.

2d. That the circulation of the blood by the collateral branches is
less free in a sound limb than in one which has suffered during several
weeks from the formation of an aneurism.

3d. That this freedom of circulation is less in the _lower_ than in the
_upper_ extremity, under all circumstances.

4th. That mortification of the foot and leg, and often of the whole
limb, followed by the death of the person, is a common occurrence
after a ligature has been placed high up on the artery in the thigh,
in consequence of a wound; while it is not so common an occurrence
when such operation is performed in the same place for an aneurism of
several weeks’ duration. If the vein be also wounded, mortification is
almost inevitable.

5th. That mortification of the hand and arm rarely follows the
application of a ligature to the artery of the _upper_ extremity in any
part of its course, however near the heart.

6th. That when the collateral vessels are capable of carrying on the
circulation through the lower extremity, the _lower_ end of the divided
artery bleeds _dark_ or _venous_-colored blood, while its _upper_ end
bleeds _scarlet_ or _arterial_-colored blood. In the upper extremity,
the color of the blood from the lower end of the divided artery is
little altered--a consequence of the greater freedom of anastomosis, or
of the freer collateral circulation in the upper extremity. Facts of
the greatest importance in surgery.

7th. That whenever the collateral vessels are not capable of carrying
on the circulation of a limb, mortification or death of the part
ensues; and _that whenever this collateral circulation is sufficient to
maintain the life of the limb, blood must pass into the artery below
the wound, and must, as a general rule, pass up and out through the
lower end of the divided artery, unless prevented by the application of
a ligature, or by some accidental circumstance, forming an exception to
the rule, but not the rule itself_.

8th. That the collateral branches are capable of bringing blood into
the artery above the aneurismal sac and between it and the ligature,
is admitted in the Hunterian theory, which blood the aneurismal sac
receives, and usually retains. When the artery is a wounded artery,
and the ligature is applied at a distance above the wound, blood is
often brought into it below the ligature in a similar manner; but as
there is _no aneurismal sac_ to receive and retain it, the patient
bleeds perhaps to death, unless surgery come to his assistance.

9th. The presence of an aneurismal sac in one case, and its absence in
the other, is the essential difference destructive of the Hunterian
theory for the treatment of aneurism being applicable to that of
wounded arteries.

10th. The processes for the natural suppression of hemorrhage are
somewhat different in the upper and lower ends of an artery, and are
less capable of resistance in the lower. This end frequently yields
to the pressure of the blood regurgitating from below, and renews a
bleeding which may have been suppressed for weeks, unless its closure
has been rendered more permanent by the application of a ligature.

11th. The absence of the aneurismal sac renders the application of two
ligatures absolutely necessary, one on each end of a divided artery, or
one above and one below the wound, if the artery should not be divided;
constituting the most essential feature of my theory, and the principal
point to be attended to in the treatment of wounded arteries.

12th. This bleeding from the lower end of the vessel, which is more
or less of a venous color, and issues in a continuous stream, may be
restrained by compression properly made on the course of the lower part
of the wounded artery; but in no instance should recourse be had to
a ligature on a distant part of the artery above the seat of injury,
until every other possible effort to arrest the hemorrhage from the
lower end of the vessel has failed.

13th. The great principles of surgery to be observed in cases of
wounded arteries, and which ought never to be absent from the mind of
the surgeon, are two in number:--

1. That no operation ought to be performed on a wounded artery unless
it bleed.

2. That no operation is to be done for a wounded artery in the first
instance but at the spot injured, unless such operation not only
appears to be, but is impracticable.

183. The means adopted by nature for the suppression of hemorrhage
have been investigated by Celsus, Rufus, Galen, Œtius, etc., down to
Dr. Jones, the most important English writer on this subject; but the
methods of inquiry they all adopted appear to have been insufficient
and unequal to the object in view. They bled an animal until he died,
and then reasoned on the manner or means by which the bleeding was
suppressed, when it was in fact arrested by death. It is obvious, then,
that it is only when nature has not been interfered with, and the
patient has not died from bleeding continued to the last moment, but
has, on the contrary, lived some time after the hemorrhage has ceased,
that the processes by which its suppression has been accomplished can
be fairly investigated. These processes essentially depend on the size
and variations of structure in an artery, which have been shown to be
dissimilar in large and small arteries, and not even quite alike in the
upper and lower ends of the same artery--facts which were elicited from
observations made on men on the field of battle during the Peninsular
war, and consequently not liable to error. It was then proved that
arteries of moderate dimensions, such as the middle part of the femoral
or the axillary, tibial or brachial, and particularly all below these
in size, are capable, by their own intrinsic powers, when completely
divided, of arresting the passage of the blood through them without any
assistance from art, or from the surrounding parts in which they are
situated. The establishment of this fact overthrew at once the theory
which relates to the importance of, and necessity for, the sheath of
the vessel, and the offices it performs in suppressing hemorrhage
in vessels of this size, and in a great measure that supposed to be
derived from the formation of an external coagulum, the _bouchon_ of
the French.

184. When the femoral artery has been fairly divided in the lower part
of the thigh, the patient has, in almost all the cases which have come
under observation, either died without assistance, or the hemorrhage
has ceased spontaneously. Having been thus arrested for twelve hours,
the efforts of nature are usually sufficient to prevent its return
from the _upper_, although not from the _lower_ end of the vessel; but
then it is of _venous_ and not of _arterial_ color--a fact I first
demonstrated, and which is now acknowledged to be of the greatest
importance. The great evil to be dreaded in such cases is not from
hemorrhage from the _upper_ end of the divided artery, but from the
_lower_, and from _mortification of the foot_.

The _upper_ end of an artery retracts on being divided, and this
retraction is accompanied by a contraction of the cut extremity of the
vessel, which assumes the shape of the neck of a French wine-bottle
or Florence oil-flask. The contraction is confined in the first
instance to its very extremity, so that the barrier opposing the flow
of blood is formed by this part alone. The contraction, however, goes
on increasing for the space of an inch; it is usually filled up with
an internal coagulum of a round, pyramidal shape, adhering firmly to
the contracted end of the artery, loose at its apex, and extending
frequently as far as the first collateral branch, but rarely under
any circumstances beyond two inches; the very orifice of the artery
on the outside being in a few days covered by a layer of a yellowish
green-colored substance or fibrin, which indicates its situation in a
remarkable manner. Some of these processes are continued even after the
external wound has healed; the artery generally goes on diminishing and
contracting as far as it is useless, so that of three or four inches,
from one to two may be impervious, the remainder being contracted,
although still permeable by a probe. An accompanying nerve, where there
is one, would do the reverse, the cut extremity would become enlarged
or bulbous, gradually diminishing as it is traced upward, until it
regains its proper size.

The processes adopted by nature for closing the lower end of a divided
artery of the size of the femoral at the inferior part of the thigh
are somewhat different from those employed at the upper or opposite
extremity. The retraction or contraction of the _lower_ end of a
divided artery is neither so perfect nor so permanent as at its _upper_
end, and the small internal coagulum is in many instances altogether
wanting, or very defective in its formation. The closure of the lower
orifice being less perfectly accomplished than of the upper, it is
the more likely to suffer from secondary hemorrhage, which may be
distinguished from that from the upper end of the artery at an early
period after the accident, by the _venous color of the blood, and from
its flowing or welling out in a continuous stream, as water rises from
a spring, and not with an arterial impulse_.

The retracting and contracting powers in the lower end of a divided
artery are nevertheless considerable, and are sufficient in some cases
to nearly close the lower end of the femoral artery when divided by
amputation above the knee. When the femoral artery is cut across, the
lower portion of the vessel is emptied by its last efforts, combined
with the action of the capillaries. When the collateral circulation
is powerful, blood soon regurgitates into the artery, but the force of
the regurgitation can be in no proportion to that of the propulsion at
the other or _upper_ divided end of the vessel, which will generally
be able to resist this impulse, while the _lower_ one often opens and
bleeds after the lapse of a few days. In all the cases I have had an
opportunity of examining, in which hemorrhage had taken place from the
lower end of the artery, the following appearances were observable
after the interval of from four to five days.

The same kind of yellowish-green matter marks and conceals the
situation of the lower extremity of the artery in the wound as it
does the upper. It is, however, thinner where it immediately covers
the end of the artery, which in none of these cases was contracted in
the conical manner described as taking place in the upper extremity.
On the introduction of a probe with the greatest gentleness into the
artery from below, it usually makes its appearance at a point on the
yellow space, raising a thin portion as it protrudes. On laying open
the artery, the orifice would seem to have been once closed by this
layer of fibrin, but with a less degree of contraction than the upper
end of the same artery; the layer still, however, forming an obstacle
sufficient to cover and close three-fourths of the orifice, the blood
having flowed through the remaining fourth, which had probably given
way by accident; which accident is usually some sudden or continued
motion being given to the extremity or part injured, and which motion
it is imperatively necessary to avoid, when the lower end of a wounded
artery has not been secured by ligature.

A soldier, who had his arm carried away by the bursting of a shell at
the siege of Ciudad Rodrigo, was brought to me shortly afterward. The
axillary artery, becoming brachial, was torn across, and hung down
lower than the other divided parts, pulsating to its very extremity.
Pressed and squeezed in every way between my fingers in order to make
it bleed, it still resisted every attempt, although apparently by the
narrowest possible barrier, which appeared to be at the end of the
artery, and formed by its contraction. The orifice of the canal was
marked by a small red point, to which a very slight and thin layer
of coagulum adhered, the removal of which had no influence on the
resistance offered by the very extremity of the artery to the passage
of blood through it. In this, and in another instance of a similar
nature, the end of the artery being cut off at less than an eighth of
an inch from the extremity, it bled with its usual vigor. In both, the
vessel for near that distance was contracted so as to leave little or
no canal at its orifice, which in these cases was filled by a coagulum
of the size and shape of a very small pin.

[Illustration:

  1. Axillary artery.
  2. Axillary vein.
  3, 3. Branches of axillary plexus of nerves.
  4. Curved, pointed and plugged ends of the artery and vein.

 The vessels are here represented as they lay exposed in the lacerated
 parts. The pointed and plugged ends of the vessels were of a dark
 coagulum color, while above both artery and vein had a reddish,
 vascular appearance, and were held in close relation by their sheath.
 The artery bent distinctly to the very base of the coagulum.]

Mr. Deputy Inspector-General Taylor informs me that a soldier of the
44th Regiment was struck by a cannon-shot on the 21st of June, 1855, in
front of Sebastopol; it carried his left arm away from the shoulder,
leaving the artery, vein, and nerves exposed as in the accompanying
sketch. The thought, he says, crossed my mind, as I held the artery
between my finger and thumb, that it might be for the benefit of
the patient to place a ligature on the artery at the highest point,
exposed, cutting off the part below, having had a precisely similar
case at Ferozeshah, in India, in which the soldier recovered without
the artery being tied, or any hemorrhage recurring. The shot, in
carrying away his arm, struck him very severely on the chest, and
I fear has injured the lungs, but there is so much ecchymosis that
the presence or absence of sounds cannot be distinguished by the
stethoscope. Of this injury of the chest the man died some days after
its receipt. The body was buried without examination, but no hemorrhage
had taken place from the wound.

Private J. Barnes, 29th Regiment, on the 16th of May, 1811, at the
battle of Albuhera, received a musket-ball in the right thigh, behind
and above the knee, inclining downward and inward, close to the
condyles of the femur, and in the direction of the femoral artery
becoming popliteal; it bled violently at the moment, and so continued
for a few minutes, during which time he conceives he lost two quarts of
blood. It then ceased, and he was dressed in the usual slight manner,
and remained two days upon the field of battle, until removed to
Valverde, nine miles, on a bad road, on men’s shoulders, in a blanket
converted into a bearer. He was considered as one of the slighter
cases, until the gentleman in immediate charge of him requested me to
see him, on account of his toes being in a state of mortification.

On the evening of the 3d of June, eighteen days after the accident,
the man was placed on a bullock car, to be removed with the rest of
the wounded to Elvas, the mortification of the foot having ceased to
increase, and a line of separation having been formed. Shortly after
the cars moved, I was informed that he was bleeding from the wound: it
evidently appeared to flow from the popliteal artery; and as it issued
slowly, I supposed from the lower divided end. The foot being partly
lost, I determined on amputation above the knee, which was performed
at Olivença. The amputated limb was sent after me to Elvas, that it
might be examined at leisure. I carefully traced the course of the
wound, and found in it a little coagulated blood, but could not see the
mouth of the vessel. A probe passed into the upper end of the artery
was obstructed before it reached the ulcerated surface by nearly an
inch; and on passing it up the lower one, it was stopped exactly in the
middle of the track of the ball, by a veil or substance drawn across
the mouth of the vessel, which, on careful examination, showed the
point of the probe at one part of the circle, although too small to let
it through; from this part I conceive the hemorrhage came. The divided
ends were one inch apart. The _upper_, or femoral portion, for nearly
an inch, contained a firm coagulum, filling up that part of the artery,
which had contracted like the neck of a claret bottle. The _lower_ or
popliteal portion of the artery had a very peculiar appearance; the
substance drawn across appeared to have closed it completely at one
time, and to have given way from the rough motion of the car at the
point now open, which was very small even when the sides of the artery
were approximated. A very little soft coagulum was behind it; and if
the man had not been removed, the vessel might have remained secure.
This case shows very distinctly the means adopted by nature for the
suppression of hemorrhage from both ends of a divided artery.

Corporal Carter, of the pioneers of the 29th Regiment, was wounded
at the battle of Roliça, in August, 1809, by a musket-ball, which
passed through the anterior and upper part of the forearm, fracturing
the ulna. Shortly afterward a profuse hemorrhage took place, and the
staff-surgeon in charge tied the brachial artery. In the night the
hemorrhage recurred, and the man nearly bled to death. The arm was then
amputated, when the ulnar artery was found in an open and sloughing
state.

_Remarks._--A simple incision to expose the wounded artery, and placing
two ligatures upon it, would have saved this man his arm and his life.

At the battle of Vimiera, which followed a few days afterward, a
soldier received a somewhat similar wound, save that the brachial
artery bled forthwith, the hemorrhage being stopped by the tourniquet.
Warned by the preceding case, I cut down on the artery, carefully
avoiding the nerve, which had been tied in the former instance, and
found the artery more than half divided. It was secured by a ligature
above and below the wound: the bleeding did not afterward return, and
the man recovered.

185. Thomas Carryan, of the 3d Regiment, was wounded at Albuhera, on
the 16th of May, 1811, on the inside of the calf of the right leg,
the ball passing out on the fore and outside of the tibia: it bled
considerably for some minutes, when it ceased, and the hemorrhage
did not return until the 15th of June, on which day a little blood
followed the dressings, and increased on the patient making any
exertion; so that on the 4th, the gentleman under whose care he was
tied the femoral artery on the outside of the sartorius muscle, which
suppressed the hemorrhage for that day, the limb continuing with little
or no interruption of the same temperature to the hand as the other. On
the 5th, the original wound had a bad appearance, and some coagulated
blood was readily pressed out of it; on the 6th, a greater quantity
came away; and on the 7th, the exertion of using the bed-pan was
followed by a stream of arterial blood, which ceased on tightening the
precautionary tourniquet.

The limb was amputated above the ligature on the artery. Its dissection
showed the anterior tibial artery to have been destroyed for some
distance, and the muscles on the back part of the leg nearly in a
gangrenous state. The patient died a few days afterward.

_Remarks._--If an incision had been made in the leg so as to expose the
artery, and ligatures had been placed on it above and below the wound,
the man, in all probability, would not have died.

Sergeant William Lillie, of the 62d Regiment, aged thirty-two, was
wounded in the right thigh, on the 10th of April, at the battle of
Toulouse, by a musket-ball, which passed through, in an oblique
direction downward and inward, close to the bone, describing a track of
seven inches. The ball was extracted behind on the field. He said he
had bled a good deal on the receipt of the injury, which he had stopped
by binding his sash round the limb. The discharge from the wound was
considerable; it appeared, however, to be going on well until the
20th of the month, when, on making a sudden turn in bed, dark-colored
blood flowed from both orifices of the wound in considerable quantity.
I had given an order, as the Deputy Inspector-General in charge of
all the wounded, that no operation should be performed on a wounded
artery without a report being sent to me, and an hour at least granted
for a reply, unless the case were of too urgent a nature to admit of
it. It appeared to be so in this instance, and before I arrived Mr.
Dease had performed the operation for aneurism at the lower part of
the upper third of the thigh. I could only express my regret that it
had been done, and point out the probability of the recurrence of the
hemorrhage from the lower end of the artery, which took place on the
7th of May, when the limb was amputated, and the man subsequently died.
On examination the artery was found to have been divided exactly where
it passes between the tendon of the triceps and the bone. The upper
portion of the artery thus cut across was closed. A probe introduced
into it from above would not come out at the face of the wound,
although the impulse given to this part on moving it was observable in
the middle of a large, yellowish-green spot, which I had previously
declared to be the situation of the extremity of the artery which had
contracted behind this, in the shape of a claret bottle, for about an
inch, having within it a small coagulum. The lower end of the artery
from which the hemorrhage had taken place was marked by a spot of a
similar character; but on passing a probe upward from the popliteal
space, it came out at a very small hole in the extremity of the artery,
in the center of the yellow spot, the canal of the artery not being
contracted and diminished, but only apparently closed by a layer of the
yellowish-green matter laid over it, and adhering to its circumference.

Sergeant Baptiste Pontheit, of the French 64th Regiment, was wounded
by a musket-ball at the battle of Albuhera, on the upper and fore part
of the thigh; it passed out behind, in the direction of the femoral
artery. He lost a great quantity of blood before the hemorrhage ceased,
but the wound went on well until the 26th, ten days after the battle,
when he felt something give way in his thigh, and found himself
bleeding from the wound, which, however, soon ceased on pressing his
hand upon it. In the afternoon, on again moving, he lost about half
a pint of florid blood, which induced the surgeon on duty to place a
tourniquet on the limb. When at leisure (in the course of two hours) I
removed the tourniquet, and as no hemorrhage occurred, and there was
no swelling in the vicinity of the wound, I replaced the dressing with
a precautionary screw tourniquet, explaining to him its use, and the
probable nature of his wound, together with the operation requisite to
be performed in case of further bleeding.

On turning in bed at night he lost a little more blood, which ceased
on his tightening the tourniquet, which was shortly after loosened. In
the morning, everything being removed, there appeared some swelling
about the wound, the opening of which was filled up by a coagulum:
gentle pressure being made, it readily turned out, and was followed
by a stream of arterial blood, leaving little doubt of the femoral
artery being wounded. Compression being effected in the groin, I
made an incision three inches and a half in length, taking the wound
as a central point, and exposed the femoral artery and vein: both
were wounded, the former being half destroyed in its circumference,
surrounded with coagulated blood, and appearing as if it had sloughed
from being touched by the ball, the course of which was directly
past it, and would have carried it away if it had not been for the
elasticity of the artery. A ligature placed above, and another below
the wound, secured both artery and vein; the incised wound was brought
together by adhesive plaster, and the limb placed in a relaxed
position. The operation was of short duration; he lost little or no
blood, but, the circulation was very languid, and the man exceedingly
low. The warmth of the leg and foot was soon below the standard of the
other; warm flannels were applied, and some brandy was given to him.
In the evening the heat was more natural, and the man returned thanks
for the humanity and kindness shown to him, congratulating himself and
me upon the success of an operation which he had supposed would be
infinitely more severe. The next morning he ate a tolerable breakfast,
but felt a pricking sensation in the calf of the leg, which was as
warm to the hand as the other, but the foot was cold. The second day
the swelling of the limb, its appearance, and discoloration on the
under part, indicated approaching mortification, which on the third was
evident, and on the fourth, at mid-day, he died, the limb up to the
wound being nearly all in a gangrenous state. No adhesion had taken
place in the wound, or in the artery, which showed the inner coat cut,
the ligatures being firm, and no coagulum behind them.

Captain St. Pol, of the 7th or Royal Fusiliers, was wounded in the
ham from behind, while in the ditch at the foot of the great breach
at Badajos. He fell instantly, and lost, as he thinks, a considerable
quantity of blood. On recovering he was raised from the ground, and
walked a few paces prior to his being carried to his tent, where I
saw him in the afternoon of the next day, the 7th. The leg had ceased
to bleed before his arrival in camp. A substance could be felt on the
inner side of the patella, which, by the sensation communicated to the
finger on moving, appeared to be the ball, which was extracted. Some
dark-colored blood issued from the cavity; the ball was lying loose
and unconnected; the finger, on being passed into the joint, which was
swollen, discovered no splinters of bone, and the entrance of the ball
behind would not admit the finger. His having walked some distance on
the leg, and the absence of any splinters between the articulating
extremities of the bones, induced Dr. Armstrong, the surgeon of his
regiment, and myself to think that the ball had entered with little
injury to the bone; and after stating to the patient the little hope we
had of ultimately saving the limb, independently of the great danger
to which he was exposed, compared to the certainty of the operation of
amputation at the moment, we recommended its being done, but he would
not consent. The next day he was removed to Badajos on a litter, the
heat of the tent being unsupportable.

On the morning of the 9th I saw him early, when the want of circulation
in the foot was evident from its having lost its natural color and
warmth; the knee was swollen, but not painful, and I had no doubt that
the artery had been divided by the ball. The marbled appearance and
tallow-white color soon indicated the loss of the leg above the calf;
and vesications had formed on the foot, already of a green color.

On the 12th, the extent of the gangrene was defined on the back of the
knee up to the original wound at its lower edge, gradually receding
as it advanced to the fore part of the leg, which for three inches
below the knee was apparently sound; the uneasiness of the knee being
moderate, and the incised wound looking perfectly healthy, although the
latter had not united.

On the 16th, the separation of the dead from the living parts having
taken place behind, and being well marked and commencing on the fore
part, the limb was amputated as low down as possible. Sixteen vessels
were tied; the parts were gently brought together, without any hope of
union. According to subsequent experience, this operation should not
have been performed. The dead parts only should have been removed, and
the stump left to nature until the health was perfectly restored.

On the 24th he died.

On examining the amputated limb, the popliteal nerve was found
untouched, the ball having passed on the inside; the popliteal vein
was also entire, having a small tumor adhering to its under part
between it and the artery, the divided end of which was closed by a
yellowish-green firm substance readily distinguishing it from the
surrounding parts. On clearing the whole from the bone, and making a
small circular opening into the tumor, which was elastic and covered
with brown fibrous layers, it proved to be an aneurismal sac, smooth on
the inside, containing florid arterial blood and some little coagula.
The artery, on being carefully opened to the closed end, appeared to
have been injured above the part divided by the ball, and communicated
with the sac by a small fissure or rupture. The end of the artery was
then slit up, so as to show the very little thickness of the closing
substance and the great original contraction of the diameter of the
vessel. There was no internal coagulum, neither was there any laid over
the external part of the artery; between it and the bone there was a
coagulum about the size of a small phial cork. The other end of the
artery could not be found, from the gangrenous state of the parts.

Private P. Turnbull, of the grenadiers of the 74th Regiment, of good
stature, was wounded on the 10th of April, 1814, at Toulouse, by a
musket-ball passing from the inside to the outside of the middle of the
thigh; he says it bled considerably at first, but the bleeding soon
ceased; the wound was not painful, and he thinks he observed the leg
and foot to be colder than the rest of his body for the first two or
three days, but did not much attend to it, further than conceiving the
numbness, coldness, and impeded power of motion as natural to the wound.

On the 18th of April, the gentleman in charge of this patient pointed
him out to me as an extraordinary case of gangrene coming on without,
as he supposed, any sufficient cause. The wound on the outside of the
thigh, or the exit of the ball, was nearly healed, and that on the
inside was without inflammation or tumefaction, and with merely a
little hardness to be felt on pressure. The pulsation of the artery
could be distinctly felt to the edge of the wound, but not below it;
the leg was warm, the gangrene confined to the toes. The artery of
the other thigh could be distinctly traced down to the tendon of the
triceps. As he was at a small hospital, about two miles from town,
on the field of battle, I did not see him again until the 20th, and
afterward on the 23d, when, although the gangrenous portion included
all the toes, it had the appearance of having ceased. Satisfied that it
would again extend, I left directions with the assistant-surgeon that
the limb should be amputated _below the knee_.

The surgeon, whom I had not seen, and who did not understand the
subject, disobeyed the order, conceiving that there must be some
mistake. On visiting the hospital, a little after daylight on the
25th, I was greatly annoyed at finding that the operation had not
been done, and that the mortification had begun to spread the evening
before. It was then too late. On the 26th it was above the ankle,
with considerable swelling up to the knee. At night the man died; and
the next morning, at six o’clock, I removed the femoral artery from
Poupart’s ligament to its passage through the triceps, which part was
affected by the mortification.

The ball had passed between the artery and vein in the spot where
the vein is nearly situated behind it and adherent only by cellular
membrane, through which the ball made its passage, the coats of the
vein being little injured, and those of the artery not destroyed in
substance, although bruised; it was at this spot much contracted in
size, and filled above and below by coagula, which prevented the
transmission of blood, and the vein above and below the wound was
filled by a coagulum and was also impassable. This preparation is
unique; it is perhaps the only one in existence proving the elasticity
which vessels possess, and their capability of avoiding to a certain
extent an injury about to be inflicted upon them. It is in the museum
at Chatham.

186. When a round and small ligature is properly applied to an artery
of a large size, such as the femoral, the sides of the vessel are
brought together in a folded, plaited, or wrinkled manner; the ancient
inner and middle coats of the artery, including the modern four, are
divided, while the outer one remains entire and apparently unhurt. If
the ligature be removed, an impression or indentation made by it on the
outer coat will remain as a mark; and if the artery be slit open in a
careful manner, the division of the inner coats will be obvious. These
changes were known to Desault, and are mentioned by Deschamps in his
work on the Ligature of Arteries. They were more satisfactorily proved
to occur by Dr. Jones, and have been clearly stated by Mr. Hodgson and
others. The remaining part of the process differs from the account they
have given, and, according to observations I have had opportunities
of making on the living and on the dead, is as follows: the inner and
middle coats, formed by four distinct layers or structures, are not
only divided, but the inner ones particularly appear to be curled
inward on themselves, so that the cut edge of one half or side is not
applied to its fellow in the usual way of two surfaces, but by curling
inward meets its opponent on every point of a circle, and in this
way forms a barrier inside that of the external coat, which is tied
around it by the ligature; so that, in fact, when a small ligature is
firmly tied, its direct pressure is not applied to the inner coats,
which have been divided and have curled away from it, but to the two
layers of the outer coat, which are in consequence of that pressure
made to ulcerate or slough--processes which could scarcely fail to
take place also in the other coats if they were subjected to pressure
in a similar manner. The cut edges of the four inner layers being from
this provision of nature perfectly free, are capable of taking on the
process of inflammation, which stops at the adhesive stage. This they
do by the effusion of lymph or fibrin both within and without, to a
greater or less extent as the case may require. The outer coat of the
artery must either yield by ulceration or sloughing, or the ligature
must remain until it is decomposed and destroyed. It usually yields by
sloughing, in consequence of its being deprived of life by the pressure
of the ligature, which is left at liberty by the ulceration which takes
place in the sound part of the artery immediately above and below the
part strangulated, which part is frequently brought away in the noose.
The artery does not always yield by sloughing, particularly if it be a
large one and the ligature thick and soft. In this case, a part of the
outer coat, and particularly the white, inelastic substance, from its
folding or plaiting under the ligature, seems to escape that degree of
pressure necessary to destroy it; and when the remaining part yields,
it continues entire, and is only removed by a subsequent process of
ulceration occasioned by its irritation as an extraneous body.

In such cases, the layers of the external coat could not close around
the inner ones, which are thus shown to be capable of forming an
effectual barrier without it, although it materially assists in giving
greater strength to the cicatrix, by the effusion of fibrin which takes
place within, without, and around.

While this process is going on without, and at the very extremity of
the artery, the vessel is gradually contracted above it, and its coats
become more or less inflamed, soft, and vascular. The inner layers
are seen to be wrinkled transversely, and a small coagulum of blood
is formed within them. This sometimes completely fills the artery,
but it is more common for a small, tapering coagulum to be formed,
adhering by its base to the extremity of the vessel; the white color
of which renders it distinctly observable, when contrasted either
with the coagulum or the inner coat of the artery, which latter is
usually of a red or scarlet color while the inflammatory action is
going on. A coagulum, contrary to the usually received opinion, is not
absolutely necessary to the permanent closure of the artery, although
it certainly assists in maintaining it. An artery is also supposed to
contract gradually up to its first collateral branch; but this is not
always the case, and depends entirely on the use for which the branch
is required. After amputation at the middle of the arm, the artery will
go on diminishing in size up to the subscapular branch, the circumflex
arteries diminishing in proportion, in consequence of their being so
much less necessary than before the operation. In several instances the
principal artery has remained pervious below the collateral branch, the
next immediately above the part where the ligature has been applied.
Neither will the presence of a collateral branch immediately above
where the ligature has been placed upon the artery always, although
it sometimes may, interfere with the consolidation of the wound, and
the closure of the canal of the vessel. It may impede the process,
and render it for a time less safe, and in some instances it may
prevent it altogether, but I have so often seen large arteries, heal
after division close to the giving off of a considerable branch,
that I consider them to be always capable of doing so, provided they
are naturally sound. If they are not sound, it is very doubtful what
process may take place; but it will be less likely to be a healthy one,
if interfered with by the immediate proximity of a collateral branch.
The power which suppresses hemorrhage in a bleeding artery resides, it
must be borne in mind, in the very extremity of the vessel itself. It
is, however, advisable to take care that a ligature shall be applied
above rather than immediately below a branch given off from a trunk,
more particularly when it may be doubted whether the trunk is free from
disease.

In 1834 I placed a ligature of strong dentists’ silk on the right
common iliac artery of a lady of middle age for a swelling in the
hip, supposed to be a gluteal aneurism, which, after commencing the
operation, was found to occupy a considerable part of the iliac region.
The lady died a year afterward, and it was then found that the ligature
had been applied at the distance of five-eighths of an inch from the
bifurcation of the aorta, and three-eighths of an inch above the origin
of the internal iliac, independently of the line of separation between
the parts of the iliac divided by the ligature, which did not seem to
be wider than the ligature itself. The separated ends were united at
the point of separation by new matter, the orifice or end of each being
closed by a very narrow barrier, the inner coat of the artery being
redder than natural, somewhat irregular and contracted, and containing
hardly any coagulum. _The fact was thus proved in the largest artery
in the body save one, that a coagulum is not necessary for the safety
of the union, while the immediate vicinity of so large a vessel as the
internal iliac, to say nothing of the aorta itself, also proves that
the danger hitherto expected from the neighborhood of a collateral
branch is more imaginary than real_--two great facts the practice of
the Peninsular war led me to declare, and which ought no longer to be
doubted.

The preparation exemplifying these points is in the museum of the Royal
College of Surgeons, together with the ligature still carrying in its
noose the portion of the artery it strangulated and brought away with
it.

187. A ligature should always be round and small, provided it be
sufficiently strong. The strength of a ligature is variously estimated;
some surgeons trying it by the strength of their own fingers, others
by what they conceive to be the resisting power of the coats of the
artery, in which perhaps they may err. The only way in which a surgeon
can hope to acquire correct information on this point is by trying on
the dead body what force of fingers is required to cut the inner coats
of arteries of various sizes; and then taking the least force required
for this purpose, to ascertain whether he can easily pull the ligature
over or off the divided end of the artery. If a surgeon will take the
trouble to do this, he will find that he has estimated the necessary
force much too highly, and that he is in more danger of breaking his
ligature than of failing to secure the artery. Hemorrhage has, however,
been known to occur from the ligature having slipped off the end of an
artery, which had been divided in the operation for aneurism, although
I have never seen it happen after amputation, where the vessels were
tied with a small, firm ligature. It constitutes a valid objection to
the division of the artery between the ligatures, when two are applied.

A ligature composed of one strong thread of dentists’ silk, well waxed,
is sufficiently firm for the largest artery. It does not, however, much
signify what may be the shape, size, form, or substance of ligatures,
when they are applied to arteries in a sound state, provided they are
not too large, are fairly and separately tied, and with a sufficient
degree of force to retain the ligature in its situation until separated
by the usual processes of nature, which generally take from fourteen to
thirty days for their completion.

188. When arteries are unhealthy, the selection and proper application
of a ligature are points of great importance. A larger although yet a
small, round ligature should be fairly, evenly, and firmly, although
not so forcibly applied as on a sound artery; without the intervention
of any substance whatever between it and the cellular covering of the
vessel. The secondary hemorrhages which are recorded by different
writers as prone to occur, and which did take place, happened, I am
disposed to believe, more from the application of improper ligatures
than from any other cause; for the inner coat of an artery is so prone
to take on the adhesive state of inflammation that if a strong, small
ligature be applied in the manner directed, it is more than probable
that the closure of the artery will be effected. Ulceration will,
however, sometimes take place on the inner coat of the vessel, and
slowly extend outward, undoing in its progress any steps which may have
been begun for the consolidation of the extremity of the artery. When
a secondary hemorrhage does occur from this or from any other cause,
it is usually from the beginning of the second to the fourth week; but
there is no security for the patient until after the ligature has come
away, unless it is retained an inordinate length of time, from having
included some substances which do not readily yield under irritation,
such as the extremity of a nerve, or a slip of ligament which is not
sufficiently compressed in the noose of the ligature.

Secondary hemorrhage may also take place from the extension of
ulceration or sloughing to the artery from the surrounding parts, and
perhaps as frequently as from any other cause; but when mortification
occurs, there is no secondary hemorrhage, unless in that species
which is called hospital gangrene. The advantages to be derived from
the application of a strong, small ligature, from the least possible
disturbance of the surrounding parts, and from absolute quietude, while
the healing processes are going on, must be so obvious as to require
no further observation. An undue interference with the ligature, by
pulling at it, cannot be too earnestly deprecated at an early period;
although, at a subsequent time, some force is occasionally required for
its removal after amputation.



LECTURE XI.

THE FEMORAL ARTERY, ETC.


189. When the femoral artery is _cut across_ in the upper part of
the thigh, whether it be done by a cannon-shot, a musket-ball, or a
knife, the patient does not always bleed to death at once, although he
frequently dies after a time in consequence of the shock and the loss
of blood.

At the battle of Toulouse a large shot struck an officer and two men
immediately behind him, and nearly tore off the right thigh of each.
The artery was divided about, or less than three inches below Poupart’s
ligament. I saw the officer shortly afterward, in consequence of his
surgeon saying it was a case for amputation at the hip-joint. The
bleeding had ceased, the pulse was feeble; the countenance ghastly,
bedewed with a cold sweat, and with every indication of approaching
dissolution. The house being at an advanced point, and close to one
of the French redoubts, the fire of round shot and musketry was so
severe upon and around it as to induce me to remain, until the battery
should be taken by the troops then advancing upon our flank. In order
to occupy my time usefully, I returned to the officer, and found he
had just expired. Desirous of seeing by what means the hemorrhage had
been arrested, I cut down upon the artery, took it carefully out, and
found that its divided end was irregularly torn; a slight contraction
had taken place just above, but not sufficient to have been of the
slightest utility in suppressing the bleeding, which was in fact
prevented by an external coagulum, which filled up the ragged extremity
of the vessel, and which in a few days, if he had lived, would have
been removed with the purulent discharge, an internal one forming
in the mean time, the extremity of the artery also contracting and
retracting, so that a secondary hemorrhage might not have taken place,
indeed would not in the generality of instances.

At Salamanca I had the opportunity of examining the thigh of a French
soldier, whose femoral artery had been divided perhaps even higher up
by a cannon-shot. He lived until the next morning, when I saw him, no
operation whatever having been attempted, nor a tourniquet applied.
He died exhausted, but not from any immediate bleeding, which, when
once stopped, had not returned. The artery was in a similar state to
the preceding one, with this slight difference, that the orifice was a
little more contracted; the external coagulum filled up the ragged end
of the artery, and was slightly compressed within by the contraction,
which kept it in its place. The rest of the coagulum filled the hollow
in the surrounding parts, which the retraction of the artery had
occasioned. In this case, so unlike those I have hitherto noticed, the
first natural cause giving rise to the suppression of the bleeding was
the diminution of the power of the heart; the second, the formation of
a coagulum in the hollow of the sheath left by the retraction of the
artery. Contraction had begun, but had done nothing essential. (See
_Aph._ 413.)

In other instances in which I have examined the extremities of such
large arteries when divided, the appearances have been more or less of
a similar nature; unless where the persons had died immediately, when
the torn extremities were found quite open, with little surrounding
coagulum. I have, however, seen persons wounded in this manner live
for several days, when I have found, after death, the extremity of the
artery open, and no appearance of blood having passed into it below
Poupart’s ligament. The consent necessary between the inner coat of the
artery and the blood for the free passage of blood had been destroyed
by the injury.

190. A _small puncture_ in an artery, made with a needle, will
sometimes heal, as it generally does in dogs. I have, however, seen
several instances in which the femoral artery was wounded by a
tenaculum, during amputation, and a secondary hemorrhage followed,
requiring the application of a ligature. A _larger puncture_, or a
longitudinal slit of from one to two lines in extent, does not commonly
unite, except under pressure, although the edges of the wound may
not always separate so as to allow blood to issue in any quantity.
It sometimes only oozes out, and occasionally does not do even that,
unless some obstacle to the circulation takes place below, when blood
is propelled with a jet; and the edges of the cut having thus been
separated, blood continues to be thrown forth in considerable quantity.
In an artery of the size of the temporal, a small longitudinal slit
may sometimes heal without the canal of the artery being obliterated,
although this very rarely takes place in one of a large calibre.

In all cases of punctured wounds, when pressure can be effectually
made, and especially against a bone, it should be tried in a graduated
manner over the part injured, in the course of the artery above and
below the wound, and if in an extremity, over the whole limb generally,
the motions of which should be effectually prevented, and absolute rest
enjoined, if the artery is of any importance. This should be continued
for two, three, or more weeks, according to the nature of the injury.

A medical student, being desirous of bleeding his friend, also a
student, in the arm, opened the ulnar artery, which in this case was
very superficial. On discovering the error he had committed, he closed
the wound, and applied a firm compress and bandage, under which it
healed. On applying the ear to the part, it sounded like an aneurism,
although there was scarcely any tumor, the thrilling sound being
apparently occasioned by friction against the cut edges of the artery.
This thrilling noise diminished, and the vessel immediately below the
wound gradually recovered its pulsation, except at the exact situation
of the injury, where none could be distinguished. It was obliterated at
that part for the length of the eighth of an inch.

The master tailor of the 40th Regiment, tempted by the approaching
prospect of plunder, was induced, on the night of the assault on
Badajos, to give up the shears, and arm himself with the halbert, and
was properly rewarded for his temerity by a wound from a pike in the
right arm, from which, he says, he bled like a pig, and became very
faint. On his arrival at the spot indicated for surgical assistance, he
fainted; but this was attributed to the unwarlike propensities of the
man, rather than to any sufficient cause. The wound was not more than
one-third of an inch long, a little below the edge of the pectoralis
major, and immediately over the artery. The arm and hand were numb and
cold; the pulse was not distinguishable at the wrist, and it appeared
to cease at the place of injury, which was harder and a little more
swollen than natural. He said that his pulse had always been felt by
the doctors in the usual place. The wound healed without any trouble.
On the 1st of May the pulsation of the artery could be felt a little
below the wound. On any exertion he had a good deal of unpleasant
numbness in the thumb and forefinger. A small cicatrix formed at the
place of the wound, which was otherwise quite natural to the touch.
This case proves that when a large artery is wounded in man by a sharp
cutting instrument, to a certain but moderate extent the process of
cure takes place through inflammation and by the obliteration of that
part of the canal of the vessel. Continental surgeons have since
sacrificed whole hecatombs of animals to prove this fact, which had
been so many years before recorded in England as having occurred in man.

It has not been satisfactorily proved in man that a large artery, such
as the femoral or even the brachial, has been opened to the extent of
one-third or a fourth of its circumference, and that the wound has
healed without the canal becoming impervious. A _smaller wound_ of a
large artery may close without obstructing the canal of the vessel, but
the part is not so firm or so solid as before, and may yield, and give
rise to an aneurism, having apparently the characters of a small true,
as opposed to the spurious diffused, or even circumscribed swelling,
which more usually follows a similar accident.

Colonel Fane was wounded by an arrow in the right side of the neck,
opposite the bifurcation of the carotid, which caused a considerable
loss of blood at the moment. The wound healed, leaving only a mark
where the point of the arrow had entered. Some time afterward he
observed a small swelling at the part, which, from its pulsation, was
declared to be an aneurism. Uneasy about it, he asked my opinion at
Badajos, after the siege. It had not increased, but it caused him some
anxiety, and I promised to place a ligature on the common carotid if
the aneurism should increase in size. He was unfortunately killed in
action a year afterward, by a shot through the head.

191. When a large artery, such as the brachial, is cut _transversely_
to a fourth of its circumference in man, it forms a circular opening as
in animals; and if the artery be large, the bleeding usually continues
until the person faints, or it is arrested by pressure. In dogs the
bleeding commonly ceases without any assistance from art, and without
the animal being exhausted; in horses and sheep the bleeding usually
continues till the animals die; while in man, even with the best aid
from compression, hemorrhage will in all probability recur, unless the
circulation be altogether arrested. If the external opening only should
be closed, a spurious, circumscribed aneurism will be the consequence
in so small an artery as the temporal, and a ligature will sometimes be
required above and below a little aneurism of this description. In a
larger artery the spurious aneurism may or may not be diffused.

When an artery of this size is _completely divided_, it is less likely
to continue to bleed than if it had been only wounded. When it is
merely cut or torn half through, but not completely divided in the
first instance, it is in the same state with regard to hemorrhage as if
it had partially given way by ulceration. It can neither retract nor
contract, and will continue to bleed until it destroys the patient,
unless pressure be accurately applied and maintained until further
assistance can be procured. The practice to be pursued is to divide the
vessel, if it be a small one, such as the temporal artery, when it will
be enabled to retract and contract; and the bleeding will in general
permanently cease under pressure, especially when it can be applied
against the bone. If the artery is of a larger class, and continues
to bleed, it should be sufficiently exposed by enlarging the wound; a
ligature should be applied above and below the opening in the vessel,
which may or may not be divided between them at the pleasure of the
surgeon.

In June, 1829, I happened to be at Windsor, on a visit to my old
friend, the late Dr. Ferguson, and was called to a young gentleman,
the upper part of whose right femoral artery had been accidentally cut
by the point of a scythe. On dilating the wound, a tourniquet being
on the limb, black blood flowed freely from it; on unscrewing the
tourniquet by degrees, arterial blood showed itself, and the upper end
of the artery was secured by ligature when the tourniquet was removed.
Venous-looking or black blood then again flowed in greater abundance
than before, evidently from a large vessel. This I restrained by
pressure made below the wound with the thumb of the left hand, while
I laid bare the lower part of the artery, from a slit in which, near
an inch in length, the black blood was seen to flow. A ligature passed
around the vessel below the wound suppressed the bleeding. The artery
was not divided, and the young gentleman perfectly recovered, and has
continued well until this day. The absolute necessity for two ligatures
was here well shown, as well as the flow of dark-colored blood from the
lower end of the artery. This gentleman is now an officer in the army,
and suffers no inconvenience from his accident.

192. When a large artery is wounded at some depth from the surface,
and the external opening is small, blood not only issues through the
opening, but is often forced into the cellular structure of the limb to
a considerable distance; the pulsation of the tumor is observable, and
the thrill or sound which accompanies a ruptured artery is distinct. If
a large quantity of blood, partly in a fluid, partly in a coagulated
state, be collected immediately over and around the wound in the
artery, the tumor may not pulsate or give forth any sound, if the
coagulated blood be in considerable quantity, although some elevation
of the tumor may be observed corresponding to the pulse.

This rising or pulsation of the swelling often depends on the impulse
given to the whole, as a mass, by the artery against which it is
lying, and not upon blood circulating through it. An impulse of this
kind is distinguishable in a bronchocele which lies immediately over
and in contact with the carotid artery. It is the same when blood is
extravasated by the rupture of several small vessels, in consequence of
the passage of a wheel over the limb, especially in the thigh, where a
swelling containing fluid blood will sometimes pulsate in a well-marked
manner, until it gradually diminishes as the blood coagulates, when
the motion becomes a mere elevation at each stroke of the heart. The
whizzing sound or thrill attendant on a ruptured artery is in these
cases wanting, being a very diagnostic mark of this accident; although
where there is true aneurism, and it has burst, forming a diffused
and spurious one, the thrill may be wanting; but the history of these
cases enables a surgeon to distinguish between them. If several ounces
of blood are thrown out, and remain fluid, they ought to be evacuated,
or suppuration will ensue. If they become coagulated, the mass will
be gradually absorbed. Fluid blood should be evacuated by a small
opening, and the part afterward treated by compress and bandage. If the
fluid or partly coagulated blood should increase in quantity, and the
swelling continue to enlarge and pulsate, the extension of the mischief
should be arrested by opening the swelling and securing the artery by
ligature. When the external opening is enlarged, and the clots which
filled it up are at all disturbed, arterial blood begins to flow, and
the finger will readily follow the track through which it passes down
to the artery, if it should not be too far distant. If the incision
be made sufficiently large to enable the operator to remove these
clots of blood with rapidity, the finger will more readily pass down
to the wound in the artery, which, if a large one, may be thus easily
discovered, if within reach and sight, provided the tourniquet be
thoroughly unscrewed, and the surgeon is not afraid. A ligature should
then be placed above and below the opening in the artery.

When an artery is wounded, and the external opening in the integument
heals so as to prevent the blood from issuing through it, a traumatic,
spurious, circumscribed, or diffused aneurism is said to form,
according to the facility which is offered by the structure of the
parts for the confinement or diffusion of the extravasated blood. A
traumatic aneurismal tumor of this nature differs essentially from
aneurism which has taken place as a consequence of disease, and not of
direct injury. If a spurious aneurism form from disease, the artery is
in general unsound for some distance above and below the tumor. In the
aneurismal tumor from a wound, the artery is perfectly sound, except as
far as concerns the seat of injury. There is, then, not only a great
and essential difference between these two kinds of aneurism as regards
their nature, but also with respect to the collateral circulation, and
the operation to be performed for their cure; and the surgeon may not
overlook these facts.

A school-boy, about fourteen years of age, let a pen-knife drop from
his hand while sitting down, and drew his knees suddenly toward each
other to catch the falling knife; the point was thus forced into the
inner and middle part of the thigh, and wounded the femoral artery.
The medical man on the spot put a plaster on the little incision in
the integuments, and the wound quickly healed. The boy complained of
uneasiness, but was supposed to be making more of it than necessary,
and was made to go into school as usual. The limb, however, began to
swell, and the boy was brought to London, supposed to be suffering from
abscess, and placed under the care of Mr. Keate, who, suspecting the
evil, carefully introduced the point of a lancet, and, after a clot
of blood had been forced out, a jet of arterial blood flew across the
room. The hemorrhage was arrested by pressure below Poupart’s ligament,
while Mr. Keate enlarged the opening in the integuments, and removed
two washhand-basinsful of coagulated blood. He then put his finger on
a large opening in the artery, under which two ligatures were passed
by means of an eye-probe, and the artery was divided between them. The
muscles had been cleanly _dissected_, and the cavity extended from the
fork internally, and trochanter externally, to the knee. There was much
less suppuration than could have been expected. The ligatures were
detached about the usual time, and the patient entirely recovered.

This admirable case should be imprinted on the mind of every surgeon.
With the hope that it will be so, I refrain from commenting on three
or four cases which have occurred within the last two years, in which,
from neglect of the precept inculcated by it, very distressing if not
fatal consequences ensued.

193. There is no precept more important than that which directs that no
operation should be done on a wounded artery unless it bleed, inasmuch
as hemorrhage once arrested may not be renewed, in which case any
operation must be unnecessary. The following case shows how firmly the
principles on which wounded arteries ought to be treated were fixed in
my mind in the year 1812; and there is no case during that eventful
period to which I look back with more satisfaction than the following:--

John Wilson, of the 23d Regiment, was wounded at the battle of
Salamanca by a musket-ball, which entered immediately behind the
trochanter major, passed downward, forward, and inward, and came out on
the inside of the anterior part of the thigh. The ball could not have
injured the femoral artery, although it might readily have divided some
branch of the profunda. Several days after the receipt of the injury, I
saw this man sitting at night on his bed, which was on the floor, with
his leg bent and out of it, another man holding a candle, and a third
catching the blood which flowed from the wound, and which had half
filled a large pewter basin. A tourniquet with a thick pad was placed
as high as possible on the upper part of the thigh, and the officer
on duty was requested to loosen it in the course of an hour; that was
done, and the bleeding did not recommence. The next day, the patient
being laid on the operating table, I removed the coagula from both
openings, and tried to bring on the bleeding by pressure and by moving
the limb; it would not, however, bleed. As there could be no other
guide to the wounded artery, which was evidently a deep-seated one, I
did not like to cut down into the thigh without it, and the man was
replaced in bed, and a loose precautionary tourniquet applied. At night
the wound bled smartly again, and the blood was evidently arterial.
It was soon arrested by pressure. The next day I placed him on the
operating table again, but the artery would not bleed. This occurred
a third time with the same result. The bleedings were, however, now
almost immediately suppressed, whenever they took place, by the orderly
who attended upon him; care having been taken to have a long, thick
pad always lying over the femoral artery, from and below Poupart’s
ligament, upon which he made pressure with his hand for a short time.
_Absolute rest_ was enjoined. The hemorrhage at last ceased without
further interference, and the man recovered.

This case was one of considerable interest at the time, and is the
model one on which the treatment of all such injuries should be
founded. If the wound had bled, I should have introduced my finger, and
enlarged it transversely, continuing the incision until the opening was
sufficiently large to see to the bottom of the wound or the bleeding
part. It is necessary in such cases to be attentive to the course of
the great vessels and nerves, but not to the safety of muscular fibers,
the division of which leads to no permanent injury. As pressure on
the main trunk led to the ultimate suppression of the hemorrhage,
it may be said that a ligature placed high up on the femoral artery
would not only have done the same, but would have relieved the man
from the anxiety necessarily dependent on the momentary fear of a
recurrence of the hemorrhage. There are two objections to this method
of proceeding: the likelihood of mortification taking place, which
in similar cases has been known to occur; and the possibility of
the hemorrhage being renewed through the anastomosing branches. The
temporary suspension of the circulation by pressure does little or no
harm, more particularly where the pad used is so thick and narrow as to
cause it to fall principally on the artery, and only in a slight degree
on the surrounding parts, which by a little attention may be readily
accomplished. It is not then good practice to cut down upon an artery
on the first occurrence of hemorrhage, unless it be so severe or so
well marked as to leave no doubt of its being from the main trunk of
the vessel itself; nor is it then advisable to do so, except the artery
continue to bleed; for many a hemorrhage, supposed to have taken place
from the main trunk of an artery, has been permanently stopped by a
moderately continued pressure exercised in the course of the vessel,
and sometimes on the bleeding part itself; particularly if the blood
be of a dark color, indicating that it comes from the lower end of the
vessel.

A painter could not have had a better subject for a picture
illustrative of the miseries which follow a great battle, than some of
the hospitals at Salamanca at one time presented. Conceive this poor
man, late at night, in the midst of others, some more seriously injured
than himself, calmly watching his blood--his life flowing away without
hope of relief, one man holding a lighted candle in his hand, to look
at it, and another a pewter washhand-basin to prevent its running over
the floor, until life should be extinct. The unfortunate wretch next
him with a broken thigh, the ends lying nearly at right angles for want
of a proper splint to keep them straight, is praying for amputation or
for death. The miserable being on the other side has lost his thigh; it
has been amputated. The stump is shaking with spasms; it has shifted
itself off the wisp of straw which supported it. He is holding it with
both hands, in an agony of despair. These Commentaries are written to
prevent as far as possible such horrors; and they may be prevented by
efficient and well-appointed medical officers; but there must also be
greater attention to these points than has hitherto been given by the
government of the country.

Don Bernardino Garcia Alvarez, captain of the regiment of Laredo,
thirty years of age, was wounded at the battle of Toulouse by a
musket-ball, which passed through the thigh, a little above its middle.
The wound was not considered a dangerous one until the 30th, twenty
days after the injury, when a considerable bleeding took place; and
as the vessel from which it came seemed to be very deeply seated, the
Spanish surgeon in charge tied the common femoral artery. I saw the
gentleman in consequence of this having been done. The hemorrhage was
suppressed by the operation, and the limb soon recovered its natural
temperature, but gangrene made its appearance on the great toe on the
third day afterward. It did not seem to increase, but the limb swelled
as if nature were endeavoring to set up sufficient action to maintain
its life; and this continued until the tenth day after the operation,
when he died, completely exhausted. On the dissection of the limb, the
femoral artery was found to be perfectly sound in every part below
where the ligature had been applied. The vessel which bled could not be
discovered; but it was certainly a branch from the profunda, and not
the femoral itself. In this case the ligature of the femoral artery
destroyed the patient, and the practice pursued must be condemned.
The gunshot wound should have been largely dilated, at both orifices
if necessary, until the wounded vessel was discovered, which possibly
had not been completely divided by the ulcerative or sloughing process
which had taken place, and its division would in all probability have
suppressed the bleeding.

A young gentleman, aged twelve, accompanying his brothers shooting, in
December, 1844, was struck in the upper part of the left thigh by a
duck-shot, which entered about three inches below Poupart’s ligament,
a little to the inner side of the femoral artery. He bled until he
fainted, and was taken home. There was no return of the bleeding for
three days, during which time the limb was exceedingly painful, and
soon began to enlarge. After this occasional and considerable bleedings
took place, the limb still continuing to increase in size. Fomentations
and poultices were applied; irritative fever set in, and the pain was
intense. At the end of a fortnight the small hole made by the shot
appeared to be healed over by a thin skin of a blue color, which tint
extended for some distance. The limb was enormously swollen, with
a feeling of distention, which induced the surgeon to puncture the
most prominent part with a lancet. After some clots of blood had been
removed, an alarming arterial hemorrhage took place. The femoral artery
was now tied high up, below Poupart’s ligament. The bleeding was in
some measure restrained, but not suppressed, and after a short time
it returned at intervals with augmented violence, until death ensued,
three weeks after the accident.

_Remarks._--If an incision had been made into the thigh in the course
of the wound when the bleeding returned on the third day, and both ends
of the wounded artery had been tied, the boy would in all probability
have recovered. The ligature placed on the femoral artery above the
wound in it did restrain for a short time the flow of blood, but could
not prevent its flowing from perhaps both ends of the vessel, until
it destroyed the patient. A ligature on the external iliac would only
have caused it to be deferred for a day or two, until the collateral
branches had enlarged, or else he would have died of mortification.

This really formidable case shows most distinctly the necessity for
always observing the rule of tying the wounded artery at the part
injured, in order that the mistake may not be made of placing a
ligature on the wrong artery--the constriction of which may cost the
patient his life, while it may not prevent a return of the bleeding.
It also shows that no loss of blood from a diffused aneurism can equal
the danger which must be encountered, and the mistakes which may be
made, by not laying it open, and seeing the hole in the artery, or its
divided extremities.

Captain Seton, a short man, fat of his age, was wounded in a duel, in
1845, in the upper part of the right thigh, a little above and in front
of the great trochanter, the wound being continued across the thigh,
its internal opening being about the middle of the fold of the left or
opposite groin. He lost a great deal of blood at the time, the issue of
which ceased on his fainting. Ten days after the duel his countenance
was blanched, his pulse rather quick and feeble. On examining the
wounds, that on the right hip (the opening of entrance) was circular,
filled with a dry, depressed slough, and there was a narrow, faint
blush of redness round its margin. In the left groin the opening of
exit was marked by a jagged slit, already partly closed by a thin
cicatrix. There was extensive mottled purple discoloration (ecchymosis)
of the skin in both groins, and over the pubes, scrotum, and upper part
of the right thigh. In the right groin was found a large, oval, visibly
pulsating tumor, its long diameter extending transversely from about
an inch and a half on the inner side of the anterior superior spinous
process of the ilium to about opposite the linea alba, and its lower
margin projecting slightly over Poupart’s ligament into the upper and
inner part of the thigh. On handling this tumor, it appeared elastic
but firm, very slightly tender, and not capable of any perceptible
diminution in bulk by gradual and continued pressure. The pulsation was
distinct in all parts of the swelling, and was equally evident whether
the fingers were pressed directly backward, or whether they were placed
at its upper and lower margins, and pressed toward the base of the
tumor, in a direction transversely to its long axis, the parts being
for the time relaxed. The femoral artery was slightly covered by the
swelling, and the pulsations of that vessel were with some difficulty
distinguished in the upper third of the thigh, below the margin of the
tumor. This appeared to depend partly on the natural obesity of the
patient, and partly on a considerable degree of general swelling of
the thigh. Pressure on the femoral artery or over the abdominal aorta
did not arrest the pulsation in the tumor, and in the former situation
was attended with severe pain. Under these circumstances it was deemed
advisable to apply a ligature on the external iliac artery, and give
the patient a chance of the occurrence of coagulation in the tumor,
and closure of the wounded vessel, before the free re-establishment
of the circulation through the femoral artery. In the present case it
was supposed that mortification of the limb was all the less likely
to occur from the circumstance that the greater part of the effusion
appeared in front of the abdominal parietes, and therefore exercised
less pressure on the femoral vein than if further extension into the
thigh had taken place. The danger of peritonitis was by this proposal
made a new element in the calculation; but it was estimated that the
chances of this and of mortification of the limb, taken together,
were less unfavorable than the chances of immediate and secondary
hemorrhage attaching to the operation of tying the artery at the spot
injured. The operation being completed, the right foot, leg, and thigh
were enveloped in lamb’s-wool and flannel, and the limb elevated on
an inclined plane of pillows, so as to favor the return of blood as
much as possible, and prevent venous congestion. The day on which the
operation was performed was passed in considerable pain, the patient
being restless, and complaining of a sense of burning in the limb.
An anodyne, however, secured him a tolerably good night’s rest. The
day after the limb was found altogether diminished in bulk, and its
temperature equal to that of the healthy limb; no return of pulsation
had taken place in the tumor. The same evening some tenderness and
tension of the abdomen came on, though the bowels had been kept in a
regular state by occasional small doses of castor-oil. In the morning
of the second day, pain in the belly, with increased tension, hurried
breathing, short, dry cough, and tenderness over the lower part of the
abdomen, were observed. Pulse quicker and small. Leeches were applied,
and three-grain doses of calomel, with a little Dover’s powder, ordered
every three hours. The symptoms, however, became rapidly worse; the
patient complained of severe pain in the right leg, and a sensation of
great heat over the whole body, although the actual temperature was
rapidly falling below the natural standard. The right leg also became
cold sooner than the left. At seven P.M. he became more easy, and
expressed an opinion that he should “do well;” but in little more than
half an hour he expired.

_Examination after death._--Swelling and ecchymosis of the right
thigh, particularly at the upper part, and in the right iliac region;
also swelling and ecchymosis of the scrotum, chiefly in the right
side, with general tumefaction of the abdominal parietes below the
umbilicus. A wound into which the little finger could be passed was
on the upper and outer aspect of the right thigh, about three inches
below the crest of the ilium and about an inch nearer the mesial
line than the great trochanter, and on the left side another smaller
wound, situated about the external aperture of the left spermatic
canal. The first-mentioned wound was open; the lips of the latter
were partially adherent. The course of the wound was traced from the
outside through a dense layer of fat about two inches in thickness,
(on an average.) It had divided one of the superficial branches of the
femoral artery, about half an inch below Poupart’s ligament, and about
an inch from the main body of the femoral artery; this had caused a
false aneurism. The sac contained about three ounces of blood. Blood
was also effused into the cellular structure of the scrotum, and
downward beneath the sartorius muscle. The wound passed through the
cellular tissue, across the pubes, and emerged about the situation of
the left external spermatic ring, without having divided the cord on
either side, and was quite superficial to the bladder. No other artery
appeared to have been wounded. When the parietes of the abdomen were
reflected, a considerable quantity of sero-purulent fluid was found in
the abdominal cavity; and on different parts of the large and small
intestines patches of acute inflammation were observed, particularly
on the ascending arch of the colon. The peritoneum adjoining the wound
of the operation was inflamed, and approaching to gangrene: it had not
been injured by the knife during the operation. The intestines were
unusually large, and distended with flatus. The other abdominal viscera
were healthy, but loaded to an extraordinary degree with fat. The
ligature had been properly applied to the iliac artery; the vein was
not injured; the surface of the wound and the cellular tissue in the
neighborhood of the artery were sloughy. There was some enlargement of
the right limb, but apparently no mortification. The femoral artery was
pervious; the course of the wound was through a bed of fat, fourteen
inches in length, and three inches in depth, over the pubes, and no
muscular substance was injured; the blood found in the aneurismal sac
was firmly coagulated, and there was no mark of recent oozing from the
injured artery.

_Remarks._--If this gentleman had been wounded at the foot of the
breach in the wall of Ciudad Rodrigo, in January, he might, to his
great dissatisfaction, have been one of eleven officers whom I saw
lying dead, and as naked as they were born, on the face of the breach
of Badajos, in April. He would have been saved by _one_ doctor, or an
old woman, and a little cold water, in 1812, and did die of _seven_ in
1845, after an operation most brilliantly performed, but done in the
wrong place, even if any operation had been necessary, which it was
not. The case is an _experimentum crucis_ of principles.

The _first error_ committed in this case was in calling and believing
a wounded artery to be a circumscribed, false, or diffused traumatic
aneurism. Nothing can be called an aneurism, by which word a dilated
vessel or a diseased shut or closed sac is understood, which has one
or more holes in it, made by a ball, or by anything else, the wound or
track of which remains open. It is simply a case of wound in which an
artery has been divided or injured, and while this track of the ball
remains open, no ingenuity of argument can make it otherwise. When the
external openings made by the ball have closed, the case may then be
called, if there be a collection of blood, whether fluid or coagulated,
one of circumscribed, false, diffused traumatic aneurism, or anything
else that philologists may please to designate it. The dissection
report proved this case to be simply a small collection of blood, three
ounces and a half, or seven small tablespoonfuls--communicating with
two open wounds. Calling this an aneurism, or a shut sac of any kind,
was then the _first_ and fundamental error, as fatal as erroneous.

The _second_ error consisted in the belief, _contrary to all
experience_, that any sac or bag, or collection of blood by whatever
name it may be called, having two openings leading to, or into it, and
communicating with the atmosphere, could be augmented to any dangerous
extent by the further pouring out of blood from an artery of any size,
or from any artery at all, without some of such extravasated blood
being discharged or forced out through one or both of the open external
wounds in sufficient quantity to show that the opening in the vessel
was not closed.

The _first two errors_, or defects of principles, gave rise to the
_third_, viz.: the belief that an operation was necessary where
none was required, the dissection having proved that the whole
idea of the nature of the injury was a mistake: there was no large
artery wounded; the small one, which had been wounded, had ceased to
bleed; the quantity of blood extravasated did not exceed seven small
tablespoonfuls. The third mistake could not have taken place if the
first two errors had not been committed.

The _fourth_ error occurred from its being taken for granted that the
femoral artery was wounded; and that ascertaining the fact by opening
the small swelling which contained only three and a half ounces of
blood, would be followed by a fatal hemorrhage; which supposition arose
from this swelling receiving a pulsatory motion from its vicinity to
the femoral artery--a mistake which should not have occurred; for it
had long before been said, (page 16 of my published lectures:) “The
motion or pulsation of the swelling often depends on the impulse given
to the whole as a mass, by the great artery against which it is lying,
and not upon blood circulating through it. When blood is extravasated
by the rupture of small vessels in consequence of the passage of a
wheel over the limb--especially in the thigh, where I have seen a
swelling containing fluid blood pulsate in an almost alarming manner,
until it gradually diminished as the blood coagulated, when the motion
became a mere elevation at each stroke of the heart--the _whizzing
sound or thrill_ attendant on a ruptured artery (of a size to require
a ligature being understood) is in these cases wanting, constituting a
very distinguishing mark of this accident.”

Surgeons fifty years ago were afraid of hemorrhage from the femoral
artery, but the practice of the Peninsular war dissipated such fears.
The reason given for not laying open the wound, and looking at the
bleeding artery, in this case, is ingenious, but not tenable. The
patient is said to have lost a large quantity of blood; and if this
were even a fact, which may, however, be doubted, is there a case on
record of a serious wound of the femoral artery, such as this was
supposed to have been, in which that vessel has been successfully
secured by ligature, without the patient having equally lost so large a
quantity of blood as to be supposed to be about to die? _It has always
been so_; the reason, however specious, is not valid, and cannot be
admitted.

The _fifth_ error arose from imagining that the considerable loss of
blood supposed to have taken place would have rendered the patient
incapable of bearing more; for it is a recorded fact that those
operations high up on the femoral artery, from which patients have
recovered, have never been done without great losses of blood having
been previously sustained; and if the patient was so weakened that his
heart and arteries could not bear the abstraction from their contents
of a few ounces more blood--supposing such loss to be inevitable--how
could they have power to drive or force the blood through the limb by
the collateral channels, in a manner sufficient to support its life,
when the main trunk was cut off within the pelvis? _They could not do
it_--_they have rarely done it_ under such circumstance; they could not
have done it in this case; and if the patient had not died within the
first forty hours of inflammation of the peritoneum, to which accident
he ought not to have been exposed, he would have died of mortification
within forty hours more, which had already commenced, as shown by the
swelling of the limb and pain in the calf of the leg, which almost
invariably attend such mortification.

The _sixth_ error consisted in the belief that if the femoral artery
had been wounded, a ligature on the external iliac would have
permanently arrested the bleeding. It would, in all probability,
have done no such thing, beyond a day or two--perhaps even only for
the moment. It is a delusion, persisted in notwithstanding the most
clear and positive proofs to the contrary. The patient will die of
mortification from the want of blood in the limb, if the circulation be
not re-established; and if this should take place, blood must find its
way into the lower end of the wounded artery, and perhaps even into the
upper, and renew the hemorrhage.

If the femoral artery had been _wounded_, as was supposed in this case,
but not completely _divided_, it _must_ and _would_ have continued to
bleed through the external wound, until the patient died, or a ligature
had been placed upon it. It has been said that, in the case as it
actually occurred, the little artery, which was divided and which had
not bled for some days, could not have been safely tied, if it had bled
again, because it was only an inch long; but this is said in defiance
of every sort of proof which has been given to the contrary.

As far back as 1815 I said: “There was no foundation for the theory
which declared that a ligature when placed on an artery such as the
femoral would fail, if in the immediate vicinity of a collateral
branch, in consequence of the flow of blood through this vessel
preventing the obstruction and consolidation of the main branch for a
distance sufficient to enable it to resist the impulse of the blood
behind.” This was said from pure practical facts, free from all kinds
of theory; and the preparation before alluded to, in the museum of the
College of Surgeons, in which I tied the common iliac artery, will show
the mark of a simple thread around it, and a single line of adhesion
resisting the whole power of the heart, the canal above the spot not
being obliterated.

The _seventh_ error committed in this case was in contravening the
great surgical precept, formed on no inconsiderable experience during
the early part of the war in the Peninsula, “_not to perform an
operation on an artery until it bleed_.”

194. When a wound occurs in the thigh, implicating the femoral artery
or its branches, and the bleeding cannot be _restrained_ by a moderate
but regulated compression on the trunk of the vessel, and perhaps on
the injured part, recourse should be had to an operation, by which
both ends of the wounded artery may be secured by ligature; and the
_impracticability_ of doing this should be ascertained only by the
failure of the attempt. If the lower end of the artery cannot be
found at the time, the upper only having bled, a gentle compression
maintained upon the track of the lower may prevent mischief; but if
dark-colored blood should flow from the wound, which may be expected to
come from the lower end of the artery, and compression does not suffice
to suppress the hemorrhage, the bleeding end of the vessel must be
exposed, and secured near to its extremity.

The instruments which have been invented for the cure of aneurism,
by compressing the main trunk of the artery, will be found eminently
useful, if applied with care, in many cases of hemorrhage in which it
may be doubtful what vessel is actually injured, as in the case of
Wilson, page 215, and in cases also of wounds of the hand or foot in
which bleeding occurs through the medium of collateral branches. These
instruments, although they cannot conveniently be placed in the capital
cases of instruments, should be in store, whether with divisional or
general hospitals.



LECTURE XII.

MORTIFICATION, ETC.


195. The gangrene, mortification, or sphacelus, consequent on a wound
of the main artery of the lower extremity, is, in the first instance,
_local_ and _dry_, unless putrefaction be induced by heat. (See
_Aphorism_ 28.) The following case is a good example of this and of all
the other points laid down as principles or facts:--

A gentleman received an injury in the upper part of the left thigh,
parallel to but a little below Poupart’s ligament, from the shaft of
a van. The late Messrs. Heaviside, Howship, and Chevalier were sent
for immediately, and my attendance was desired next day. I called the
attention of these gentlemen to the _tallowy-white_ and _mottled_
appearance of the foot and lower part of the leg, and assured them that
the femoral artery was injured, and the femoral vein in all probability
also, from the rapid appearance of the first signs of dry gangrene. In
this they would not believe, until the shrinking and drying of the foot
and leg became obvious, the course of the tendons on the instep and
toes being marked by so many dark-red lines under the drying skin above
them. The amputation I recommended below the knee they would not hear
of, although they reluctantly admitted the fact of the mortification.
On the eighteenth day after the accident, blood flowed from the wound
in quantity, of a dark-venous color. This bleeding I pronounced to be
from the lower end of the artery. My three friends, in whose hands
the case was, could not understand this, and placed a ligature on
the external iliac artery, which did not arrest the bleeding. They
now, although too late, saw their error, and desired me to do what I
pleased, and a ligature secured the lower end of the artery from which
the blood flowed. The man died exhausted a few days afterward.

This is a remarkable case, deserving the most serious attention.
According to the principle laid down at first as a general rule, the
thigh should have been amputated at the seat of injury the morning
after the accident, when the signs of mortification of the foot
were obvious. But it must be borne in mind that amputations at the
trochanter major or hip-joint are most formidable and not generally
successful operations; in consequence of which I have recommended
another course, deserving, in such cases, of the most deliberate
consideration and trial. (See _Aphorism_ 29.) The leg should have been
amputated immediately below the knee, as I had ordered it to be done
in the case of Turnbull, (page 202,) because that is the part in all
such cases at which nature seems capable of arresting the progress of
the mortification, if the constitution and powers of the sufferer are
good, and equal to the calls upon them. The impairing, the destructive
influence a mortified leg exerts on the whole system is removed, and
an amputation substituted for it of comparatively little moment. When
the hemorrhage took place, the lower end of the artery should have
been tied. The upper end never bled, and the ligature on the iliac
artery was useless. In this case, it is probable, as the vein was also
injured, that the life of the part at and above the knee might not have
been preserved, and the patient would have died.

In a case of the kind in which the artery was wounded at the _lower_
part of the thigh instead of the _upper_, amputation at or just
below the wound may be the proper course; this amputation, although
dangerous, being much less so than one at the upper part of the thigh
or hip-joint. Nevertheless, amputation should not be had recourse to
unless the extension of the mortification is beyond a doubt.

196. In Aphorism 29, it is strongly recommended not to amputate a thigh
when mortification has stopped just below the knee, and a line of
separation has been formed between the dead and the living parts--an
opinion formed on a principle laid down in opposition to those usually
received by the profession at large, and which have been entertained
from the fact that amputations done under these circumstances are
commonly fatal.

Richard Cook, aged fifty, a mason, while sitting on a square block
of stone, on the 23d of February, was struck by another, which drove
the popliteal space or ham against the edge of the block on which he
sat, causing him great pain, and otherwise greatly bruising the leg,
although no bones were fractured, nor was the skin torn. The limb, on
his admission into the Westminster Hospital half an hour afterward,
was much larger than the other, and of a dark reddish-blue color,
evidently from the bruise or extravasation of blood, which appeared
to be still issuing from the vessel or vessels, as the limb continued
to increase in size, until it became at last greatly swollen. The
pulsation of neither the anterior nor the posterior tibial artery could
be distinguished through the swelling the next morning. The bowels
were opened, and a cold spirit lotion was applied to the calf and
around the leg, and the swelling somewhat subsided, the limb becoming
quite a blue-black, which, with the tenseness of the parts, distinctly
indicated the effusion of a large quantity of blood. It was soon
obvious that greater mischief had occurred than had been expected;
and on the 2d of March, as vesications, filled with a bloody fluid,
were formed on the outside of the leg, over the fibula, and the whole
limb was manifestly about to pass into a state of gangrene, if it had
not already done so, I prepared everything for tying the popliteal or
other arteries, if found necessary, and made a long and deep incision
on the outer and back part of the leg, through the integuments and
muscles posterior to the fibula, and removed a considerable quantity of
coagulated blood from between the muscles and from a large cavity which
extended upward into the ham, without causing further hemorrhage; in no
part of that cavity could an artery be felt. The patient’s countenance
and body had assumed a jaundiced hue; the pulse was very quick; the
tongue foul; the countenance sunken; the skin hot; the head wandering.
Poultices of linseed-meal and stale beer were applied, with gentle,
stimulating applications. Brandy and wine were ordered in proper
quantities every hour or two, with sufficient doses of the muriate of
morphia at night to allay irritation and induce sleep. The incision,
together with these remedies, gave great relief, and on the 7th the man
seemed to have been saved from a state of the most imminent danger.
On the 8th the pulse was 112, the tongue clean, the skin of a whiter
color, the bowels opened by injections; eight ounces of brandy were
given in the twenty-four hours; wine, with sago, arrow-root, jelly,
oranges, and anything he chose to ask for. The greatest cleanliness was
observed, and the chloride of lime was used in profusion all around
him. The mortification of the limb was complete; a line of separation
formed about four inches below the knee in front, and extended behind
toward the ham. On the 26th, the dead parts having almost entirely
separated from the bones all round, those which remained were cut
through where dead, the bones were sawn about five inches below the
knee, and the lower part of the limb removed, leaving an irregular,
and, in part, a granulating stump, with an inch of bone projecting from
it. On the 24th of May this portion was found to be loose; diluted
nitric acid had been applied to its surface, and on the 20th of June
it separated. On the 16th of August Cook left the hospital in good
health, with a very good stump, having cost the hospital £57 in extra
diet. In this case, there can be little doubt of the popliteal artery
having been torn; and if the incision made on the 2d had been had
recourse to during the first two or three days, and the artery sought
for, and secured if found bleeding, it is possible the mortification
might have been prevented; although it is probable, from the pressure
arising from the great extravasation and coagulation of blood, that
the collateral circulation was so much impeded as not to have been
able to maintain the life of the limb below even during that time. The
incision made on the 2d saved the life of the patient, by taking off
the tension of the part, and relieving thereby in a remarkable manner
the constitutional irritation which hourly appeared likely to destroy
him; indeed, no one expected anything but his dissolution. When the
line of separation had formed, he was evidently unequal to undergo the
operation of amputation, in order to make a good stump, without great
risk, and the dead parts were therefore merely separated for the sake
of cleanliness and comfort. Experience has demonstrated in too many
cases of the kind that the formal operation of amputation at this time,
as recommended by most modern surgeons, would in all probability have
cost him his life.

The application of powdered charcoal, particularly that made from bog
earth, or of areca wood, or Macdougall’s disinfecting powder, or of the
disinfecting liquids now in use, such as the chlorides of lime, sodium,
and zinc, removes in a great degree the intolerable odor which renders
the room of the sufferer unbearable, and essentially interferes with
his amendment. Incisions should be made into the dead parts to allow
the evacuation of the fluids contained within them, while the parts
themselves may be removed from time to time; so that when the period
arrives at which an amputation is considered advisable, the bones, if
of the leg, may be sawn through at or below the line of separation,
and nearly the whole of the mortified soft parts removed, so as to
leave little of those which are dead and offensive. This operation is
done without the patient feeling it; it gives rise to no irritation,
inconvenience, or danger; Nature is not interfered with in her
operations; and in due time the parts which remain are separated and
fall off, leaving a stump more or less good, but which will always bear
the application of a wooden leg; and thus the knee-joint is saved--a
saving of no small importance to the patient, and a new precept in
surgery.

197. The following cases may be considered conclusive:--

A private of the 5th division of infantry received a wound at the
battle of Salamanca from a musket-ball, which passed across the back
part of the right leg, from above downward and inward. It entered
about two inches below and behind the head of the fibula, and passed
out near the inner edge of the tibia. There was little blood lost at
the time, and it was considered to be a simple wound; eight days after
the injury, some blood flowed with the discharge; this increased during
the night, and, on examining the limb on the morning of the ninth day,
it was evidently injected with blood, which flowed of a scarlet color
from both orifices. It being doubtful which vessel was wounded--whether
it was the trunk of the popliteal artery, or the posterior tibial
or peroneal after its division into these branches--it was thought
advisable to place a ligature on the femoral artery about the middle
of the thigh, which suppressed the hemorrhage. The case was now shown
to me, as one in proof of the incorrectness of the opinion I had a few
days before stated, of the impropriety of such an operation being done.
The seeming success did not long continue; hemorrhage again took place
from the original wound, and the limb was then amputated. The posterior
tibial artery had been injured, and had sloughed. The man died.

_Remarks._--A straight incision, directly through the back of the calf
of the leg, of six inches in length, and two ligatures on the wounded
artery, would have saved this man’s leg and life.

Henry Vigarelie, a private in the German legion, was wounded on the
18th of June, at the battle of Waterloo, by a musket-ball, which
entered the right leg immediately behind and below the inner head
of the tibia, inclining downward, and under or before a part of the
soleus and gastrocnemius muscles, and coming out through them, four
inches and three-quarters below the head of the fibula, nearly in the
middle, but toward the side of the calf of the leg. In this course
it was evident that the ball must have passed close to the posterior
tibial and peroneal arteries; but, as little inflammation followed, and
no immediate hemorrhage, it was considered to be one of the slighter
cases. On the latter days of June he occasionally lost a little blood
from the wound, and on the 1st of July a considerable hemorrhage took
place, which was suppressed by the tourniquet, and did not immediately
recur on its removal. It bled, however, at intervals, during the
night; and on the morning of the 2d it became necessary to reapply the
tourniquet, and to adopt some means for his permanent relief.

The man had lost a large quantity of blood from the whole of the
bleedings; his pulse was 110, the skin hot, tongue furred, with great
anxiety of countenance: the limb was swollen from the application of
the tourniquet from time to time, a quantity of coagulated blood had
forced itself under the soleus in the course of the muscles, increasing
the size of the leg, and florid blood issued from both openings on
taking the compression off the femoral artery. On passing the finger
into the outer opening, and pressing it against the fibula, a sort of
aneurismal tumor could be felt under it, and the hemorrhage ceased,
indicating that the peroneal artery was in all probability the vessel
wounded.

In this case there was, in addition to the wound of the artery, a
quantity of blood between the muscles, which in gunshot wounds,
accompanied by inflammation, is always a dangerous occurrence, as
it terminates in profuse suppuration of the containing parts, and
frequently in gangrene. Its evacuation therefore became an important
consideration, even if the hemorrhage had ceased spontaneously.

The leg having been condemned for amputation above the knee, the
officers in charge were pleased to place the man at my disposal: and
being laid on his face, with the calf of the leg uppermost, I made an
incision about seven inches in length in the axis of the limb, taking
the shot-hole nearly as a central point, and carried it by successive
strokes through the gastrocnemius and soleus muscles down to the deep
fascia, when I endeavored to discover the bleeding artery; but this was
more difficult than might be supposed, after such an opening had been
made. The parts were not easily separated, from the inflammation that
had taken place; and those in the immediate track of the ball were in
the different stages from sphacelus to a state of health, as the ball
in its course had produced its effect upon them, or their powers of
life were equal or unequal to the injury sustained.

The sloughing matter mixed with coagulated blood readily yielded to the
back of the knife, but was not easily dissected out. The spot which
the arterial blood came from was distinguished through it, but the
artery could not be perceived, the swelling and the depth of the wound
rendering any operation on it difficult. To obviate this inconvenience,
I made a transverse incision outward, from the shot-hole to the edge
of the fibula, which enabled me to turn back two little flaps, and
gave greater facility in the use of the instruments employed. I could
now pass a tenaculum under the spot whence the blood came, which I
raised a little with it, but could not distinctly see the wounded
artery in the altered state of parts, so as to secure it separately.
I therefore passed a small needle, bearing two threads, a sufficient
distance above the tenaculum to induce me to believe it was in sound
parts, but including very little in the ligature, when the hemorrhage
ceased; another was passed in the same manner below, and the tenaculum
withdrawn. The coagula under the muscles were removed, the cavity
washed out by a stream of warm water injected through the external
opening, the wound gently drawn together by two or three straps of
adhesive plaster, and the limb enveloped in cloths constantly wetted
with cold water. The patient was placed on milk diet.

On the 4th, two days after the operation, the wound was dressed, and
looked very well; the weather being very hot, two straps of plaster
only were applied to prevent the parts separating. On the 5th a
poultice was laid over the dressings, in lieu of the cold water, the
stiffness becoming disagreeable. On the 6th, as the wound, although
open in all its extent, did not appear likely to separate more, the
plasters were omitted, and a poultice alone applied. On the 8th and
9th it suppurated kindly; and on the 10th, or eight days from the
operation, the ligatures came away, the limb being free from tension,
and the patient in an amended state of health, his medical treatment
having been steadily attended to.

The man was brought to England, to the York Hospital at Chelsea, and
walked about without appearing lame, although he could not do so for
any great distance. He suffered no pain, except an occasional cramp
in the ball of the foot, and some contraction of the toes, which took
place generally when he rose in a morning, and continued for a minute
or two, until he put them straight with his hand; this I did not
attribute to the operation, but to some additional injury done to the
nerves by the ball in its course through the leg.

This case, which has been followed by many others equally successful,
even after the femoral artery had been ineffectually tied, established
the practice now followed in England by all educated surgeons; and
is another of those great additions to surgery for which science is
indebted to the Peninsular war.

198. It may be permitted to repeat, that if an artery such as the
axillary be laid bare previously to an operation for amputation at the
shoulder, and the surgeon take it between his finger and thumb, he will
find that the slightest possible pressure will be sufficient to stop
the current of blood through it. Retaining the same degree of pressure
on the vessel, he may cut it across below his finger and thumb, and
not one drop of blood will flow. If the artery be fairly divided by
the last incision which separates the arm from the body, without any
pressure being made upon it, it will propel its blood with a force
which is more apparent than real. All that is required to suppress this
usually alarming gush of blood is to place the end of the forefinger
directly against the orifice of the artery, and with the least possible
degree of pressure consistent with keeping it steadily in one position
the hemorrhage will be suppressed. It is more important to know that if
the orifice of the artery, from a natural curve in the vessel, or from
other accidental causes, happen at the same time to retract and to turn
a little to one side, so as to be in close contact with the side or end
of a muscle, the very support of contact will sometimes be sufficiently
auxiliary to prevent its bleeding.

In amputation at the hip-joint, the femoral and profunda arteries
are frequently divided at or just below the origin of the latter,
and bleed furiously if disregarded; but the slightest compression
between the finger and thumb stops both at once. They never have given
me the smallest concern in these operations, or others of a similar
nature; and surgeons should learn to hold all arteries that can be
taken between the finger and thumb in great contempt. It is quite
impossible for a man to be a good surgeon--to do his patient justice
in great and difficult operations attended by hemorrhage, unless he
has this feeling--unless his mind is fully satisfied of the truth
of these observations. While his attention ought to be directed to
other important circumstances, it is perhaps absorbed by the dread
of bleeding, by the idle fear that he will not be able to compress
the artery and restrain the bleeding from it--that he may have half
a dozen vessels bleeding at once--that his patient will die on the
table before him. Once fairly in dismay, and the patient is really
in danger; but, endowed with that confidence which is only to be
acquired through precept supported by experience, he surveys the scene
with perfect calmness: taking the great artery between the finger and
thumb of one hand, he places the points of all the other fingers, of
both hands if necessary, on the next largest vessels; or he presses
the flaps or sides of the wound together until his other hand can be
set at liberty by an assistant, or in consequence of a ligature having
been passed around the principal artery. This is a scene sufficient
to try the presence of mind of any man; but he is not a good surgeon
who is not equal to it--who does not delight in the recollection of
it when his patient is in safety, and his recovery assured. It was in
consequence of what was then considered the too great boldness of the
practice that my old friend, Sir Charles Bell, whose loss to science
cannot be too much regretted, represented me seated on a pack saddle
on the back of a bourro, (_Anglice_, a jack-ass,) on the top of the
Pyrenees, expatiating on their merits (which he did not believe) to the
descendants of the Bearnois of Henri Quatre on one side, and to the
children of the lieges of Ferdinand and Isabella on the other; but no
one now disputes their accuracy. The surgery of the Peninsular war was
many years in advance of the surgery of civil life.

199. The principles laid down for the treatment of wounded arteries in
the _lower_ extremity are equally to be observed with respect to those
of the _upper_. There is, however, little or no fear of mortification
taking place in the upper extremity, the collateral circulation being
more direct and free; while there is greater danger from this cause of
hemorrhage from the lower end of the artery, if a ligature should not
have been placed upon it, or if it should not be retained a sufficient
length of time.

200. The error of placing a ligature on the subclavian artery above
the clavicle, for a wound of the axillary below it, should never be
committed. One person dies for one who lives after this operation, when
performed under favorable circumstances, independently of the loss
which may be sustained by a recurrence of bleeding from the original
wound, which is always to be expected and ought to take place; when
it does not happen, it is the effect of accident, which accident in
all probability occurs from the state of _absolute rest_ having been
carefully observed.

201. The necessity for an aneurismal sac below the clavicle, and
for its remaining and continuing to remain intact, until the cure is
completed, when the subclavian artery has been tied above, is rendered
unmistakable by the following case:--

Ambrose C. was admitted into the Charing Cross Hospital, in August,
1848, in consequence of a bruise from a sack of beans; there was
axillary aneurism, extending under the pectoral muscle up to the
clavicle. A ligature was applied in the usual situation on the
outside of the scalenus muscle, and came away on the twenty-second
day. The aneurismal sac suppurated, and burst three days afterward,
when a quantity of pus and blood, partly fluid, partly coagulated,
but very offensive, was discharged. The opening was enlarged, and
everything appeared to be going on well, at which time I saw him. On
the nineteenth day after the ligature came away, I visited him again
with Mr. Hancock, and merely observed that he must keep himself very
quiet, and I thought he would do well. In the evening he died from
hemorrhage, while eating some gruel. On examination after death, the
artery was found to be sound, except where it communicated with the
sac by an opening three-quarters of an inch in length. The ligature
had been applied midway between the thyroid axis and the first of the
thoracic branches. There was a small coagulum, of half an inch in
length, both internal and external to the ligature, _but not extending
to the branch above or below it_. The artery was of its natural size as
far as the remains of the sac, but beyond it the axillary artery was
diminished; the remains of the sac were void of coagulum, except where
it communicated with the artery, to which opening a small coagulum
had adhered, but had given way at its lower part, and thus caused his
death. _Between the opening and the ligature_, five large branches
entered into or were given off by the artery, and through some of these
blood was brought round by the collateral branches in an almost direct
manner, so that the man’s life depended on the resistance offered by
the small coagulum after the sac had given way; proving in an exemplary
manner the value of the sac remaining entire.

If this case will not convince the incredulous, it would be useless to
bring even the sufferers in such cases from their graves, to affirm the
fact of the inapplicability of the theory of aneurism to the treatment
of a wounded artery--of the impropriety of placing a ligature on the
subclavian artery above the clavicle, for a wound of the artery below
it.

Corporal W. Robinson, 48th Regiment, was wounded at the battle of
Toulouse, by a piece of shell, which rendered amputation of the right
leg immediately necessary, and so injured the right arm as to cause
its loss close to the shoulder-joint eighteen days afterward. At the
end of a month the ligatures had separated, and the wound was nearly
healed, although a small abscess had formed on the inside, near where
the upper part of the tendon of the pectoralis major had been separated
from the bone. Sent to Plymouth, this little abscess formed again, and
was opened on the 2d of August, three months after the amputation.
The next day blood flowed so impetuously from it as to induce the
surgeon to make an incision, and seek for the bleeding vessel, which
could not be found. The late Staff-Surgeon Dease, warned by the case
of Sergeant Lillie, (page 198,) strongly objected to the subclavian
artery being tied above the clavicle, and, true to the principle
inculcated at Toulouse, advised the application of a ligature below
the clavicle on a sound part of the artery, but as near as possible to
that which was diseased. The operation was done by the senior officer,
Mr. Dowling, who carried an incision from the clavicle downward through
the integuments and great pectoral muscle, until the pectoralis minor
was exposed. This was then divided, and a ligature placed beneath it
on the artery where it was sound, at a short distance from the face of
the stump, where it was diseased. The man recovered without further
inconvenience.

202. In all those cases in which it has been supposed necessary to
place a ligature on the artery above the clavicle, after a _failure_
in the attempt to find the artery below it, the failure has occurred
from _the error committed_ in not dividing the integuments and great
pectoral muscle _directly across_ from the lower edge of the clavicle
downward. It is quite useless dividing these parts in the course of
the fibers of the muscle, and the case of Robinson is the model on
which all such operations should be done. If this operation had not
succeeded, the ligature of the artery above the clavicle was a further
resource; but as the artery was sound below, with the exception of the
end engaged in the face of the stump, the operation was successful;
no doubt should be entertained in such cases of the propriety of an
operation which is attended with little risk, compared with that which
destroys one man for every one it saves.

203. Punctured wounds of the arteries of the arm and forearm ought to
be treated by pressure applied especially to the part injured, and
to the limb generally; but when the bleeding cannot be restrained in
this manner, in consequence of the extent of the external wound, the
bleeding artery is to be exposed, and a ligature applied above, and
another below the part injured, whether the artery be radial, ulnar, or
interosseal.

204. When the external wound closes under pressure, and blood is
extravasated in such quantity under the fascia and between the muscular
structures as is not likely to be removed by absorption under general
pressure, the wounded artery should be laid bare by incision and
secured in a similar manner, even at the expense of any muscular fiber
which may intervene.

205. When an aneurismal tumor forms _some time_ after such an accident,
in the upper part of the forearm in particular, the application of
a ligature on the brachial artery is admissible, on the Hunterian
principle.

206. When the ulnar artery is wounded in the hand, which is
comparatively a superficial vessel, two ligatures should be placed upon
it in the manner hereafter to be directed. When the opening is small,
pressure may be tried.

207. When the radial artery is wounded in the hand, in which situation
it is deep seated, the case requires greater consideration. When there
is a large open wound, and the bleeding end or ends of the artery can
be seen, a ligature should be placed on each; but this cannot always be
done without more extensive incisions than the tendinous and nervous
parts will justify.

208. When search has been made by incisions through the fascia, (as
extensively as the situation of the tendons and nerves in the hand
will permit,) which are best effected by introducing a bent director
under it, the current of blood, through either the ulnar or the
radial artery at the wrist, or even through both, should be arrested
in turn by pressure, which in most cases of this kind will succeed,
if properly applied, and thus show the vessel injured. The bleeding
point should be fully exposed, and all coagula removed, when a piece
of lint, rolled tight and hard, but of a size only sufficient to cover
the bleeding point, should be laid upon it. A second and larger hard
piece should then be placed over it, and so on, until the compresses
rise so much above the level of the wound as to allow the pressure to
be continued and retained on the proper spot, without including the
neighboring parts. A piece of linen, kept constantly wet and cold,
should be applied over the sides of the wound, which should not be
closed so as to allow of any blood being freely evacuated; and if the
back of the hand be then laid on a padded splint, broader than the
hand, a narrow roller may be so applied as to retain the compresses
in their proper situation, without making compression on or impeding
the swelling of the adjacent parts, the fingers being bent, in order
to relax the palmar aponeurosis--a proceeding which should never be
neglected in any operation in the palm of the hand. It has been lately
proposed by M. Thierry, a French surgeon, to raise and bend the arm,
as a means of impeding the circulation where the artery passes over
the elbow-joint, and the proposal deserves adoption, but not to the
extent he recommends, which cannot be long submitted to. Pressure made
at the same time on the radial or ulnar artery, or on both, by a piece
of hard wood two inches long, shaped like a flattened pencil, is much
more effectual, and more to be depended upon. When from the bones
being broken, or the hand so swollen, or from other circumstances,
pressure, however lightly and carefully applied, cannot be borne in
the manner directed, and the attempts to secure the artery at the
bleeding spot have failed, and pressure on the radial or ulnar artery
has been equally unsuccessful, in consequence of the swelling or other
circumstances, both may be tied at the wrist in preference to placing
a ligature on the brachial artery, although that even must be done as
a last resource, if the bleeding should still continue. If it be asked
why not do this in the first, rather than in the last instance, the
answer is, that it has so often failed to prevent a renewal of the
bleeding from both ends of a wounded artery in the hand, that complete
dependence cannot be placed upon it, particularly if there should be
a division high in the arm of the brachial into the radial and ulnar
arteries. When, however, the arteries leading to the wound have been
secured, either by pressure or ligature, NEAR to the part, and the
bleeding returns by the collateral circulation, which in the hand is so
free, the arresting the supply of blood through the main trunk may and
often has suppressed the hemorrhage, at all events for a sufficient
time to enable the injured parts to recover themselves, provided the
forearm is bent and raised, and the person kept at _rest_ in the most
restricted manner, without which this operation will in all probability
fail. It is in these cases that the instrument alluded to, page 226,
will be useful, rendering the ligature on the trunk of the vessel
unnecessary, more particularly if the bleeding should appear to depend
on some peculiarity in the structure of the coats of the artery.

209. When the obstacle to the application of pressure arises from the
injured state of the metacarpal bone or bones, one or more should be
removed, with the fingers if necessary, so as to expose a clear and
new surface, on which the bleeding vessels may be seen and secured.
In some cases, particularly if there should be a hemorrhagic tendency
in the arterial system generally, as known from previous accidents,
the first compress may be wetted with the perchloride of iron, the
ol. terebinth., the dilute sulphuric acid, or the tincture of matico;
these remedies may be also administered internally. Some new styptics
have lately been much lauded in Malta and other places, but sufficient
proofs have not been given of their efficiency.

210. When the radial artery is wounded as it turns from the back to
the inside of the hand, to form the deep-seated palmar arch, it meets
a branch of the ulnar nerve about to terminate in the muscles of the
thumb. If the treatment by pressure above recommended should not
succeed, the muscles forming what is called the web, between the thumb
and metacarpal bone of the forefinger, should be cut through, and the
bleeding vessel exposed. They are the adductor pollicis on the inside,
and the abductor indicis on back of the hand.



LECTURE XIII.

WOUNDS OF THE ARTERIES, ETC.


211. The precept so strongly insisted upon, that no operation should
be done on a wounded artery unless it bleed, and at the place from
which it bleeds, has been particularly opposed with reference to the
neck, the opponents believing that placing a ligature on the primitive
carotid is an operation not attended with much risk, and that it may
therefore be done as a precautionary measure when the wounded part
does not bleed; this statement is an error. Of thirty-eight cases
collected by Dr. Norris in 1847, in which this vessel was tied for
aneurism, twenty-six died, and twelve suffered from affection of the
brain, the frequency of which occurrence has been singularly overlooked
by practical surgeons; although proving, in a very marked manner,
that the operation of tying the primitive carotid is not a trifling
affair, and that the success, when compared with the failures, is only
as one and one. A much more important objection is the difficulty of
deciding, in many cases of wounds of the neck, what artery is wounded,
and what trunk should be tied; whether it be the external carotid or
its branches, or the internal, or the vertebral artery. Errors have
been committed on all these points by men of the greatest anatomical
and surgical knowledge; the trunk of a sound artery having been tied
instead of that of a wounded one, inflicting thereby on the patient a
second and useless wound, more dangerous, perhaps, than the original
one it was intended to relieve.

When Professor of Anatomy and Surgery to the College of Surgeons in
1830, I stated that in wounds of the neck which rendered it advisable
to place a ligature on some part of the carotid, on account of the
supposed impracticability of laying bare the bleeding orifice, it was
generally the _external_ carotid which should be secured, rather than
the primitive trunk; there not being sufficient reason for cutting off
the supply of blood to the head by the internal carotid, unless the
operation on the external carotid should fail. This direction should be
implicitly followed.

212. A man was wounded by a ball in the side of the neck, and suffered
severely from secondary hemorrhage. Some days after being brought into
the hospital, M. Breschet, unable to arrest the bleeding, was about to
apply a ligature to the common carotid, when the man died in time to
prevent it. On examination after death, the vertebral was found to be
the artery wounded, between the second and third vertebræ. The ligature
of the carotid, had he lived a little longer, would have been a useless
addition to his misery.

Professor Chiari, of Naples, tied the trunk of the left common carotid
on the 18th of July, 1829, on account of a false aneurism below the
mastoid process, consecutive to a wound made by a sharp-pointed
instrument under the angle of the jaw. The man died on the ninth day,
and the wounded artery was found to be the vertebral, between the
transverse processes of the first and second vertebræ. M. Ramaglia
says, a man, thirty-nine years of age, was wounded by a sharp-cutting,
penetrating instrument, below the left ear, from which an aneurismal
swelling resulted. The common carotid was tied, but as this did not
arrest the pulsations of the aneurism, the ligature was removed, and
the patient, after suffering from various accidents, died, when the
vertebral was found to be the artery wounded.

M. Maisonneuve, of Paris, lately laid the following most instructive
case before the Academy of Medicine: A lady was shot by her husband,
who stood close to her, with a pistol loaded with ball. The wound was
inflicted on the anterior part of the neck, on a level with the left
side of the cricoid cartilage. The hemorrhage had been considerable
when the surgeons, Messrs. Maisonneuve and Favrot, arrived, though
the wound looked at first as if the ball had not penetrated deeply.
There were pain and numbness of the left arm; respiration, voice, and
deglutition were, however, normal. On examining with the probe, it was
found that the cricoid cartilage had been bared, and that the ball
had then run from above downward, leaving the trachea and œsophagus
internally, and the common carotid artery, the internal jugular vein,
and the pneumogastric nerve externally, and was impacted in the body
of the sixth cervical vertebra, where it could easily be felt. Some
attempts at extraction were made, but they caused so much pain that
they were given up. The patient was bled six times in four days,
and had large doses of opium; she improved considerably under this
treatment, and the inflammation was very moderate.

On the eighth day hemorrhage occurred at the wound, and again on the
ninth, but it ceased of itself on each occasion. When, however, it
broke out a third time, the surgeons proceeded at once to search for
the bleeding vessel. An incision about three inches long was made on
the anterior edge of the sterno-mastoid muscle, a little external to
the wound inflicted by the ball; the carotid sheath was then brought
into view, and the vessels were found intact. The cricoid cartilage
and the first rings of the trachea were afterward seen to have been
grazed by the ball, which was found implanted in the body of the sixth
cervical vertebra, whence it was easily extracted. Severe hemorrhage
ensued immediately upon the removal of the ball, the blood seeming to
proceed from the vertebral artery, which appeared to have been wounded
within the canal formed by the foramina of the transverse processes.
By placing the finger on the hole left by the ball, the orifice whence
the blood issued was distinctly seen; forceps were applied to it, and
held firmly for a little while to arrest the hemorrhage. An aneurismal
needle, with a very small curve, was then made to carry a double thread
behind the vessel. One of these was used to tie the artery above, and
the other below the aperture whence the blood issued.

The operators at first thought they were mistaken in supposing that
they had tied the vertebral artery, as the vessel seemed quite free,
while it is known to be protected by the transverse processes in
that locality, and believed they had secured the inferior thyroid.
The hemorrhage ceased at once, and some smaller vessels were then
tied, among which was the inferior thyroid artery. Everything went
on favorably at first; the threads fell on the ninth day after the
deligation of the vessel, and the patient remained in a satisfactory
state for the next five days, when severe febrile symptoms, unpreceded
by shivering, set in; and on the eighteenth day after the operation,
the twenty-seventh after the infliction of the wound, the patient was
suddenly seized with a violent pain in the cervical region, cried out
loudly, and fell into deep coma, which lasted for about seven hours,
when she expired, notwithstanding the most strenuous means were used to
rouse her.

On the post-mortem examination, the course of the ball was found as
stated above, viz., it had run from the integuments to the body of the
sixth cervical vertebra, leaving the trachea and œsophagus internally,
and the carotid sheath and its contents externally, untouched. The
inferior thyroid artery was wounded just before it reaches the thyroid
gland, and had a firm clot, about half an inch in length, filling its
cylinder. The transverse process of the sixth cervical vertebra was
fractured, and had left the wounded vertebral artery unprotected.
The vessel above and below the wound in its coats was filled with a
firm clot for about an inch in each direction. The body of the sixth
cervical vertebra had been perforated by the ball, which had dug for
itself a canal communicating with the cavity of the spine by a small
aperture, evidently of very recent formation. This aperture resulted
clearly from the necrosis of the thin shell of bone which formed the
bottom of the canal. The cancelous texture of the body of the vertebra
was infiltrated with pus, and a sero-purulent fluid was found in the
spinal canal, both in the cellular tissue external to the dura mater
and in the sub-serous texture of the meninges. No other lesion existed
in any other part of the frame.

213. M. S., a female, aged fifty-three, was admitted into the
Westminster Hospital, with a large, movable tumor in the neck, under
the sterno-mastoid muscle of the right side. An operation having been
commenced for its removal, the tumor was found to be of a more than
doubtful character, and to dip down between and behind the great
vessels of the neck. In the course of the operation, the external
carotid was opened a little above its bifurcation, and a ligature
was applied on the common carotid. The bleeding was not in the least
arrested; a ligature was then placed on the external carotid above
the hole in the artery, which still continued to pour out blood; a
third ligature was now put upon the internal carotid, with no better
success. A fourth ligature was then applied on the external carotid,
below the hole in it, including the superior thyroid, which was given
off at that part; after which the bleeding ceased, and never returned.
Three ligatures came away in three weeks; the fourth remained during
five weeks. The patient recovered from the operation, but the tumor
grew again, and the woman died exhausted at the end of six months. On
examination after death, the arteries referred to were found to be
obliterated for some distance above and below the parts injured.

The utter inefficiency of everything but the two ligatures, the one
immediately above, the other immediately below the part opened, could
not be more distinctly proved, if a case were even invented for the
purpose; and the fact could not be more satisfactorily shown that in
every case of wounded--not aneurismal--artery in the neck, one ligature
should be applied above, and another below the opening in the injured
vessel, and not one alone on the common trunk, even if that should be
the part injured.

It is argued that when a man has his internal carotid cut on the inside
of his throat, by a foreign body of any kind thrust through his mouth,
the artery cannot be tied by two ligatures at the wounded part through
the mouth, not even if it were enlarged from ear to ear. What, then,
is to be done? The artery should be secured by ligature by an incision
made on the outside of the neck. This being admitted, the question then
is, shall the wounded artery be laid bare at the part injured, or two
inches or so lower down, where the main trunk can be most easily got at
by men of even very moderate anatomical knowledge?--an operation which
has frequently failed, although it has frequently succeeded, and is
therefore most approved. _I am willing, for the present_, to consider
it nearly impracticable to tie the internal carotid safely from the
outside of the neck, at the part wounded, without great anatomical
knowledge, and to accept, for the moment, as the proper operation, the
ligature of the common trunk of the carotid, at the distance of two
or more inches, being the operation of Anel; but I venture to ask,
with what fairness can this operation, thus done on one side of the
neck, at the distance of two inches, the other side remaining sound,
be considered similar to that of Mr. Hunter, done on the thigh for a
wound in the calf of the leg, at the distance of perhaps twenty inches,
with all the intervening collateral branches perfectly sound? It cannot
be considered an analogous operation, with propriety or fairness, nor
ought the one to be compared with the other, although it is done; and
thus the subject is mystified to all those who do not understand it
thoroughly. It is because English surgeons miscall this the operation
of Hunter, that French surgeons claim the operation of Hunter as that
of Anel, and deny the priority of Hunter, although the two operations
are essentially distinct. The operation of Anel for _aneurism_ of the
popliteal artery would be destructive; the operation of Hunter for _a
wound_ of the popliteal artery would be equally so.

This point must, however, be pressed further. Let us suppose that the
internal carotid has been opened by a wound inflicted through the
mouth, and death is about to follow, unless the hole in the artery
can be tied up. How is it to be done? The Hunterian theorists say it
is _impracticable_ to tie the artery at the wounded part, and the
primitive trunk must therefore be secured.

Let us now suppose that a ligature has been placed on the common
carotid, and the bleeding continues; what is to be done? By the
Hunterian and Anellian theorists there is nothing more to be done--the
patient _must_ die. By my theory there is another operation to be done,
and the patient need not necessarily die. As there is already a wound
in the neck made by the surgeon, there would be little difficulty, by
extending it, in ascertaining that the blood came from the brain, and
that nothing but a ligature on the internal carotid artery above the
part wounded through the mouth could save the patient; and why not do
this operation at first, and place a ligature above and another below
the wound in the artery?

214. It is with great satisfaction I quote the opinion of M. Velpean
on this subject, as showing the greater advance Parisian surgeons have
made than even many of high attainments in London: “In hemorrhage from
the neck, the mouth, the throat, the ear, or the skull, everything
should be done to reach the branch of the carotid which has been
wounded, rather than tie the carotid itself.” Alluding to a wound of
the inferior pharyngeal artery, he says: “The search for this artery
will cause but little or no inconvenience, for the same incision will
suffice for the ligature of the external or internal carotid, the
lingual, the facial, or the superior thyroid artery, if it become
necessary, each artery being capable of being taken hold of and
compressed, until the one which is really wounded is ascertained.” He
further adds: “Surgeons found it formerly more convenient and sure
to tie the primitive trunk of the carotid, for all arterial diseases
of the head, than to tie the external or internal carotid or their
branches; _but this is not admissible in the present day_.” Operating
for a tumor on the left temple, which he considered aneurismal, he
first tied the common trunk of the carotid, and then the internal. The
tumor diminished in size, but hemorrhage took place from the wound,
and was frequently repeated until the sixteenth day, when the patient
died hemiplegic. The hemorrhage came from the external carotid, and the
blood escaped through the upper opening of the common carotid. He says
himself he ought to have tied the external carotid also; or, after the
first bleeding, have applied a ligature on the upper end of the common
trunk.

215. Dr. Twitchell, of Keene, N. H., United States, says a soldier,
in a sham fight, in 1807, received a wound, from the wadding of a
pistol, on the right side of the head, face, and neck, which was much
burned. A large wound was made in the mouth and pharynx; nearly the
whole of the parotid gland, with the temporal, masseter, and pharyngeal
muscles, was destroyed. The neighboring bones were shattered, and the
tongue injured. The hemorrhage was not copious, although the external
carotid and its branches were divided. Ten days after the accident,
the sloughs had all separated, and left a large circular aperture, of
from two to three inches in diameter, at the bottom of which might be
seen distinctly the internal carotid artery, denuded from near the
bifurcation of the common trunk to where it forms a turn to enter the
canal in the temporal bone. Directly on this part there was a dark
speck, of a line or two in diameter, which suddenly gave way while
Dr. Twitchell was in the house. With the thumb of his left hand he
compressed the artery against the base of the skull, and effectually
controlled the hemorrhage. The patient fainted. As soon as he
recovered, the doctor says: “I proceeded to clear the wound from blood,
and having done this I made an incision with a scalpel downward, along
the course of the artery, to more than an inch below the point where
the external branch was given off, which, as stated above, had been
destroyed at the time of the injury. Having but one hand at liberty, I
depended upon the mother of the patient to separate the sides of the
wound, which she did, partly with a hook, and occasionally with her
fingers. At length, partly by careful dissection, and partly by using
my fingers and the handle of the scalpel, I succeeded in separating the
artery from its attachments; and, passing my finger under it, I raised
it up sufficiently for my assistant to pass a ligature round it. She
tied it with a surgeon’s knot, as I directed, about half an inch below
the bifurcation.” Dr. Twitchell removed his thumb, and sponged away the
blood, not doubting that the hemorrhage was effectually controlled;
but, to his surprise and disappointment, the blood immediately began to
ooze from the rupture in the artery, and in less than ten minutes it
flowed with a pulsating jet. He compressed it again with his thumb, and
began to despair of saving his patient, but resolved to make another
attempt. Raising his thumb, he placed a small piece of dry sponge
directly over the orifice in the artery, and renewed the compression
till a rather larger piece of sponge could be prepared. He placed
that upon the first, and so went on, pressing the gradually enlarged
pieces obliquely upward and backward against the base of the skull,
till he had filled the wound with a firm cone of sponge, the base of
which projected two or three inches externally. He then applied a linen
roller in such a manner as to press firmly upon the sponge, passing
it in repeated turns over the head, face, and neck. On the 30th of
December the patient was discharged cured, several fragments of bone
and two teeth from the upper jaw having been cast off. Some deformity
remained, in consequence of the depression on the side of the face.

The inutility of tying the primitive trunk for a wound of the internal
carotid is distinctly shown in this case, which is no less valuable
from the fact demonstrated, that if the internal carotid can be exposed
and injured within the angle of the jaw by an accident, it can be
exposed and secured by ligature at the same part by an operation.

216. When, then, the internal carotid is wounded through the mouth,
what operation is to be performed? That of placing a ligature
above, and another below the opening made into it; and after much
consideration, and many trials, the following operative process is
recommended to the attention of those who are best acquainted with the
subject:--

An incision is to be begun opposite to and on the outside of the
extremity of the lobe of the ear, and carried downward in a straight
line, until it reaches a little below the angle of the jaw, at the
distance of nearly half an inch, more or less, as may be found most
convenient from the form of the neck. This incision exposes the parotid
gland without injuring it. A second is then to be made from the
extremity of the first, extending at a right angle forward, under or
along the base of the lower jaw, until the end of it is opposite the
first molar tooth. This incision should divide the skin, superficial
fascia, platysma myoides muscle, and the facial artery and vein. The
second molar tooth should then be removed, and the jaw sawn through
at that part. Then cut through the deep fascia, the mylo-hyoideus
muscle, and the mucous membrane of the floor of the mouth, exposing the
insertion of the internal pterygoid muscle, which is to be divided. The
surgeon will next be able to raise and partially evert the angle of the
jaw, and thus obtain room for the performance of the remaining part of
the operation, which should be effected by the pointed but blunt end of
a scalpel, or other instrument chosen for the purpose of separating,
but not of cutting. The styloid process of the temporal bone may
then be readily felt, and exposed by the separation of a little
cellular membrane, and with it the stylo-hyoid muscle, which is to be
carefully raised and divided. The external carotid artery will thus be
brought into view, together with the stylo-pharyngeus muscle and the
glosso-pharyngeal nerve attached to it. These are to be drawn inward by
a blunt hook, when, if care be taken to avoid the pneumogastric nerve,
the internal carotid may be felt, seen, and secured by ligature with
comparative facility outside the tonsil, there being between them the
superior constrictor of the pharynx, which, in a case of wound through
the mouth, must have been divided. The pneumogastric nerve should be
drawn outward, and the external carotid artery also, if in the way.
The division of the jaw will not lead to further inconvenience, as the
bone always reunites, when divided, with little difficulty. That this
operation requires a thorough knowledge of the anatomy of the parts, is
true; and this can only be acquired by repeated dissections.

217. The nearest successful case to the operation thus recommended was
performed by Dr. Keith, of Aberdeen.

E. Kennedy, aged twenty-five, accidentally swallowed a pin, the head
of which could be felt below and behind the left tonsil, covered by
the lining membrane of the pharynx; it could not be extracted by any
attempt made for its removal. The membrane was snipped by a pair
of probe-pointed scissors, to expose the head of the pin. This was
followed by the discharge of mouthfuls of arterial blood, and it was
evident that the internal carotid artery had been injured. Pressure on
the common carotid stopped the bleeding, and the operation of placing
a ligature on the internal carotid was effected in the following
manner: The patient’s head being supported by a pillow, her face was
turned toward the right shoulder, when an incision was made from
below the ear along the ramus of the lower jaw to below its angle. No
hemorrhage occurred, and the vessel was speedily exposed and secured by
a double ligature passed under it, with less difficulty than the depth
of the vessel would lead one to expect. One ligature arrested the flow
of blood, and the other was therefore withdrawn. The woman recovered,
without any return of the bleeding. Dr. Keith, aware of the necessity
for tying the other end of the artery, if it should bleed, watched the
case day and night until the period of danger had passed away. The
pin gave no trouble, until felt by the patient as about to go down
the œsophagus, which it did to her great satisfaction and relief from
further anxiety.



LECTURE XIV.

LIGATURE OF THE COMMON ILIAC ARTERY, ETC.


218. The operation for placing a ligature on the aorta should not be
done by making an opening through the front of the abdomen, as has
hitherto been proposed. It should in future be attempted and executed
nearly in the same manner as the operation for placing a ligature on
the common iliac, which has succeeded. The aorta bifurcates usually on
the body of the fourth, or on the inter-vertebral substance between
it and the fifth vertebra, although it may be higher or lower--a fact
which cannot be ascertained previously to the operation; the most usual
place is nearly opposite to the margin of the umbilicus on the left
side. It is about half an inch above this that the ligature should
be placed on the aorta, if this operation is ever done again, rather
lower than higher, on account of the origin of the inferior mesenteric
artery. As the aorta is to be reached by carrying the finger along the
common iliac, the comparative situation of that vessel is next to be
estimated.

The length of the two common iliac arteries varies according to the
stature of the patient, and the place at which the aorta bifurcates.
The common iliacs again divide into the external and internal iliacs,
which division is usually opposite to the sacro-iliac symphysis. The
length of the common iliac artery is therefore tolerably well defined,
as scarcely ever exceeding two inches and three-quarters, and seldom
being less than two inches. The external iliac is a little longer
than the common iliac, and the place of subdivision of the common
iliac into external and internal can always be ascertained, during an
operation, by tracing the external iliac upward to its junction with
the internal to form the common trunk, which proceeds upward and inward
to the aorta. The left margin of the umbilicus being taken as a point
opposite to that which may be presumed to be the part at which the
aorta divides, and the situation of the external iliac becoming femoral
being clearly ascertained, a line drawn between the two will nearly
indicate the course of these two vessels; sufficiently so, at all
events, to enable the operator to mark with his eye, or with ink, the
place where he expects to tie the artery; and to regulate the length of
the incision, so that this ideal spot may correspond to its center. It
is necessary to recollect, also, that the whole of one hand and part
of the other must be introduced into the wound, to enable the operator
to pass a ligature round the artery, and to tie the knots: so that an
external excision of less extent than five inches will not suffice, and
six will afford a facility in operating, which will save pain to the
patient and inconvenience to the operator. In calculating the length
of the incision, allowance must be made for the size, obesity, and
muscularity of the patient. If a rule be placed on the crest of each
ilium, about one inch and a half behind the anterior superior spinous
process, it will pass in a well-formed man across the junction of the
fifth lumbar vertebra with the upper part of the sacrum, and a little
way behind where the common iliac divides into external and internal.
The center of an incision, six inches in length, beginning about half
an inch above Poupart’s ligament, and about the same distance to the
outside of the inner ring, and carried upward, will fall nearly on a
line with this point. The incision should be nearly parallel to the
course of the epigastric artery, but a little more to the outside,
in order to avoid it and the spermatic cord, and having a gradual
inclination inward toward the external edge of the rectus muscle; the
patient being on his back, with the head and shoulders raised, and
the legs bent on the trunk. The aponeurosis of the external oblique
muscle having been opened inferiorly, is to be slit up for the whole
length of the external incision; and the director having been first
passed under the internal oblique muscle, through a small opening
carefully made into it, it is to be divided in a similar manner. The
transversalis is then to be cut through at the under part, and its
tendinous expansion divided at the upper part, the greatest precaution
being taken by the finger to prevent the peritoneum being injured.
The fascia transversalis is then to be torn through at the lower and
outer part, so that the fingers may be passed inward from the ilium,
and the peritoneum detached from the iliac fossa, and turned with its
contents inward, by a gradual and sidelong movement of the fore and
second fingers inward and upward, until, passing over the psoas muscle,
the external iliac artery is discovered by its pulsation. It is then to
be traced upward and inward toward the spine, when its origin and that
of the internal iliac from the common trunk will be felt. The point of
the forefinger will then be nearly in the center of a line drawn from
the umbilicus to the anterior superior spine of the ilium; hence the
necessity for an incision six inches in length, if the artery is to be
tied high up, which is to be accomplished by tracing it in a similar
manner to its origin from the aorta.

The _common trunk_ of the iliac arteries and the _aorta itself_ may
be tied by the same method of proceeding; the only difference which
can be practiced with advantage will be to make the incision a little
longer at its upper part, no inconvenience arising from the addition
to the length of the external wound, while the subsequent steps of
the operation will be much facilitated by it. The following method of
proceeding, adopted in two cases in which I placed a ligature on the
common iliac artery with a successful result, will bring the operation
so graphically before the reader that it cannot be misunderstood,
and may be readily followed in operating: I began the operation,
the patient lying on the back, by an incision on the fore part of
the abdomen, commencing an inch and a half below the inside of the
anterior spine of the ilium, and the same distance within it, carrying
it upward, and diagonally inward toward the edge of the rectus muscle
above the umbilicus, so that the incision was between six and seven
inches long. If the incision be made more outwardly, toward the side
in a straight or vertical line from the ilium toward the ribs, great
difficulty will be experienced in turning over the peritoneum with its
contents, so as to place the finger on the last lumbar vertebra--an
inconvenience which will be avoided by making the incision diagonally,
and of the length directed.

After dividing the common integuments, the three layers of muscles
were cut through in the most careful manner; the division of the
transversalis muscle was attended with some difficulty, inasmuch as
there was but little fascia transversalis, and the peritoneum was
remarkably thin--as thin as white silver paper. On attempting to
reach the under part on the inside of the ilium, so as to turn the
peritoneum over, which in sound parts is always done without the least
difficulty, I found that it could not be done on account of the tumor
which projected inward adhering to it; some bleeding took place from
the large veins which surrounded it, giving rise to the caution not
to proceed further in that direction. At this moment, in spite of the
greatest possible care that could be taken by Mr. Keate, who raised and
protected the peritoneum, a very small nick was made in it, sufficient
to show the intestine through it. Perceiving that I could not tie the
internal iliac as I had at first intended, and that I must place the
ligature on the common iliac, I tried to gain a greater extent of
space upward; but where the tendon of the transversalis muscle passes
directly across from the lower ribs to aid in forming the sheath of
the rectus, the peritoneum is usually so thin and so closely attached
to it that it can only be separated with great difficulty. I knew this
from the operation I had before performed, when, in spite of all the
precaution I could then take, the peritoneum was at this spot slightly
opened. It occurred in the present instance, and the right lobe of the
liver was thus exposed.

The opening thus made on the fore part of the abdomen was not large
enough to admit two hands. The peritoneum being, however, separated a
little from the posterior wall of the abdomen from the outside, by the
fingers, for a cutting instrument was inadmissible, four of the fingers
of one hand were introduced beneath it, and it was turned a little over
toward the opposite side. In doing this it must be remembered that the
peritoneum must be raised, the hand being pushed toward the back as
little as possible, in order to avoid getting behind the fat commonly
found in that part of the body, which would lead to the under edge
of the psoas muscle instead of the upper surface, and thus render the
operation embarrassing.

The peritoneum being carefully drawn over with its contents, I found
I could only get one hand, or a little more, underneath it in search
of the artery, the tumor below preventing any further detachment of
the peritoneum in that direction. I therefore passed my finger across
the psoas muscle, and it rested on the fifth lumbar vertebra. The
common iliac artery was not to be felt, however, even as high up as the
fourth lumbar vertebra, nor was the aorta; they had both risen with the
peritoneum, and my finger resting on the spine was beneath them. Mr.
Keate endeavored to raise or draw over the peritoneum, to give me an
opportunity of seeing the vessels, but it could not be done. However,
he felt the pulsation of the iliac artery, which had been raised with
the peritoneum, to which I found it adhering. Carefully separating it
with the end of the forefinger of the right hand, I passed a single
thread of strong dentists’ silk, as it is termed, in a common solid
aneurismal needle, by the aid of the thumb and forefinger of the left
hand, round the artery without seeing it. I could then bring the artery
a little forward by means of the aneurismal needle, when it appeared
to be perfectly clear, and from the distance of the bifurcation of the
aorta above, which could be distinctly felt, I calculated that the
common iliac was tied exactly at its middle part. All pulsation below
immediately ceased.

The two ends of the ligature were twisted, and the peritoneum replaced
in its proper situation, care being taken that the two small openings
into it should be well covered under the skin, so that they might not
be in the line of the incision, and that they should be covered by
newly divided healthy parts, so that they might thus adhere to each
other. Three strong sutures and three or four smaller ones were put in
through the skin, in order to prevent the parts bursting asunder from
the movements of the patient. This operation was only formidable, as a
whole, from the circumstance that space could not be obtained for the
introduction of both hands; for, strange as it may appear, the safety
of and ease in doing the operation depend on the first incision in the
fore part of the abdomen being so large that the peritoneum containing
the bowels may be freely drawn over by the expanded hands of the
assistant, so that the operator can see what he is doing beneath. In
my first case the whole of the parts under the peritoneum could be
distinctly seen, and several gentlemen (not in the profession) who were
present saw the common iliac artery in its natural situation.

The patient suffered little or nothing from the operation, which was
performed on the Saturday; there was no augmentation of the pulse until
Sunday evening, when it rose to 120; she then experienced some pain,
which was materially diminished, although not altogether removed, by
the abstraction of fourteen ounces of blood. At four in the morning,
Mr. Hancock, now senior surgeon to the Charing Cross Hospital, took
away fourteen ounces more, after which she had not a bad symptom. The
bowels were not moved for the first four days. The temperature of the
limb diminished, but not much, which may be attributed to its having
been constantly rubbed night and day by two persons; and a hot brick,
or bottles of hot water, covered with flannel, having been applied to
the feet, of the temperature of from 120° to 140°. One nurse rubbed the
lower part of the limb, and another the upper, for three days and three
nights; if an interval of a few minutes occurred, a hot flannel was
put on the limb. The friction was very slight, so as not to injure the
cuticle. The patient occasionally dozed a little; still the same gentle
friction was kept up. The ligature came away on the twenty-sixth day
after the operation. The external incision healed very readily, but was
followed, as is usual in all extensive wounds of the muscular wall of
the abdomen, by a slight herniary projection, requiring the support of
an abdominal bandage.

The situation of the ureter and rectum on the left side in this
operation, and of the ureter and cæcum with its appendix on the right
side, should be well understood, and it should be known that the ureter
rises with the peritoneum. The relative situation of the common iliac
artery and vein should be particularly attended to, when passing the
ligature around the vessel. On the left side, the artery lies external
and anterior to its commencement; on the right, the artery passes over
the commencement of the vena cava and the left iliac vein, which do not
follow the peritoneum when drawn toward the opposite side. The bowels
should be thoroughly well evacuated before the operation is performed,
but purgatives should not be given for some days after it has been
done. The food should be liquid, and inflammation should be subdued by
leeches, general bleeding, fomentations, and opium.

219. The _aorta_ may be as readily tied by this mode of proceeding
as the common iliac; and I am satisfied it is in this way such an
operation ought to be performed, provided it become necessary to
attempt it, which I suspect it will not be; for when an aneurism has
formed so high up that it prevents the application of a ligature on
the side on which the disease is situated, the common iliac will be
more readily tied above it, instead of the aorta, by performing the
operation on the opposite or sound side of the body; for as a ligature
can be applied with great ease on the sound side on the middle of
the common iliac artery, it requires very little more knowledge and
dexterity to pass over to the opposite or diseased side, and tie
the artery above the aneurismal tumor, the size of which would have
prevented the operation being done on its own or the affected side.
The placing a ligature on the aorta for an aneurism in the pelvis will
thus be rendered unnecessary--a most important result, deduced from the
operation described.

220. If the _internal iliac_ is to be tied, the operator traces it
downward from its origin, in preference to passing his finger from
the external iliac artery inward in search of it. Having placed the
point of his forefinger on the vessel at the part where he intends to
pass his ligature, he scratches with the nail upon and on each side
of it, so as to separate it from its cellular attachments, and from
the vein which accompanies, but lies behind it. Thus far the operator
proceeds by feeling; but it is now necessary that the sides of the
wound should be separated, and kept apart by blunt spatulæ curved at
the ends, so as to take up as little space as possible, and not to
injure the peritoneum. The surgeon should, if possible, see the artery,
and the ligature carried on the eye of a bent probe, or a convenient
aneurismal needle, should be passed under it from within outward,
when it should be taken hold of with the forceps; the probe or needle
should then be withdrawn, and the ligature firmly tied twice, or with
a double knot. Great care must be taken to avoid everything but the
artery. The peritoneum which covers it and the ureter which crosses it
must be particularly kept in mind. The situation of the external iliac
artery and vein, which have been crossed to reach it, must always be
recollected, and, if there be sufficient space, they should be kept
out of the way, and guarded by the finger of an assistant.

221. The _external iliac_ artery has been so often and so successfully
tied that a description of the two methods of proceeding commonly
adopted will suffice, with a few additional remarks. The first,
recommended by Mr. Abernethy, is in accordance with the operations
on the common, and on the internal iliac. The patient being laid on
his back, with the shoulders slightly raised, and the legs bent on
the trunk, an incision is to be made about three inches and a half in
length in the direction of the artery, terminating over or a little
above Poupart’s ligament. The aponeurosis of the external oblique
muscle will be exposed, and an opening being made into it, a director
is to be introduced, and it is to be slit up to the extent of the
external incision. The internal oblique and transversalis muscles
are then to be “nicked,” so as to allow a director or the point of
the finger to be introduced below them, when they also are to be
divided, the finger separating them from the fascia transversalis
and the peritoneum. The fascia transversalis running from Poupart’s
ligament to the peritoneum is now to be torn through with the nail,
immediately over the pulsating artery, and the peritoneum is to be
separated by the finger, and pushed upward until sufficient room has
been obtained; which in this, as well as in all other operations on the
iliac arteries, is sometimes difficult on account of the protrusion
of the intestines covered by the peritoneum, when the patient is not
sufficiently tranquil. The artery is yet at some depth; it is covered
by a dense cellular membrane, connecting it to the vein on its inside,
which must be torn through with the nail. The anterior crural nerve
is separated from the artery by the psoas muscle, at the outer edge
of which it lies. The aneurismal needle should be passed between the
vein and the artery, and the point made to appear on the outside of the
latter.

In this operation the ligature is placed on the external iliac, above
where it gives off the epigastric and the circumflexa ilii arteries;
as the operation is very much the same as that already described, with
the exception of the incision being shorter and nearer to Poupart’s
ligament, it is obvious, if it were found necessary from disease to tie
the artery higher up, or even to tie the common iliac, that it might be
done by merely enlarging the wound. It is therefore the best mode of
proceeding when the aneurismal swelling in the groin has encroached on
Poupart’s ligament.

Another method has been recommended by Sir Astley Cooper, which is
perhaps more followed where there is little doubt of the artery being
sound.

“The patient being placed in the recumbent posture, on a table of
convenient height, the incision is to be begun within an inch of the
anterior superior spinous process of the ilium, and is to be extended
downward in a semicircular direction to the upper edge of Poupart’s
ligament. This incision exposes the tendon of the external oblique
muscle; in the same direction the above tendon is to be cut through,
and the lower edges of the internal oblique and transversalis abdominis
muscles exposed; the center of these muscles is then to be raised
from Poupart’s ligament; the opening by which the spermatic cord
quits the abdomen is thus exposed, and the finger passed through this
space is directly applied upon the iliac artery, above the origin of
the epigastric and circumflexa ilii arteries. The iliac artery is
placed upon the outer side of the vein; the next step in the operation
consists in gently separating the vein from the artery by the extremity
of a director, or by the end of the finger. The solid curved aneurismal
needle is then passed under the artery, and between it and the vein
from without inward, carrying a ligature, which, being brought out
at the wound, the needle is withdrawn, and the ligature is then tied
around the artery, as in the operation for popliteal aneurism. One end
of the ligature being cut away, the other is suspended from the wound,
the edges of which are brought together by adhesive plaster, and the
wound is treated as any other containing a ligature.”

This method of operating will suffice when the artery is to be tied for
an aneurism which does not extend as high as Poupart’s ligament. When
it does, the operator will be so much inconvenienced by it, while the
sound part of the artery above the tumor will be so much in a hollow
behind it in the pelvis, that a ligature cannot readily be passed
around it; the disturbance to the peritoneum will be much greater, and
much more likely to give rise to peritonitis, than if the incision were
made an inch longer on the face of the abdomen. The surgeon, instead of
searching for the artery, as Sir Astley Cooper has directed, through
the passage by which the spermatic cord quits the abdomen, and thus
passing the fingers directly under the peritoneum, will find it very
much for his own ease, and for the advantage of his patient, to pass
his fingers under the peritoneum from the inside of the wall of the
ilium, from which it readily separates, and thus approach the artery
from the outside instead of from below. He will obtain more room, reach
the artery easily above the origin of the circumflexa ilii, and avoid
that disturbance of the peritoneum, in applying the ligature, which
often leads to inflammation. The ligature should be passed under the
artery from within outward, so as to avoid the vein, which I have seen
injured by passing the needle from without inward.

If the surgeon have unluckily divided the epigastric artery, either in
this or in any other operation, all that he has to do is to enlarge the
incision, and tie both ends of the divided vessel; I have no hesitation
in saying it will not be of any consequence, either in this operation
or in one for hernia.

222. In all cases of aneurism of the gluteal and sciatic arteries,
the internal iliac artery should be tied, instead of an operation on
the part itself. In all cases of wounds of those arteries, which are
the only ones rendering an operation for placing a ligature on these
vessels necessary, the wound should in a great measure regulate the
course of the incision. The operation is an act of simple division,
first through the common integuments for the space of five inches,
then through and between the fibers of the gluteus muscle to the same
extent; a dense aponeurosis covering the vessels is to be next divided,
when the bleeding will lead to the injured vessel. Place the body on
the face, turn the toes inward; commence the incision one inch below
the posterior spinous process, and one inch from the sacrum; carry it
on toward the great trochanter in an oblique direction to the extent of
five inches. Divide the gluteus muscle and the aponeurosis beneath it,
and seek for the artery as it escapes through the upper and anterior
part of the sciatic notch, lying close to the bone. If the vessels
of the gluteus muscle bleed, so as to be troublesome, and cannot be
stopped by compression, they must be secured.

If the sciatic artery be the vessel injured, the incision should be
made in the same direction, but about an inch and a half lower down.
If the course of the wound render it doubtful which artery has been
injured, the incision should be as nearly as possible between the two
lines directed, the wound being always the best guide; care should
be taken in every instance to include nothing in the ligature but the
artery.

Dr. Tripler, of the United States Army, was called to a person who had
fallen backward with great force on a glass bottle, which had thus been
driven into the right buttock, within an inch of the ischiatic notch.
The fingers passed into the wound could be felt on the inside of the
thigh. The man was deluged with blood, and in a state of syncope. The
wound was plugged and bandages applied. Several hemorrhages took place,
and on the thirteenth, five days after the receipt of the injury, the
wound was enlarged, and the gluteal artery tied as it emerged from the
pelvis. The bleeding ceased for three hours, when it returned with as
much force as ever. After various ineffectual attempts to suppress
the bleeding by pressing on the external iliac and femoral arteries,
it was determined to tie the internal iliac, which was done in a very
satisfactory manner, and the bleeding did not return. The man died
three days after the operation, and an examination after death took
place; but, strange to say, no notice is taken, no mention whatever
is made of the wounded vessel. It is simply remarked that the last
ligature was found embracing the internal iliac artery an inch below
the bifurcation, and a firm coagulum already deposited above the point
of ligation.

According to the principles laid down in this work, two errors were
committed in this case. The first, in tying the gluteal artery _as it
emerged from the pelvis_. The second, in tying the internal iliac,
which was unnecessary. The bleeding which caused this operation to
be resorted to is described _as a welling up of the vital fluid_, as
returning _slowly and sluggishly_; the color is not alluded to. It is
probable that the gluteal artery was not divided, but only wounded;
and if the injured part had been sought for, and one ligature applied
above, and another below the wound in it, the hemorrhage would not have
returned, and life perhaps might not have been lost.

The operations were highly honorable to the gentlemen concerned, as
proving their anatomical knowledge. The principle on which they acted I
presume to condemn.

223. Compression should never be made on the femoral artery when a
ligature is about to be placed upon it for aneurism, because the
pulsation is thereby suppressed, and the most important guide to the
vessel is at the same time taken away. When the artery has been wounded
near the groin, and is bleeding, compression must be had recourse to
in the first instance to arrest the hemorrhage; the first incisions
must therefore be made without the information which the pulsation
gives as to the precise situation of the artery, although a finger may
be allowed to rest, or a mark be made on the part, beneath which the
artery could be felt before the pressure was applied. The external
incision should always be made longer or shorter in proportion to the
depth at which the artery is situated. It should be at least one-third
longer in the middle than at the upper part of the thigh; for, while a
long incision always facilitates the subsequent steps of the operation,
it never does harm, unless it is out of all reasonable proportion.
The center of the incision should be, if possible, directly over that
part of the artery on which it is intended to apply the ligature; but
no inconvenience will arise from its being applied nearer its upper
extremity. The patient being laid on his back, and properly supported,
the knee is to be bent and turned outward, by which the head of the
femur will be rolled in the acetabulum, and the femoral artery will be
more distinctly felt at the upper part of the thigh, below Poupart’s
ligament. It lies on the psoas muscle, having the vein on its inside,
and the anterior crural nerve about half an inch on its outside,
having passed between the psoas and iliacus muscles, although some
branches soon approach the artery, and run down on the external part
of the sheath. The relative position of the parts having been duly
considered, an incision is to be made _directly_ in a line over the
pulsating artery, and carried through the skin, cellular tissue, and
superficial fascia, down to the deep-seated or fascia lata of the
thigh. If an absorbent gland should be in the way, it must be turned
aside or removed. The arteria profunda femoris is given off about
two inches below Poupart’s ligament, on the back part of and outside
the femoral, while three or four small vessels spring from half an
inch to an inch below it on the fore part, and one or other of these
may be divided. They are the superficial epigastric, the superficial
pudic, the superficial circumflex of the ilium, and probably an artery
supplying the absorbent glands. If they bleed so as to be troublesome,
they must be secured, more particularly if the femoral artery is to
be tied below them. The fascia lata is now to be divided, with that
part of the fascia transversalis which, descending beneath Poupart’s
ligament, forms the sheath of the artery, when the vessel will be
exposed. In dividing this fascia and sheath, the point of the knife
is always to be directed to the center of the artery, so that if it
be cut by accident it may be seen, when the only result will be the
necessity for the application of a ligature above and one below it. The
artery being fully exposed, as ascertained by the pulsation being felt
by the finger, it is to be separated from its cellular attachment to
the sheath on each side by a blunt or silver knife; and the aneurismal
needle or probe, armed with a strong single thread of dentists’ silk,
is to be passed under it from the inner or pubic side outward, by which
all injury to the vein from the round point of the needle or probe will
be avoided. Two common knots are to be made in the usual manner, when
one thread may be cut off, or the two twisted together and brought
carefully out of the wound; the edges of which are then to be duly
approximated and retained in that situation by sticking-plaster and
a moderate compress, secured in a similar manner. The knee is to be
bent forward to relax the parts, and laid on the outside with a pillow
beneath it.

The needle will pass more easily under the artery if the thigh be bent
on the trunk; before the knots are tied, the surgeon should ascertain
that pressure on the part or artery, which he has nearly surrounded by
the ligature, suppresses the pulsation in the tumor below.

224. The point of a sword entering the anterior part of the thigh two
inches below Poupart’s ligament, and wounding the superficial femoral
artery, will necessitate the application of two ligatures, one above
and the other below the wound in the vessel; but as the profunda under
ordinary circumstances is given off posteriorly at this spot, it is
possible the upper ligature may be placed on the main artery a little
above the bifurcation. The result might, and would probably be, on
some sudden movement of the patient, a recurrence of the hemorrhage by
regurgitation from the profunda into the main trunk below the ligature;
and thus through the wound in the artery, the lower ligature assisting
by the obstacle it offers to the passage of blood through it. In such
a case, the wound should be reopened, and the profunda sought for and
tied. It has been argued that the ligatures, being applied close to
the origin of collateral branches, must fail. This error has been
demonstrated, (Aph. 186,) and need not be further insisted upon. That
it should still be maintained by some surgeons and teachers, who prefer
old jog-trot theories to demonstrated facts, and cannot perceive that
an exception is not a fundamental rule, is much to be regretted.

225. The operation for popliteal aneurism lower down in the thigh is to
be done in the following manner:--

The surgeon, having turned the knee outward and bent the leg inward
into the tailor’s sitting position, to show the course of the sartorius
muscle, should trace the artery from the groin downward, until it
appears to pass under that muscle. The external incision, four inches
in length, made in the course of the artery, should pass over this
point one inch, so that when the fascia lata is divided, the sartorius
muscle may be seen crossing over to the inside at the lower extremity
of the wound. The fascia lata is to be divided upward for the space of
two inches of the incision. The forefinger is then to be introduced
into the wound, and pressure made with it rather outwardly, when it
will readily distinguish the pulsation of the artery, still included in
its sheath. This is to be opened by slight and repeated touches of the
knife directly over the center of the line of the vessel, or it may be
divided on the director, when the artery will be exposed. The point of
the forefinger will easily recognize it from the roundness and firmness
of the feeling communicated by it, as well as by its pulsation; and
the end of the nail, or handle of the scalpel or blunt knife, will
separate it with facility from its attachments, to such an extent as
to admit the blunt point of the solid, unyielding aneurism needle to
be passed beneath it from the pubic side. If the point of the needle
do not readily come through the cellular attachments of the artery on
the outside, this part must be touched lightly with the scalpel, or
rubbed with the nail until the ligature is exposed, which should then
be taken hold of with the forceps and one end drawn out, while the
instrument with the other end is withdrawn. The operator, taking both
ends of the ligature, which has been in this manner passed under the
artery, between the fingers of one hand, presses upon the artery with
the forefinger of the other, so as to arrest the course of the blood in
it, when, if there be an aneurism blow, the pulsation in it will cease.
The ligature is then to be pressed upward as far as the artery has
been detached, and is to be tied with a double knot. The wound is to
be dressed as in the previous case with adhesive plaster and compress,
but without a bandage; and the patient is to be placed in bed, with his
knee bent forward, or resting on the outside, if more agreeable to him.

The operation is done in this manner on that part of the femoral
artery which is not covered by muscle, and all interference with the
sartorious is avoided. It is the improvement on the Hunterian operation
recommended by Scarpa, and ought always to be adopted. This method
obviates all discussion as to placing the ligature on the outside of
the sartorious muscle, or as to the fear of injuring the absorbents;
as to the saphena vein, it can always be seen, and its course traced
up the thigh and avoided. After the first incision has been made and
completed down to the fascia lata, that part is to be divided to the
extent of two inches, but this must be dependent on circumstances; the
object being to obtain a view of the sheath containing the artery,
the opening into which, after the first touch of the knife, may be
completed with the assistance of the director under it. The artery will
be less disturbed in its lateral attachments by an opening into the
sheath, of three-quarters of an inch in length, than by one of half
the extent, as it will admit of the aneurism needle being passed under
it with more facility, and consequently with less disturbance to the
surrounding parts. There is no reason to believe that a free opening
into the fascia of the thigh has ever done mischief, or even one made
in the sheath, provided the artery has not been unnecessarily disturbed.

The warmth of the limb operated upon should be maintained by gentle
friction from the toes upward to the knee; when left at rest it should
be enveloped in flannel. The wound should not be dressed until the
fourth day, the limb being kept quite quiet; the patient should move as
little as possible in bed, and the part of the heel on which the limb
rests should be examined from time to time, as it may under pressure
become gangrenous.

Suppression of the secretion of urine is not uncommon during the first
twenty-four hours after all these operations; it may be gradually
removed by the patient’s taking mild diluent drinks. The constitutional
irritation is frequently great, the pulse rising in forty-eight hours
from 85 to 120; if this continue until the third day, when the fear
of mortification will have passed away, it should be moderated by the
abstraction of a small quantity of blood. In some cases of this kind
I have had occasion to bleed twice, and with the happiest effect,
the pulse having fallen in consequence to its natural standard. The
medicines given at the same time were saline draughts every six hours,
with from four to six or more drops of Battley’s solution of opium. The
ligatures come away on and about the fifteenth day. In many cases they
remain a much longer time without inconvenience.

226. The popliteal artery is never to be secured by ligature, unless
wounded and bleeding. Under ordinary circumstances, an incision should
be made at least three inches long in the course of the wound, the
patient being laid on his face and the limb extended. If the injury
to the artery has been committed where it lies in the ham between the
heads of the gastrocnemius muscle, the bleeding and the pulsation
will point out its situation. The integuments and fascia having been
divided, the posterior saphena vein and nerve, if seen, are to be
avoided and drawn aside, when, by carefully separating some dense
cellular or areolar membrane and drawing the heads of the gastrocnemius
from each other, the bleeding artery will be seen as well as the vein
and nerve. The nerve should be drawn inward with a blunt hook and the
vein carefully drawn outward.

“On the 2d of February, 1855, a young gentleman, aged nineteen, had
a heavy mortising chisel thrown at him, which entered the upper part
of the calf of the leg. There was arterial bleeding, which a man near
him stopped by keeping his finger on the wound. I saw him two hours
after the accident; there was bleeding ‘per saltum;’ presumed that
the posterior tibial was cut. Consulting with two other surgeons, he
was turned over on the table; the limb was distended, and a firm clot
filled up the cavity; I pressed moderately upon either side of the
wound, but there was no return of hemorrhage. The patient was therefore
put to bed, a bandage applied, and an assistant left in charge. The
day following there was less tension in the calf; no hemorrhage.
Having recently read a case by Butcher, in the ‘Dublin Quarterly,’
upon the treatment of wounded arteries by compression, I followed out
his rules. The case did well up to February 13th, when he had a sudden
and severe pain in the calf of the leg, which was much distended, and
the clot pulsating strongly. In a few minutes a large stream burst
out, so large that I was satisfied it could not be from the posterior
tibial. I put my finger in the sinus and found that its direction was
first backward, then backward and upward. I again proposed to dilate
the wound and search for the vessel, when an objection was started by
one of my friends, that if the artery were wounded immediately on its
division, there would not be sufficient space for the clot to form.
As this objection was made, and I failed to combat it, I summoned
the consulting surgeon of the district. After carefully considering
the case, he strongly advised a fair trial should still be given to
compression. Hemorrhage returned upon the 16th. A consultation advised
ligature of the femoral artery, which operation I did. Bleeding
returned on the 25th, and on the 26th I cut down and found a small slit
in the popliteal, and put a ligature above and below it, which saved
the life of the patient.”

227. The posterior tibial, or the peroneal artery, or both, if wounded
at the same time, are to be tied according to the principles laid down
in Aphorism 197, page 231. An incision, from six to seven inches long,
should be made nearer to the inner edge of the leg than to the center,
and should be carried through the gastrocnemius muscle, the plantaris
tendon, and soleus muscle, down to the deep fascia, under which the
arteries lie with their accompanying veins, having the posterior tibial
nerve on the fibular side of the artery. If the incision has been
made in the upper part of the calf of the leg, the peroneal artery
will be exposed by it; but if it be certain that the peroneal artery
is the vessel injured, the incision should be made toward the fibular
side of the leg. When the surgeon has divided the fascia, he will
find this artery covered by the fleshy fibers of the flexor longus
pollicis muscle, at any distance below three inches and a half from
the head of the fibula; these fibers being divided, the artery will be
found close to the inside of the bone. Above that part the artery is
under the fascia, and upon the tibialis posticus muscle. It has not an
accompanying nerve. Both arteries will be readily found by either of
the incisions, if the surgeon be acquainted with their situation.

The posterior tibial artery may require to be tied between the ankle
and the heel. In this situation its pulsation may be felt, and that
will be the best guide to the artery. It has the tendons of the
tibialis anticus, and of the flexor digitorum communis, nearer to the
malleolus than itself, and distant about a quarter of an inch; there is
a vein on each side of the artery. Posterior to this is the posterior
tibial nerve, and nearer the heel the tendon of the flexor longus
pollicis. To tie the artery near the heel, its pulsation should be
felt, and an incision more than two inches long made upon it, through
the common integuments and superficial fascia; a strong aponeurosis
will be found beneath, covering the sheath of the vessels and adhering
to the tendons. This aponeurosis must be carefully opened on a director
passed beneath it, and then the sheath of the vessels: the artery
should be tied with a single ligature, unless wounded. The nerve is
nearer the heel.

The posterior tibial artery may be tied a couple of inches higher up in
the small part of the leg, by making the incision on the tibial edge of
the soleus muscle, under which it lies.

228. The posterior tibial artery, an inch and a quarter or from that
to an inch and a half below the inner ankle, gives off the internal
plantar artery, and assumes the name of external plantar. The internal
and smaller artery passes forward on the inside of the foot, under the
origin of the abductor pollicis, to the outer or metatarsal side of the
great toe.

The external plantar artery, from the point of division, takes a course
curved toward the heel to the metatarsal bone of the little toe, which
is prominent, being a distance of about three inches; during this
course it is covered by the integuments, lateral ligament of the joint,
a quantity of granular fat, the thick plantaris fascia, the origin of
the abductor of the great toe, and the flexor brevis of the other toes.
The artery may then be felt and seen near the os calcis, having the
nerve and vein to the inner side; and lying on the accessorius muscle
and its fascia, at the depth, in ordinary cases, of about an inch and a
half. The plantar fascia extends in considerable strength from the os
calcis forward to the toes, and divides into two portions opposite the
first phalanx of each, which are inserted laterally into the sheaths
of the flexor tendons, and the sides of the ligaments connecting the
phalanges to the metatarsal bones. This fascia should, when necessary,
be slit up at the part injured, or a bent probe forcibly passed under
it to the required extent, when any intervening muscular fibers should
be divided until the bleeding point is perceived, when a ligature
above and another below the wound should be placed upon the artery.

The external plantar artery, on reaching the metatarsal bone of the
little toe, runs forward, in nearly a straight line, between the middle
and outer divisions of the plantar fascia, the section of which will
expose it as far forward as the end of the metatarsal bone.

229. The anterior tibial artery is to be tied at that part of its
course at which it may be wounded. When the operation is done for
aneurism, it should be performed a short distance above the tumor,
and sometimes a second operation below it will become necessary. If
the aneurism should be situated so high up and so close to the origin
of the vessel as not to admit of a ligature being applied anterior to
the interosseous ligament, it may be placed on the femoral artery of
the thigh, and the result awaited. If it appeared likely to succeed at
first, and yet the pulsation returned, the artery should be tied below
the tumor, because the return of pulsation would probably depend on the
blood regurgitating into the vessel.

In order to tie the anterior tibial artery after it has passed from the
back to the fore part of the leg through the interosseous space, and
over the interosseous ligament, and for one-third of its descent toward
the instep, draw a line from the head of the fibula to the base of the
great toe, which will nearly describe its course. An incision four
inches in length is to be made in this line down to the fascia covering
the muscles; if the foot be bent upward, and again extended, the
bellies of the tibialis anticus and extensor digitorum communis muscles
will be more distinctly seen. The fascia is to be divided for the whole
length of the incision between them; they are then to be separated for
the same distance by the scalpel and the finger; the artery will be
found close on the interosseous ligament, between its two venæ comites.

A case has been supposed, in which a knife, a sword, or other narrow
instrument, having penetrated the upper part of the leg, has wounded
the anterior tibial artery just after it has been given off from the
posterior tibial, behind the interosseous space or ligament. The
bleeding is free, and from the wound in the front of the leg, although
the artery cannot be secured, from the narrowness of the space between
the tibia and fibula, behind which space it is situated. This very
peculiar injury, which may, however, occur at any time, cannot be
known until an incision has been made on the fore part of the leg, and
the bleeding point seen so deep between the bones as not to admit of
two ligatures being placed on the artery above and below it. In such
a case, an incision is to be made through the calf of the leg, when
the artery can be secured without difficulty. No great inconvenience,
it is apprehended, would result from the two operations. If the sword
wound should have been a small one, although deep, compression on its
surface would in all probability have been had recourse to in the first
instance; which, while it prevented the flow of blood externally, would
scarcely impede its effusion above the fascia and under the soleus
muscle, the distention of which and of the calf of the leg would, to a
careful observer, point out the evil, and lead to the operation being
done in the first instance through the calf of the leg.

In the middle third of the leg the origin of the extensor proprius
pollicis intervenes between the tibialis anticus and the extensor
communis digitorum muscles. The anterior tibial nerve, a branch of
the peroneal, attaches itself to the artery a little above this
middle part, and is usually found in front of it, although it is not
constantly in that situation: care should always be taken to avoid it.

In the lower part of the leg the artery lies on the tibia, having
the tendons of the extensor digitorum communis on the outside, and
that of the extensor proprius pollicis on the inside, by which it is
overlapped, being also covered by the fascia and the integuments.

On the instep this artery runs over the astragalus, the naviculare,
and the os cuneiforme internum, to the base of the metacarpal bone
supporting the great toe. It here divides into two branches: one
dips down between the first and second metatarsal bones, to join the
terminating branch of the external plantar artery, rendering the
collateral circulation free; the other passes on to the inside of the
great, and the opposite sides of the first and second toes. The artery
is always to be found on the fibular side of the tendon of the extensor
proprius pollicis.



LECTURE XV.

THE COMMON CAROTID ARTERY, ETC.


230. The carotid artery may be tied, in almost any part of its
course, in the following manner: The patient being seated, with the
shoulders supported, so that the light may fall on the neck, the head
is to be bent a little forward, to relax the muscles on the fore
part. An incision is then to be made on the line of the inner edge
of the sterno-cleido-mastoideus muscle, by which the integuments,
the platysma myoides, and the superficial cervical fascia are to be
divided. The extent of this incision, in persons with long necks,
may be from a line beginning parallel with the cricoid cartilage to
within about half an inch of the sternal end of the clavicle: when
the neck is very short, it must be begun as high up as the lower edge
of the thyroid cartilage, so as to be as nearly as possible three
inches in length. The sterno-cleido-mastoideus muscle is then to be
drawn outward, with any vein which may be seen attached to its under
edge. The pulsation of the artery under the finger will point out its
situation, and the sterno-hyoideus and sterno-thyroideus muscles being
drawn and kept inward, the omo-hyoideus will be seen crossing in the
upper part of the hollow thus formed by the separation of these parts.
The central tendinous portion of this muscle is attached and fixed
by the deep cervical fascia, and lies immediately over the sheath of
the vessels, particularly over the jugular vein. This fascia, which
is strong although thin, is to be carefully divided below the muscle,
immediately over the center of the artery, the position of which is to
be accurately ascertained by the finger. At or beneath the same spot,
the sheath of the artery is to be opened; and the long, thin nerve, the
descendens noni, which runs upon the sheath, will at this part be seen
inclining to the tracheal side of the artery. It is to be separated and
drawn inward with the muscles. If the sheath of the artery be carefully
opened immediately over its center, the jugular vein will scarcely
interfere with it. But as it has been known to enlarge suddenly under
the exertions or excitement of the patient so as to overlap the
artery, it has been recommended to make gentle pressure on the vessel
at the upper part of the incision, and below if necessary, in order to
prevent that occurrence. The aneurismal needle is then to be introduced
and passed under the artery from without inward, by which the jugular
vein and the par vagum nerve will be avoided, more particularly if the
sheath of the vessels has been undisturbed, save where it has been
opened immediately over the artery. The point of the aneurismal needle
is to be brought out close to the inside of the artery within its
sheath, by which means all danger will be avoided of injuring either
the recurrent or the sympathetic nerves which lie behind or to the
inside of it. As to the œsophagus, thoracic duct, or thyroid artery,
they are not likely to be injured by any common operator; but he should
be aware that on the left side, if he be obliged to operate low down,
he may meet with greater inconvenience from the jugular vein, which is
more anterior to the artery, and rather overlaps it, while on the right
side it inclines outward from it.

The carotid artery may be tied higher up in the following manner: The
incision in this instance should be begun a little below where the
former one was commenced, and should be continued upward for the same
length of three inches, in a line extending toward the angle of the
jaw. The head should be laid back to enable this to be done, and ought
to be kept in that position by an assistant. The artery at this part of
the neck is covered by the integuments, the platysma myoides muscle,
and the fascia. After the muscle has been divided, the strong fascia
must be carefully raised with the forceps and opened, and the operator
will do wisely if he divide it upward and downward on a director.
With the end of the scalpel or a blunt knife he should separate the
cellular tissue from the veins, which appear in this situation, and are
often the source of much embarrassment. The sheath of the artery is
to be opened over the center of the vessel, and the ligature is to be
passed around it as before. The descendens noni nerve runs in general
on the outside of the artery in this part of the neck, and afterward
crosses over to the tracheal side. The par vagum, which lies in the
angle formed posteriorly by the apposition of the carotid artery and
jugular vein, to which latter it is more particularly attached, is to
be avoided on introducing the aneurismal needle; and on bringing it
out on the inside, the same attention must be paid to prevent injury
to the great sympathetic or any of its branches. The surgeon in both
these operations should draw the ligature first a little outward and
then inward, so as to enable him to ascertain that he has included in
it nothing but the artery, which is to be tied with two knots; one
end may be cut off, or both may be twisted together, and brought out
of the wound opposite where the vessel has been tied. The integuments
should be accurately closed by adhesive plaster, and the patient put to
bed with the head bent forward, and properly supported. He should eat
as little solid food as possible until after the ligatures have come
away, and observe even greater precautions as to quietude than in other
instances.

231. The external carotid artery may be tied by an operation conducted
in a similar manner. After the first incisions have been made, and
the strong cervical fascia divided, the operator must feel for the
pulsating vessel, which will be found on a line parallel with the cornu
of the os hyoides, below which part the common trunk usually divides
into the external and internal carotids, the external being the more
superficial and internal of the two at their origin. The external
carotid turns with its convexity inward; nearly opposite to but rather
above the os hyoides it is crossed by the ninth or lingual nerve, the
digastric and stylo-hyoid muscles; it should be tied below this part.

When any of the branches of the external carotid has been wounded,
it ought to be tied by a similar operation at both ends, at the part
wounded. If the surgeon cannot do this, and the hemorrhage demand it,
the trunk of the external carotid is the vessel on which the ligature
should be placed, not that of the common carotid.

232. The internal carotid artery, when wounded near the bifurcation
of the common carotid, is to be secured by two ligatures, and the
steps in the operation are the same as those for exposing the external
carotid, the surgeon recollecting that the internal carotid is more
deeply seated and to the outside of the external. A ligature may be
placed on the internal or external carotid, close to the bifurcation,
with safety; but if the wound of either vessel should encroach on the
bifurcation, one ligature should be applied on the common trunk and
another above the part wounded; but as neither of these would control
the collateral circulation through the _uninjured_ vessel, whichever of
the two it might be, a third ligature should be placed on it above the
bifurcation.

When the internal carotid is wounded through the mouth, at the upper
part of the neck, it should be secured by the operation described on
page 248, Aph. 216.

233. The arteria innominata arises from the upper part of the arch of
the aorta, generally on a line nearly parallel with the upper edge of
the cartilage of the second rib, ascends obliquely toward the right
side, and usually divides opposite the sterno-clavicular articulation
into the right subclavian and the right carotid arteries; the last of
which appears to be its continuation, although the smaller in size.
The arteria innominata is about two inches in length, rarely exceeding
two inches and a half, although it is very variable both in length
and situation, so much so as sometimes to render the operation of
placing a ligature upon it during life impracticable. It is covered
by the right vena innominata, which receives the left at a right
angle, near the origin of the artery. Exterior to the vena innominata
are the sterno-thyroideus and sterno-hyoideus muscles, some strong
fascia covering the vein at its upper part, and the first bone of the
sternum. The arteria innominata may ascend higher in the neck before
it divides, in which case its pulsation will be perceptible in front
of the trachea, and the subclavian artery will cross higher in the
neck, which is one reason for not continuing the external incision down
to the sterno-clavicular articulation in the operation on the right
carotid. The subclavian artery, given off behind or a little above the
articulation, proceeds outwardly for the space of one inch before it
reaches the inner edge of the scalenus anticus muscle, which is about
half an inch in width; so that the subclavian artery, when it clears
the outer edge of the scalenus anticus muscle in a tall man, is not
more than one inch and a half or three-quarters from its origin, even
to the spot at which a ligature is usually placed upon it. The first
branch given off is the vertebral on the upper and back part of the
artery, distant half an inch from the carotid at the bifurcation. The
thyroid axis is given off at the anterior and upper part of the artery,
a quarter of an inch more outwardly, and the internal mammary often
arises directly opposite from the anterior and inferior part of the
artery, descending into the chest behind the junction of the first and
second ribs with their cartilages. The inner edge of the scalenus
anticus muscle is close to these two last vessels. The phrenic nerve,
crossing this muscle obliquely, lies on the outside of the thyroid
axis, and on the inside of the internal mammary artery; having crossed
the subclavian artery at this part, it descends between it and the
junction of the internal jugular and subclavian veins to the chest.
Internal to this, some small branches of the great sympathetic nerve,
which lies behind, pass over the artery; and still more internal, but
distant about a quarter of an inch from the carotid artery, the par
vagum crosses likewise. The only point at which the subclavian artery
can be tied internal to the edge of the scalenus anticus muscle is at
this point, on the inside of the par vagum, in a space scarcely more
than one-quarter of an inch in width, to which the carotid will be the
best guide. It would appear that a ligature may be as readily applied
around the innominata, immediately below the bifurcation, as around the
subclavian, although little or no reliance can be placed on success
attending either operation.

From this view of the parts it will be evident that the operation may
be done in the following manner: Raise the shoulders of the patient,
and allow the head to fall backward, by which the artery will be drawn
a little from within the chest. Let an incision be made over and down
to the sterno-cleido-mastoideus muscle, the sternal origin of which,
and nearly the whole of the clavicular origin, should be divided on
a director, carefully introduced below it, avoiding some small veins
which run below and parallel with its origin. An incision is now or
previously to be made, two inches in length, through the integuments,
along the inner edge of the muscle, which will admit of its being
raised and turned upward and outward. Some cellular texture being torn
through, the sterno-hyoideus muscle is brought into view, and should be
divided on a director. The sterno-thyroideus is then to be cut through
in a similar manner. A strong fascia and some cellular texture here
cover the artery, having the nerves above mentioned running beneath
it, the carotid being to the inside, the internal jugular vein to the
outside. By following the carotid downward, the finger will rest on
the innominata and on the origin of the subclavian, and a ligature
may be placed on either. If on the innominata, the aneurismal needle
(and several kinds should be at hand) should be passed from without
inward, immediately below the bifurcation, close to the vessel. If on
the subclavian, the surgeon must recollect that there is only about a
quarter of an inch of this artery on which the ligature can be applied;
this small space being bounded internally by the carotid artery, and
externally by the par vagum above, and the vertebral artery below. The
ligature should be applied close to the vertebral artery, the needle
being passed from below upward, the greatest care being taken to avoid
the recurrent nerve, which separates from the par vagum at this part,
and winds under the subclavian and carotid arteries, to be continued
upward to the larynx. If the ligature be placed on the arteria
innominata, the same care must be taken to draw the par vagum outward,
and to avoid the recurrent nerve. The edges of the wound should be
brought together and dressed in the usual manner, the head being bent
forward on the trunk, and maintained in that position, in order to
relax the parts, and admit of their being kept in apposition.

This operation ought only to be performed in cases of aneurism of the
subclavian artery, in which it is presumed that the disease extends as
far as the external edge of the scalenus anticus muscle, but not more
inwardly. The arteria innominata has certainly been tied five, if not
six times in vain, and in two or three other instances the attempt
failed, the operator not succeeding in his object. In Dr. Mott’s case
the ligature came away on the fourteenth day, but the patient died
from hemorrhage, in consequence of ulceration of the artery, on the
twenty-sixth day after the operation. Dr. Graëfe’s patient also died
from hemorrhage on the sixty-seventh day. It is evident, from these
cases, that a man may live so long after the operation as to show that
he does not die from its immediate effects, or from any that must
necessarily take place. It is therefore possible that if the operation
be often repeated it may eventually be successful.

234. The left subclavian artery rises perpendicularly out of the chest
like the innominata, but on a plane much posterior to it, so that at
the part where the vertebral artery is given off, which is about an
inch and a half from the origin of the artery, it lies nearly an inch
deeper from the surface than the vessel on the opposite side. It is
covered by, or is more directly connected with, the important parts
which are also in the vicinity of the right subclavian. The pleura
adheres to it, and can scarcely avoid being torn in putting a ligature
around it. The par vagum is parallel with and anterior to it. The
internal jugular vein and the left vena innominata lie over it. The
thoracic duct and œsophagus are connected with it; and the carotid
artery is in front. So that with the most careful dissection it is
not a very easy matter to place a ligature upon the ascending portion
of the left subclavian artery, without doing more mischief than is
compatible with the life of the patient.

Aneurisms of the arch of the aorta have been sometimes known to appear
so far beyond the outer edge of the scalenus anticus muscle as to
impress the surgeon with the idea that they arose from the subclavian
artery, and that an operation on that vessel might be attended with
success. This error is not likely, however, to occur in the present
day, for the stethoscope will always point out the existence of such
an aneurism within the chest, and will therefore demonstrate the
impropriety of the operation. Aneurisms of this nature are usually
attended by some circumstances indicating their more internal origin,
independently of the information derived from the stethoscope. An
operation should only be attempted when the case is free from doubt.

Whenever an aneurismal tumor in the neck is accompanied by any
alteration of the sterno-clavicular articulation, the case is clearly
one totally unfitted for any operation. The same may be said of any
case of aneurismal swelling, either internal or external to it, in
which the stethoscope applied on the sternum in the course of the
arteria innominata, or of the arch of the aorta, indicates disease. A
swelling at the root of the carotid is more likely to be an aneurism
of the arch of the aorta, or of the arteria innominata, than of the
carotid itself. The stethoscope will remove all doubt.

235. The subclavian artery has been frequently tied above the clavicle,
_external_ to the scalenus anticus muscle. It should be done in the
following manner: The patient being placed horizontally on the table,
in such a situation that the light may be directed into the hollow
in the bottom of which the artery is to be tied, the shoulder is to
be depressed, and an incision made along the edge of the clavicle,
commencing one inch nearer the sternum than the clavicular edge of the
sterno-cleido-mastoideus muscle, and carried outward to the extent
of three inches and a half or four inches. The platysma myoides
and the superficial fascia are to be divided, taking care not to
injure the external jugular vein, which should be drawn to the outer
side of the wound. By this incision the edges of the trapezius and
sterno-cleido-mastoideus muscles will be exposed.

The object of the operation is in the first instance to reach the outer
edge of the anterior scalenus muscle: this lies immediately below the
outer edge of the clavicular portion of the sterno-cleido-mastoideus,
and the division of a portion of this part of the muscle will greatly
facilitate the subsequent steps of the operation, although it may be
done without it. The artery will be found crossing over the first rib
at the very edge of the attachment of the scalenus anticus to it;
but a quantity of cellular substance and fascia intervenes, which
must be torn through before it can be exposed. This should be done
with a blunt, round-pointed knife, in a line parallel with the first
incision, but more immediately over the outer edge of the scalenus
muscle. The omo-hyoideus muscle passing obliquely across the root of
the neck will be in this manner exposed, which should be clearly done,
because it narrows the space in which the operation is to be performed
to a small triangle; the outside and apex of which is formed by this
muscle, the inside by the scalenus anticus, the base by the rib, above
it the subclavian vein, and above it again, but under the clavicle,
the supra-scapular artery and vein. The blunt knife, working in the
triangular space, will first expose one or more of the nerves of the
axillary plexus, which again diminishes the space; more inwardly the
scalenus anticus will be felt, and should be seen by tearing through
the thin fascia which lies behind the omo-hyoideus, and is connected
with it. The point of the finger, assisted if necessary by the blunt
knife, should be passed along the edge of the muscle until it rests
on the first rib, and at the angle formed between the muscle and the
rib the artery will be found and known by its pulsation. The operator
should detach the artery in a slight degree from its connections, with
the nail of the forefinger, and the aneurismal needle should be passed
in preference from below upward, by which the pleura will be avoided.
After the ligature has been passed under the artery, the vessel should
be pressed upon with the finger, while the ligature is firmly held in
the other hand, by which the circulation through the artery will be
stopped. The pulsation in the tumor and at the wrist should cease, when
the ligature may be tied with a double knot; for doing this, one or
two steel probes, having a ring at the end, placed at a right angle
with the shaft, will afford great assistance.

In some instances, particularly in short-necked persons, the
omo-hyoideus lies close to the clavicle, and requires to be drawn
upward and outward from it. In others, the lowest nerve of the axillary
plexus lies over the artery, and may be mistaken for it. When the veins
coming from the neck are large and numerous, great care should be
taken to avoid injuring them, as they frequently cause not only much
hemorrhage, but great delay. Great care must also be taken in all these
operations to prevent the ingress of air into any of the veins which
may by accident be opened, as its admission in quantity has occasioned
sudden death, although the entrance of a few bubbles may not be so
dangerous as has been supposed.

236. When the axillary artery is to be tied for a _wound_ caused by a
sharp-pointed or other instrument which has been forced through the
pectoral muscle or under it from the axilla, the patient is to be
firmly supported or placed in the horizontal position, the arm to be
slightly separated from the body, and an incision made in the course
of the axillary artery, through the integuments, superficial fascia,
and the great pectoral muscle--in fact, through the anterior fold of
the armpit. The length of the incision will depend on the part at
which the artery is to be secured. The parts divided being separated,
the pectoralis minor will be seen crossing to the coracoid process
at the upper part of the wound, and the artery may be felt below it,
inclosed in its cellular sheath, with the nerves of the arm and its
venæ comites. All other modes of attempting this operation are unworthy
consideration, and ought to be discarded as dangerous and insufficient.

At the lower edge of the pectoralis minor, the artery is crossed by the
outer of the venæ comites, which passes between the external cutaneous
and the external origin of the median nerve, at the spot where they
separate from the plexus. The artery may be tied below this separation,
or the nerves and vein may be drawn to the outside, and the artery tied
above the union of the external with the internal root of the median
nerve as high as the origin of the arteria thoracica acromialis, the
pectoralis minor being either raised and pushed upward, or divided if
necessary. The internal root of the median nerve is in connection with
the internal cutaneous and ulnar nerves; the larger of the venæ comites
is to the inside and behind, but as it ascends it receives its fellow,
and with the cephalic vein forms in front of the artery the subclavian
vein.

237. The brachial artery can be traced by its pulsation from the lower
edge of the teres major muscle to below the bend of the arm, where
it is covered by the pronator radii teres muscle. At first it is on
the ulnar side of the humerus, resting on the triceps, and slightly
overlapped by the coraco-brachialis and biceps muscles. In the middle
of the arm it rests on the tendon of the coraco-brachialis, is close
to the bone, and lies under the lower edge of the biceps; in which
situation it may always be compressed by bending the forearm, so
as to cause the belly of the biceps to enlarge, when pressure made
immediately below it will arrest the circulation in the brachial
artery. It then crosses toward the anterior part of the arm, and rests
on the brachialis anticus muscle until it passes the bend of the elbow.
It is accompanied by two veins, which are connected with it by a loose
cellular membrane forming a sheath. The external cutaneous and median
nerves lie a little to the outside of the artery in the upper third of
the arm. In the middle third the median nerve lies generally in front
of, but sometimes between the artery and the bone, and is on the inside
at the inferior part. The internal cutaneous nerve runs parallel with
but superficial to the artery, the ulnar nerve nearer but posterior
to it. When a ligature is to be placed on the brachial artery in the
upper part of its course, the incision should be made about three
inches in length, directly on the line of the pulsating vessel, by
which all mistakes will be avoided. The integuments should be divided
carefully, that the internal cutaneous nerve may not be injured; the
fascia is then to be cut through and the forearm bent, when the vessels
and nerves will be relaxed. The artery is to be separated from its
veins, one on each side; and it must be recollected that the external
cutaneous and median nerves are to the radial side of the artery,
the internal cutaneous and the ulnar nerves to the ulnar side of it.
In the middle of the arm the median nerve lies immediately over the
artery, except in those cases where it passes behind it; when it lies
in front it may be mistaken for the artery, from the pulsation being
communicated to it. The incision should be to the same extent of three
inches, directly in the course of the artery, and the ligature should
be passed from the ulnar to the radial side of the vessel, in order to
avoid the possibility of including either the internal cutaneous or the
ulnar nerve, and for the purpose of excluding both the veins.

238. The brachial artery, a little below the bend of the arm, divides
into the radial and ulnar arteries--the radial being the continuation
of the brachial in direction, the ulnar in size. The brachial artery,
at the bend of the arm, is cushioned on the brachialis internus muscle,
having the tendon of the biceps on the outside, the median nerve on its
inside, which is at first continued on the same side of the artery,
which now takes the name of ulnar. This vessel inclines toward the
ulna for about an inch, and then passes between the two origins of
the pronator radii teres muscle; the median nerve crosses it at this
part to get into the middle of the arm, and is then separated from it
by the ulnar origin of the muscle. The artery continues its course,
inclining outwardly, under the pronator radii teres, the flexor carpi
radialis, the palmaris longus, and the flexor sublimis muscles, lying
on the flexor profundus. On clearing the ulnar edge of the flexor
sublimis, it is covered by the flexor carpi ulnaris, the course of
the artery having been obliquely under these muscles to the extent of
two inches. To tie it in any part of this course, they must be more
or less divided, and the only difficulty or danger arises from the
median nerve, which lies deeper under the radial origin of the pronator
teres. But the whole of the muscular fibers may be divided, without
injuring the nerve, by successive and careful incisions through them
until the artery and nerve are exposed, and a ligature may then be
applied above and below the wound in the vessel. It may be supposed,
by way of elucidation, that a man has received a wound from a sword
through the flexor muscles, which injures also the ulnar artery, as may
be presumed from its situation and the continued and impetuous flow
of blood. It may be further supposed that this wound is in a slanting
direction from the ulna toward the radius. The surgeon, if he thinks he
can calculate the point at which the artery is injured, should cut down
upon it in the direction of the fibers of the intervening muscles, and
even through them until he reaches the artery; but if he has erred in
his calculation, he should introduce a probe into the wound, and, after
having ascertained the line it has taken, he should cut, if necessary,
across the muscular fibers in that direction until he exposes the
bleeding artery; if he be careful not to divide the median nerve, no
inconvenience will arise from the operation. (_Aph._ 184, page 192.)

239. If the ulnar artery be wounded near its origin, through the radial
side of the pronator teres muscle, an incision should be made through
the integuments and the aponeurosis of the biceps muscle; the pronator
muscle being then exposed, it is to be drawn inward and downward, or
toward the ulna, and the dissection continued until the median nerve
is brought into view. The probe introduced through the original wound
will lead to the artery, the pulsation of which will be felt and the
bleeding seen. Where the nerve crosses the artery, the vessel will be
found above or to the radial side of it, and to the ulnar side below.
It may be tied above without dividing a muscular fiber; but at the part
where the nerve crosses, and below it, some fibers of the pronator
teres must be divided, and in some cases the whole of them, before the
artery can be properly secured by two ligatures; but this division is
of little or no consequence, as the muscular fibers reunite without
difficulty.

240. To tie the ulnar artery in the _middle third_ of the arm, the
surgeon should bend the wrist, and trace upward the tendon of the
flexor carpi ulnaris as far as it can be felt. At the point where it
becomes indistinct, an incision should be commenced and carried upward
for the space of four inches; the fascia is then to be divided to the
same extent, when the flexor carpi ulnaris may readily be traced upward
by its tendon, which is on the radial side of it; this muscle may then
be easily separated from the flexor sublimis, beneath the edge of which
the artery will be found covered by the deep-seated fascia, having a
vein on each side, and the ulnar nerve to the ulnar side of it. By this
method of proceeding the artery will be readily exposed, which is not
always the case by any other manner of operating, and it may be tied as
high up as where it passes from under the flexors of the arm.

The ulnar artery may be easily tied near the wrist, where it is most
superficial. Bend the wrist, and make the flexor carpi ulnaris act,
when the tendon will be felt internal to the styloid process of the
ulna; make an incision two inches and a half in extent along the radial
edge of this tendon, dividing the fascia of the arm which covers it.
The artery will be felt below the deep-seated fascia, and, on dividing
it, will be seen with its venæ comites, the ulnar nerve being behind
it; that nerve must be avoided, in the application of a ligature.

241. The radial artery may be secured by ligature with great ease in
any part of its course to the wrist. At the upper third of the arm, the
radial artery is covered by the approximation of the supinator radii
longus and pronator radii teres muscles. To expose it at this part, a
line may be drawn from the middle of the bend of the arm to the thumb,
which will indicate its course; or the supinator radii longus being
put into action, an incision is to be made from the bend of the arm
obliquely outward along its ulnar edge to the extent of three inches,
avoiding the median vein, but dividing the integuments and the fascia.
The supinator muscle is then to be gently separated from the pronator
radii teres by the handle of the knife, and the artery will be felt
covered by the deep-seated fascia; on the division of which, it will be
seen with its venæ comites lying on some adipose membrane, and on some
branches of the musculo-spiral nerve, which separate it from the tendon
of the biceps, and are to be carefully avoided. The musculo-spiral
nerve itself lies nearer the radius, rendering it advisable to pass the
aneurismal needle from that side.

In the middle third of the forearm, the inner edge of the supinator
radii longus marks the line of the incision, which should be to the
extent of three inches. The fascia being divided, the supinator longus
is to be separated from the flexor carpi radialis, and, on the division
of the deep fascia, the artery will be found passing with its venæ
comites over the insertion of the pronator radii teres and the radial
origin of the flexor digitorum sublimis. The musculo-spiral nerve lies
close to the radial side of the artery.

Near the wrist, the radial artery may be tied with great facility.
Make an incision two inches and a half long on the radial side of the
tendon of the flexor carpi radialis, which becomes prominent on bending
the wrist; the superficial and deep fasciæ are to be divided, when the
artery and its veins will be exposed; the nerve has not accompanied the
artery to this point, where it lies on the pronator quadratus, whence
it turns below the styloid process of the radius to the back of the
hand.

The radial artery, on giving off the superficialis volæ to the palm
of the hand, near the end of the radius, inclines outward, and, when
between its styloid process and the trapezium, lies beneath the two
first extensors of the thumb. Passing onward to reach the angle formed
by the metacarpal bones of the thumb and forefinger, it lies first
in a triangular space between these two extensor muscles and the
third, in which situation a ligature may readily be placed upon it by
a simple incision. Proceeding onward, the artery passes _under_ the
third extensor and lies to the outside of it, where it may also be
secured by ligature without difficulty, just before it dips into the
palm and gives off the principal artery to the thumb. After the radial
artery has reached the inside of the hand, to form the deep-seated
palmar arch, it crosses the metacarpal bones nearly at a right angle,
covered by all the muscles, tendons, and nerves of the palm. A branch
of the ulnar nerve is here seen going to the muscles of the thumb.
If the graduated compression recommended in Aphorism 208, page 238,
together with due pressure on the radial and ulnar arteries at the
wrist, should fail to arrest the bleeding from a wound at this part,
the two muscles, forming what may be and is called the web, between the
thumb and forefinger should be divided until the wounded artery can be
seen. These muscles are the adductor pollicis on the inside, and the
adductor indicis on the back of the hand; and their division would lead
to little or no inconvenience. If a man, in opening an oyster, were to
divide these muscles by an accidental thrust of his knife, it would
not be considered a serious accident, although some surgeons might be
dismayed if desired to divide them surgically, to expose the artery at
the spot where it has been wounded.



LECTURE XVI.

INJURIES OF THE BRAIN.


242. Injuries of the head affecting the brain are difficult of
distinction, doubtful in their 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 frequently met
with in another. It may even be 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 presence of a most
serious injury the existence of which had not even been suspected;
and death has often ensued immediately, or shortly after the most
marked and alarming symptoms, without any adequate cause for the event
being discovered on dissection. One man shall lose a considerable
portion of his brain without its being productive at the moment of
the slightest apparent functional inconvenience; while 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. During the war with the
United States, in 1814, a soldier in Canada was struck by a ball which
lodged in the posterior part of the side of the head; the wound healed,
and the man returned to his duty. Twelve months afterward, having got
drunk, he fell in the streets of Montreal, and died. The ball was found
lying on the corpus callosum, where it had made a small hole or sac for
itself. After the battle of Waterloo, I recommended, in the case of a
soldier similarly wounded, that nothing should be done unless symptoms
arose demanding the use of the trephine; as none occurred, and the
wound healed, the man was sent home to Colchester, where he got drunk,
and fell dead in the marketplace. The ball was lodged deeply in a cyst
in the posterior lobe of the brain. Persons rarely live with a foreign
body lodged in the anterior lobe of the brain, although many recover
with the loss of a portion of the brain at that part. An injury of
apparently equal extent is more dangerous on the forehead than on the
side or middle of the head, and much less so on the back part than on
the side. A fracture of the vertex is of infinitely less importance
than one at the base of the cranium, which, although not necessarily
fatal, is always attended with the utmost danger. The treatment of
these several injuries (although they may be at first sight apparently
similar) cannot, and must not be alike in all--a fact which should
always be borne in mind in their management. In civil life, both in
hospitals and among private persons, injuries of the base of the
cranium are most frequently met with, because they are generally the
consequence of falls; while in military life injuries of the base of
the skull are rare, and those of other parts are common. The practice
of the military surgeon, with respect to injuries of the cranium and
its contents, is therefore more successful, all things considered,
than that of the surgeon in civil life, and particularly in a great
metropolis; this may perhaps account for some of the discrepancies in
opinion which have existed between them.

243. Many physiologists have thought they could indicate the part of
the brain injured from the symptoms which followed, and there are
some which do not admit of dispute as to their cause; but there are
very many which at present do not admit of being distinctly traced
to their source. Birds, small quadrupeds, fishes, and reptiles will
live for some weeks after nearly all the contents of the skull have
been removed. Sensation, volition, memory, judgment, sight, hearing,
and all other sensations are lost by the removal of the cerebral
hemispheres. The mobility of the iris is destroyed, not by the removal
of the hemispheres, but of the corpora quadrigemina. If the cerebellum
be cut away, a bird can no longer jump, walk, or retain its natural
position, but it can move and live. When the medulla oblongata, or
medulla spinalis, or the nerves of these parts, have been divided,
muscular contraction ceases, and all power of movement is lost. Life
is destroyed because respiration ceases when the medulla oblongata
is divided at or immediately below the origin of the eighth pair of
nerves. The removal of any one of these nervous parts in the lower
animals only weakens the powers of those which remain. In man it
destroys them, and life is extinguished.

244. Respiration consists of four movements--1, the opening of the
mouth and dilatation of the nostrils; 2, the opening of the glottis;
3, the elevation of the ribs; 4, the contraction of the diaphragm. The
division of the dorsal spinal marrow, below the origin of the phrenic
nerve, paralyzes the movement of the ribs; above the phrenic nerves it
paralyzes the diaphragm, and respiration ceases; the yawning or opening
of the mouth and glottis alone remain. On dividing the point of origin
of the par vagum, the movements of the glottis cease. On slicing the
upper part of the medulla oblongata instead of the lower, from before
backward, the opening or yawning of the mouth ceases; another slice,
and the dilatations of the nose are arrested, and the inspiratory
movements of the trunk alone remain.

While the power of motion in each part seems thus to be dependent on
isolated points of the medulla oblongata and the medulla spinalis, an
indirect or connecting influence is admitted to take place between them
and the remaining parts of the brain; and whatever may be its nature
or extent in animals, there can be no doubt of its being so infinitely
greater in man as to be essentially different; for none of these
experiments can be made either artificially or accidentally on any one
of these parts in him, without being productive of the ultimate if not
almost immediate death of the whole.

Dr. Marshall Hall, in the comprehensive and luminous view he has taken
of the nervous system, supposes that each sentient and motor nerve
of the spinal marrow is further endowed with an excito-motor power
for reflex action. He calls these generally excito-motor nerves, and
considers them to be connected with a part of the medulla spinalis,
distinct from that portion which is strictly an appendage to the brain.
_Incident_ nerves arise from the skin and certain mucous membranes,
and convey impressions from them to the spinal marrow. _Reflex_ nerves
convey back the nervous influence excited through the medium of the
incident nerves, to the voluntary muscles in which they terminate;
and Dr. Marshall Hall further considers that these nerves, and the
part he calls the true spinal cord, constitute the true spinal system
which presides over ingestion and exclusion, retention and egestion;
and consequently that its influence is exerted upon the muscles which
belong to the entrances and outlets of the animal frame; or, in other
words, upon the sphincters, and the muscles of deglutition and of
respiration; and that the true spinal system maintains the tone of the
whole muscular system. Stimulating an incident or excitor nerve of the
extremities, by tickling or pricking the sole of the foot or the palm
of the hand after sensation is apparently destroyed, causes a special
muscular contraction or motion in the limb, if the excito-motor system
be uninjured. Irritating the eyelashes induces contraction of the
eyelids; and the irritation of one will sometimes cause contraction
of both. Tickling the verge of the anus induces contraction of the
sphincter muscle. Irritating the fauces and the root of the tongue,
by pressing it down with the handle of a spoon, induces an action of
deglutition. Respiration is excited by irritating or exciting the
trifacial or fifth pair of nerves, by throwing cold water on the face,
and stimulating the nostrils; by influencing the spinal nerves by a
similar use of cold water to the body and chest, and by tickling or
stimulating the sides, soles of the feet, and verge of the anus.

The great object or value of these and other facts and physiological
experiments is to enable us to conclude, as far as possible, what part,
what great division of the brain or spinal marrow is most seriously
injured, more particularly with respect to the prognosis than to the
treatment. Great severity and persistence of the symptoms lead to the
belief that the part of the brain or spinal marrow on which they depend
is directly injured rather than indirectly affected, and that the
result is more likely to be fatal. Permanent insensibility and loss of
motion may depend on cerebral mischief only. The loss of the mobility
of the iris implies an affection of the tubercula quadrigemina.
Convulsions, vomiting, a drawing up of the limb not affected by
paralysis, stertor, a difficulty in swallowing, strabismus, and relaxed
sphincters, show derangement of the spinal functions; which is well
marked when tickling the eyelashes does not cause closing of the lid,
of the verge of the anus no contraction of the sphincter, of the sole
of the foot no motion of the toes.

245. In order to simplify the investigation of Injuries of the Head,
they have been divided into two great classes: one denominated Injuries
from Concussion; the other, Injuries from Compression or Irritation of
the Brain. By the term Concussion of the Brain, a certain indefinable
something, or cause of evil which cannot be demonstrated, is understood
to have taken place; the effect of which is often clearly proved by
the almost instantaneous death of the individual, or by a succession
of symptoms which quickly lead to his destruction. The term concussion
is very aptly and forcibly illustrated by the homely but striking
expression in use in the sister country, when a man has been suddenly
killed by a fall on the head, “that the life has been shook out of
him.” On a dissection of the brain in a pure case of this kind, no
trace of injury or even of derangement of any part of it can be
perceived. Life is extinct, but the brain is intact. The immaterial
has been separated from the material part, by an injury apparently
inflicted on the very seat of life, with as little apparent derangement
of its structure as if death had occurred in a secondary manner from
the abstraction of blood by a rupture of the heart.

Modern surgery has in fact added nothing to our information on the
subject, perhaps from the peculiar difficulties of the case, which may
not admit of removal in the present state of our knowledge; although
all writers seem to coincide in opinion that a sudden stoppage of the
circulation of the blood is the more immediate cause of death. That the
positive shock communicated to the brain from one side to the other,
and the repercussion which follows from its resiliency, are capable of
giving rise to a direct and visible injury, is indisputable. It usually
forms on what may be termed the edges of the hemispheres, which appear
to be discolored, bruised, and sometimes torn, so as to have caused
the term laceration to be given to this kind of injury. This mischief,
however, is most commonly found in the examination of those persons
who have survived the accident for some days, and is therefore only a
predisposing cause of death.

246. When an injury is not immediately fatal, and life, although for
a time in imminent danger, is not destroyed, yet fluctuates on the
verge of destruction, gradually to be restored, again to fail, and at
the end of several days to be eventually extinguished, the changes
which take place in the functions of the brain during this period are
accompanied by alterations which are observable in its appearance. The
assemblage of phenomena which have taken place constitute inflammation;
and it is only by that vigorous treatment which subdues inflammatory
action that a person in whom they have occurred can be preserved. The
immaterial part of man is so intimately connected with his material
part that they cannot be suddenly separated without the material part
receiving an irrecoverable though often an imperceptible detriment;
the bonds which unite them cannot be temporarily loosened without a
derangement taking place, which appears to require for its recovery
the aid of some of those processes of nature which are known to occur
in the restoration to health of other parts of the body. A moderate
shock is often immediately followed by sickness, faintness, weakness,
and in a few hours by a slight headache, from which the person quickly
recovers without further inconvenience; or the headache may remain
for several days the sole symptom or sign of an injury having been
sustained; the slightest possible approach to that action which we
call inflammation having sufficed to effect a cure. One step further,
the headache continues, the stomach sympathizes, there is little or
no desire for food, the whole person feels more or less deranged, and
the pulse quickens. A smart purgative will perhaps relieve all these
manifestations of approaching evil, but the loss of a little blood will
be more certainly efficacious.

A child ten years of age fell over the banisters into the passage, and
struck its forehead. It was taken up apparently lifeless, but it soon
appeared that it was only stunned; it breathed deeply, looked about
vacantly, and could not speak; it then vomited, and gradually recovered
its speech and senses. A brisk purgative was all that was required to
remove the slight headache which followed on the subsequent day.

In more dangerous cases which ultimately prove fatal, the laceration
of the brain alluded to complicates the mischief as well as the
symptoms, and is perhaps the actual cause of death. It has, however,
been demonstrated that a slighter injury of the kind, giving rise
to long-continued symptoms, need not necessarily be fatal; in which
case it is supposed that the cure is effected by adhesion, and not by
granulation accompanied by the secretion of purulent matter.

247. When a concussion of the brain has rendered the sufferer
insensible and motionless, the countenance is deadly pale, (the
reverse of what takes place in sanguineous apoplexy;) the pulse is
not discoverable: the man does not appear to breathe. It is useless
to open his veins, for they cannot bleed until he begins to recover;
and then the loss of blood would probably kill him. It is as improper
to put strong drinks into his mouth, for he cannot swallow; and if he
should be so far recovered as to make the attempt, they might possibly
enter the larynx and destroy him. If he should appear to breathe, and
be made to inhale very strong stimulating salts, it will probably
give rise to inflammation of the inside of his nose and throat, to
his subsequent great distress. Mild stimulants and disagreeably
smelling substances held to the nose, together with partial as well
as general friction with the warm hands, are the best means to be
adopted, and should be continued until it be ascertained that life is
extinct. If the patient should recover, some signs of breathing will
be discoverable, followed by a distinct inspiration, repeated at so
distant an interval as to render its recurrence uncertain. At last
respiration is satisfactorily established, and the pulse, which was
doubtful at the commencement of the restoration to existence, becomes
perceptible, although often irregular, and sometimes continues so until
reaction has taken place. With this partial recovery of the natural
functions of the body, vomiting is apt to supervene, and is one of
the earliest and most satisfactory symptoms of returning sensibility.
It was formerly supposed to be peculiar to cases of concussion, but
it is often present in cases evidently of compression or irritation
from external violence. The breathing becomes in general quite free;
and although it is occasionally labored, it is rarely stertorous, a
symptom which may be considered, when permanent, as a more distinct
sign of continued irritation, or of compression and of extravasation,
than of concussion. The sensibility of the surface, however, is not
fully re-established, the patient is not cognizant of any injury
committed upon him, and if he should recover, has no recollection of
what has passed. This first stage does not last long, and with the
partial re-establishment of the functions of the lungs and of the
heart, and of the circulation of the blood through the brain, although
irregularly or insufficiently performed, the second stage may be
supposed to begin. The patient is still in a state of stupefaction,
although now perhaps sensible to personal maltreatment; and in this
condition he may remain for many days; he draws away or moves the part
aggrieved; he may be able to answer in a monosyllable correctly or
otherwise to questions loudly put, as if to rouse him from slumber;
but if the answer should be longer, it will generally be incoherent.
The pupils are for the most part in a medium or in a contracted state,
but rarely dilated. Stimulants were formerly given at and up to this
point, with a view of reviving and restoring the patient to greater
activity, and to prevent a relapse into his former state. Dissection
has, however, proved that it is a state in which congestion is about
to be followed by inflammation of the brain or of its membranes; that
the stage succeeding to this is one of active inflammation, even if the
patient should eventually recover; and if he relapse into that state of
stupefactive insensibility which precedes death, sufficient evidence to
account for his decease may be found in the laceration of the substance
of the brain, in small extravasations in various parts, or in other
mischief which may not perhaps be expected. Previously to this stage
of fatal termination, the muscles are not relaxed, and do not lose
their tone, as in a similarly fatal case of compression of the brain;
the urine does not flow involuntarily until after the spinal marrow
has been some time seriously implicated, and death is at hand. This
renders it necessary, in all cases of injury of the head, to attend to
the state of the bladder, which may become distended, and render the
use of the catheter necessary. The urine will be acid as long as the
catheter is required, and will become alkaline as soon as it dribbles
away involuntarily. The bowels will at an early period be confined,
and more powerful doses of aperient medicines will be required than
are needed under more ordinary circumstances, although the sphincter
ani may be relaxed, and the power of retention be lost from the
first, provided the injury has been very severe. When the feces pass
involuntarily, it is presumed that the cerebro-spinal axis is seriously
affected, and that the excito-motory system is greatly impaired, if
not wholly destroyed. When a person is insensible, it is not always
easy or convenient to ascertain whether the feces pass involuntarily
from loss of power of the sphincter ani, or are discharged from the
ordinary action of the bowels, of which the patient cannot give
notice. It may be inferred when the urine flows in a stream, although
apparently in an involuntary manner, that the power of the detrusor
muscle of the bladder is only impaired. In general, certain efforts are
made to evacuate the bowels, although the person may be upon the whole
unconscious of the act, showing that the defect is not essentially in
the sphincter ani, but in the want of consciousness in the brain.

Vomiting should not be solicited, as it may do harm when in excess,
but when slight, it has appeared to be beneficial. The more simple
the treatment during this the period of commencing reaction, the
more likely is it to be ultimately successful. The period at which
insensibility ceases, and the re-establishment of the natural functions
of respiration and of the circulation begins, must always be uncertain.

248. The termination of the first and the commencement of the second
or really inflammatory stage, or that tending to recovery, is marked
on dissection by the vessels of the brain and of its membranes being
full of blood, and showing those appearances which are indicative
of inflammation. If the patient is to recover, the stupefaction, or
_assoupissement_, continues, although a greater degree of sensibility
prevails; the pulse becomes regular, if it were not so before; the
skin is hotter than natural; the patient can often be induced to show
his tongue, which is white, and to answer shortly, and tell where he
feels pain, although he often answers incorrectly; he can sometimes
put out his hand and help himself, and occasionally even get out of
bed. He usually turns to avoid the light, and the pupils are for the
most part contracted; but no reliance can be placed on the state of the
pupils at this period of the complaint; both are sometimes dilated,
or one is dilated and the other contracted--sometimes dilating on
the admission of light, sometimes contracting; or they may not be in
the least changed until shortly before death. An alteration from the
ordinary state of the pupils does not prove the absence or presence
of any serious general injury, but only that a particular part of the
brain has been more or less affected. The breathing at this period is
free, and not in the least noisy or stertorous, unless the concussion
be complicated with irritation occurring from lesion of the brain or
its membranes, or of the medulla oblongata. The patient may remain in
this state without any sensible alteration for several days, or he may,
as is more commonly the case when restoration to health is to follow,
recover his speech as well as his general sensibility; nevertheless he
frequently speaks more or less incoherently, mutters to himself as if
thinking of something, and wanders at night, becoming even delirious,
and requiring restraint to keep him in bed. Inflammation of the brain
is now fully established and must be subdued. It is at or about this
period that other symptoms occur, which are frequently enumerated as
those indicative of concussion--it should be added, of concussion in
its latter stage. The pulse becomes quicker, perhaps full or hard,
varying from 84 to 90, and even to 100. In such cases, an augmented
pulsation of the carotids may often be observed, and is considered by
some to be confirmative of the fact of concussion, although it is by
no means a sign to be entirely depended upon. Such a person will not
be comatose, but watchful, sleeps little or none, talks incoherently,
or is often really delirious, refuses food if offered, drinks with
avidity, has a hot skin, and a white tongue. If other symptoms occur,
such as spasms or convulsions, the absolute loss of any sense, or
paralysis of any or the whole of a part, the case is complicated by
laceration of the brain, compression, or other causes of mischief,
from the effects of which, if he cannot be relieved by blood-letting,
he gradually sinks into a state of coma, and dies.

The deviations which take place from the usual and ordinary modes
of breathing are supposed to offer distinctive signs of the nature
of the injury which has taken place, but they are uncertain; they
mark the degree of injury, and perhaps the part injured, rather than
anything else. Stertorous breathing has always been considered a
sign of extravasation causing compression of the brain. Many cases,
however, have occurred of slight extravasation with partial loss of
power of one-half the body, accompanied by great numbness, without any
stertor in breathing; but a well-marked case of large extravasation has
rarely or never been observed without it, or another peculiarity of
breathing which is less thought of, although an equally characteristic
and dangerous sign of such mischief having taken place when it is
permanent; this is a peculiar whiff or puff from the corner of the
mouth, as if the patient were smoking. This, when observed among other
urgent symptoms, is usually followed by death. Stertorous breathing and
the whiff or puff at the corner of the mouth are presumed to indicate
an injury to the cerebro-spinal axis as well as to the cerebrum; but
whether the injury be direct or indirect is uncertain, although it
is frequently accompanied by extravasation or laceration. When the
breathing is only oppressed or labored or heavy, neither extravasation
nor lesion to any extent can in general be discovered after death.
The surgeon will then practically be right in considering the stertor
or whiff in breathing to be accompanied by, if not directly dependent
on, extravasation or lesion; and the heavy or labored breathing to
be dependent generally on a derangement of function, which is not
perceptible on examination. If there be truth in experimental anatomy,
stertorous breathing ought to be dependent on a direct affection of the
medulla oblongata; nevertheless there can be no doubt that a temporary
stertor or a puff at the corner of the mouth may exist without it, as a
consequence of too great an abstraction of blood.

An officer, exercising his regiment under a hot sun in Portugal,
suddenly fell back on his horse, and was carried home insensible and
breathing stertorously; from this state he soon recovered, feeling weak
in his lower limbs and incapable of influencing the sphincter ani,
which was soon followed by incontinence of urine. His intellectual
faculties were never affected after the first insensibility; and on
the third day he rode on a mule, with care, twenty miles to Lisbon.
Many months elapsed before he recovered the necessary command over the
sphincter ani. Years have elapsed, and he cannot now always retain
his urine. In this case the spinal marrow would seem to have been
principally affected.

It is important to recollect that the stupefaction or insensibility
of concussion is coeval with the injury, and that as few cases of
compression of the brain occur without some degree of concussion, the
insensibility may in many instances depend on it. The stupefaction
peculiar to compression, demanding relief by blood-letting or by
operation, is that which comes on some two or more hours after the
accident, and is caused by congestion or by extravasation; it must
also be distinguished from that which appears after several days, and
is the consequence of inflammatory action and effusion. The pulse has
been supposed to offer a diagnostic sign of the nature of the mischief
which has taken place in the brain; pressure or extravasation, it is
said, being attended by a slow and labored action of the heart. This
may be admitted as a general, but by no means as a certain rule, for
many of the largest extravasations, and many of the most diffused,
have been accompanied throughout by a very quick pulse. When the
physiological doctrines of the circulation are duly considered, as
well as the experiments on which they are founded, it will be evident
that the action of the heart may be influenced by other causes than
those occurring from the part of the brain apparently injured. Pressure
made purposely on the brain or dura mater in man during life is always
followed, when carried to too great an extent, by a diminution in the
frequency of the pulse, and even by syncope.

When the stage of depression is slowly passing into that of excitement,
and inflammation is about to be set up, bleeding may be had recourse
to; but what quantity of blood, if any, should be taken away, is often
doubtful. The loss of six, eight, or even of ten ounces can do no
harm, if it do no good, and it may enable the surgeon to form a more
accurate judgment of the state or degree of the complaint than he could
otherwise have done.

A laboring man, thirty years of age, fell from a height of fifteen
feet, on the back of his head, a small puffy tumor being perceivable
near the junction of the right parietal with the occipital bone. He was
insensible and motionless; countenance deadly pale; circulation weak
in the arms, but more marked in the carotids; respiration heavy and
slow; pupils much dilated and fixed; no relaxation of the sphincters.
Hot-water bottles were applied to the feet, and friction to the body
generally. In the afternoon he became warmer; some reaction seemed
to be taking place, accompanied by slight twitchings of the face,
and shiverings. At four o’clock he was bled to sixteen ounces, in
consequence of the pulse having become fuller, although soft and 96 in
the minute. The surface was warm and moist, and he was so far sensible
as to complain, on being pressed for an answer, of pain at the part
of the head injured. The bleeding was discontinued, in consequence of
its bringing on _convulsive_ movements ending in syncope; the pupils
contracted, the countenance became deadly white, and he breathed on
the right side of his mouth for a few minutes, with the whiff or puff
so peculiar in cases of compression of the brain. On recovering from
his swoon, the pulse became regular and 85 in number, the skin warm
and moist, and the pupils more sensible to their proper stimulus. The
bladder, which had been a little distended, acted voluntarily. The next
day he was perfectly collected, and complained only of a little pain
in the head. Pulse 84; was quiet and slept during a part of the night.
The bowels acted under the influence of the calomel and colocynth given
the evening before, and of a senna draught in the morning. He quickly
recovered, without any further bad symptoms.

The effects of a large abstraction of blood at too early a period are
well shown in this case, especially by the convulsions and by the
peculiar kind of breathing.

249. When the period of excitement or of inflammation has begun,
and the patient, although disposed to coma, is still irrational and
impatient when roused, he is not to be left to await the effects of a
blistering plaster or of a dose of physic, as has been recommended in
such cases, but ought to be bled sitting up in bed to whatever extent
may be necessary to relieve the symptoms, or at least to cause a near
approach to fainting, for nothing less can relieve such a person
effectually, and give him a fair chance for life. The bleeding must
be steadily repeated as the symptoms recur until relief has been
obtained, or until it becomes evident that the powers of the patient
cannot resist the inroads of the disease and of the efforts made for
its cure. The quantity of blood that may be lost in two or three days
by powerful, healthy men is sometimes enormous, amounting to 100, 150,
and even 200 ounces, with the happiest effect. The following case,
which was one of inflammation tending to effusion, will show the extent
to which it ought to be carried in an elderly person of a different
habit of body:--

A gentleman, sixty-seven years of age, had suffered for three weeks
from occasional attacks of gout in his right foot, which he had himself
treated by simple means, taking the pulvis ipecacuanhæ compositus at
night to relieve pain. Once or twice his family had observed that his
head was, for a short time, not so clear as usual; but no suspicion
of further evil was entertained until he awoke one morning, evidently
talking incoherently. As the gout had nearly disappeared from his feet,
sinapisms were applied to both; purgatives and diaphoretics were freely
administered, and he appeared to be relieved. On the third morning he
became more loquacious and forgetful, was occasionally incoherent, and
complained of a certain loss of power, and of numbness in the right
side. Pulse 84, full and regular; tongue white; some confusion of ideas
was evident, with slight headache. He was cupped at ten in the morning
to ten ounces, without advantage; as all the symptoms appeared to be
increasing, at four in the afternoon sixteen ounces of blood were taken
from the arm, which produced a marked effect for some time. At ten at
night, the symptoms having returned, and the blood drawn being very
much cupped and buffed, twelve ounces more were taken from the arm,
when the pulse quickened and began to intermit; he appeared to be about
to faint, and the object seemed to be attained. Calomel and opium were
then given every four hours, until the mouth became affected; but the
essential symptoms were already subdued, and the patient recovered,
with a slight sensation of numbness and loss of power of the right side
of the body and head.

The necessary effect was in this case produced by the loss of forty
ounces of blood. In a younger and more vigorous man it might have
required three or four times as much to have been taken away by
repeated bleedings, before the object could have been attained; of
this the following case is a good instance:--

Mr. B., having jumped out of a carriage, the horses of which were
running away at full gallop, fell on his face, and was found insensible
and motionless. Some cold water having been poured upon him, he
gradually recovered, and afterward ate a hearty dinner, drank a
bottle of port wine, and walked home, a distance of three miles. He
thought himself quite well the next morning, and went to bathe; but on
returning about noon he felt uneasy, lay down on a sofa, began to talk
incoherently, and was soon quite delirious. At one o’clock he was bled,
but the symptoms of inflammation were not completely subdued until he
had lost eighty-four ounces of blood, the last quantity being taken
away at eleven at night. The vigorous treatment adopted in this case
during the first ten hours in all probability saved the life of the
patient.

250. It sometimes happens that congestion precedes inflammation to such
an extent as to give rise to stupefaction and symptoms of compression.

A Portuguese soldier of General Harvey’s brigade of the fourth division
of infantry was struck by a musket-ball at the first siege of Badajos,
on the top and toward the back part of the head; it divided the soft
parts, and grazed the bone without fracturing it. He walked from the
trenches to the rear, and said he was not much hurt. About five or
six hours afterward, he was found apparently asleep, and could not be
awakened, on which I was asked to see him. Finding the pulse at 60,
regular and full, although compressible, I directed him to be raised
and blooded until he fainted. When he had lost some twenty ounces of
blood, he opened his eyes, recovered his senses, and knew those about
him. The next day he went to the rear, free from all symptoms, and
rejoined some time afterward, in apparent good health, although he
complained more than was usual to him of the heat of the sun.

In some less important cases of injury, one bleeding will answer the
purpose; cupping and leeches may also be resorted to with advantage;
but in all very severe ones general blood-letting is the only
trustworthy source of relief. It should always be done with effect,
the finger examining the opposite pulse, and regulating the amount to
be taken away. At an early period of concussion, the quantity drawn
should not be large; it should increase with the urgency for its
abstraction, and diminish with the frequency of the repetition, being
always, however, carefully regulated by the effect. The inability of
blood-letting to overcome the disease will be shown by the increase
in frequency of the pulse, its diminution in power under slight
compression, its greater softness, together with the persistence of the
other symptoms.

It is in these cases that repeated small bleedings, to the amount of
six or eight ounces, ought to be resorted to, when it is doubtful
whether the loss of blood can or cannot be borne; they may then be
considered not as curative, but as explorative measures, although they
sometimes prove very effective; and when not properly regulated, the
reverse.

In all these, and in other more desperate cases, the effect of mercury,
provided it has been early and rapidly administered, may yet be
decisive. Calomel, combined with another and not less important remedy,
opium, ought to be given every two or three hours until the effects of
both are fairly induced.

Blisters should never be applied to the head until after the leading
symptoms of inflammation have been overcome; they will do more good
at a later period, applied between the shoulders or on the nape of
the neck. They should be dressed with mercurial and savine, or other
stimulating ointment.

The hair should be cut close in ordinary cases, or shaved off in the
more serious ones. The head should be raised in bed, and kept wet with
a cold evaporating lotion, or one composed of two ounces of the nitrate
of potash, one of the muriate of ammonia, one pint of vinegar, and
five of water, made in small quantities at a time, as may be required;
or with a small quantity of pounded ice and water in a large bladder.
Perfect quietude, cold drinks, at pleasure, and nearly absolute
starvation should be enforced.

The different points of practice which have been noticed are well
illustrated by the following case, in which the symptoms of concussion
were complicated by those which are commonly observed in compression of
the brain:--

An old man, when cleaning windows, fell from some steps on his
forehead, which he slightly cut and bruised, the left temporal
artery being divided by another small cut: it bled profusely until
the hemorrhage was arrested by a surgeon. He remained in a state of
insensibility for nearly two hours, when he rallied, and answered
questions, although imperfectly. Pulse quicker than natural,
and intermittent. He shortly afterward relapsed into a state of
insensibility, with convulsions, stertorous breathing, puffing at the
corner of the mouth, and complete loss of voluntary motion: the pulse
could scarcely be felt. This convulsive fit lasted about ten minutes,
when his respiration became natural, and his pulse was restored. The
insensibility continued for an hour, when it was attempted to bleed
him, but the pulse fell immediately, and it was not persisted in.
He soon, however, became quite sensible, sat up in bed, and vomited
some blood. In the afternoon he had another and slighter fit, from
which he quickly recovered. On the third day he was free from all
bad symptoms, and said, when asked, that he had only a very slight
headache. The pulse occasionally intermitted. On the fourth he declared
he was starved, became snappish and irritable, complained of pain in
the head, and had a quick and irregular pulse. On the fifth he got up
and dressed himself, had another slight convulsive fit, and fell into
a state of stupefaction, for which bleeding gave little relief; and
in the evening he died. From the first period of his improving until
his death, sensation and motion remained. On examination, a starred
fracture without depression was found corresponding to the wound on
the forehead, continuing to the base of the frontal bone, across
the ethmoid, over the body of the sphenoid bone, breaking off the
posterior clinoid processes, and extending to the basilar process of
the occipital bone, but not quite to the foramen magnum. The anterior
lobe of the right hemisphere of the cerebrum was lacerated to the
extent of an inch; that part was surrounded by the usual appearances
of inflammation. Some blood was extravasated on the tentorium, beneath
the posterior lobe of the brain, and lymph was effused over the whole
of its surface, between the arachnoid membrane and the pia mater. The
trephine, if resorted to, would have only added to the mischief.

Inebriation from spirituous liquors may complicate a case at its
earliest period, from the stupefaction it occasions; but the odor of
the spirits is usually demonstrative of the fact, and the stomach-pump
in such cases is an admirable remedy.

251. Mania sometimes supervenes on concussion, as the inflammatory
symptoms subside. It is best treated by the different preparations of
opium.

George Grey, aged forty-five, a stout man, fell from an omnibus,
Nov. 1, 1839, and received a blow on the right parietal bone, a
little behind the coronal suture. He lies on his back in a state of
stupefaction, although sensible when pinched, but is restless, and
suffers from convulsive motions of the mouth and limbs; pupils fixed,
the right being more dilated than the left; pulse 120; heat of skin
natural; respiration deep and rapid, without stertor; the sphincters
not relaxed. A turpentine enema was given, and a calomel pill was
swallowed with great difficulty. The head was shaved, and a cold lotion
applied; he soon afterward became violent, and required the restraint
of a tight jacket. The pulse fell in the afternoon to 84.

Nov. 2d.--Passed a restless night without sleep, and has a wild
appearance: pulse 96, and regular. At twelve o’clock became sensible,
and gave a confused account of the accident. Was freely purged, and
a quarter of a grain of the acetate of morphia was given every four
hours: the first at seven, the second at eleven, and the third at three
in the morning.

3d.--Has passed a quiet night, but with little sleep; the morphia has
had a soothing effect; talks rationally, although a little confusedly,
and recognized his mother, who says he received a violent blow on the
head three years ago, which has rendered him mad ever since whenever he
drinks too much. Pulse 72; bowels open, and is free from restraint. At
seven in the evening, he suddenly started up in bed, saying some one
was going to murder him. Half a grain of the acetate of morphia quieted
him; it was repeated at half-past twelve and at half-past four, and
kept him quiet, although he did not sleep.

4th.--He was collected, quiet, and free from restraint; pulse 96,
rather full; secretions natural. The morphia was continued in adequate
doses for a few days, and he gradually recovered.

252. Concussion induces affections of the brain and of its membranes
of an equally serious nature, at a more distant period of time, when
the stage of stupefaction and insensibility is wanting; it is to guard
against such an occurrence that persons who suffer from falls or severe
blows on the head usually lose blood. A gentleman was thrown from
his gig near Hounslow, and received a very severe shock and several
bruises, without feeling much hurt, or being aware that his head had
actually touched the ground. He came up to town, went to bed, and got
up next morning suffering only from a slight headache, and stiff from
his bruises, of which, however, he thought nothing. On the second
day I saw him in consequence of headache, throbbing in the temples,
sickness, and general malaise or discomfort. Being a stout young man,
thirty ounces of blood were taken from the arm in a sitting posture,
until he nearly fainted, after which he was relieved. In the evening,
the symptoms having all returned, pulse 88, and full, he was bled in
the erect position until he fainted, forty ounces being taken away. The
blood of the morning was buffed and cupped, and the bowels had acted
freely. On the morning of the third day the pulse, which had become
fuller, yielded to the loss of twenty-four ounces of blood, and in
the afternoon, on its rising again, to sixteen more; after which the
symptoms gradually subsided, and he appeared to be restored to health,
with one interruption from irregularity in diet, requiring the further
loss of blood by cupping behind the ears, and some sharp purgation.
His cure was not, however, permanent; for having dined out a month
afterward, he became delirious during the night, and required to lose
sixteen ounces of blood in the morning, which relieved, but did not
cure him. Some pain remained in his head, the pulse continued at 90,
the tongue was white, with thirst, loss of appetite, and watchfulness.
Calomel and opium were now administered until the mouth became
affected, when he quickly got well; although a slight relapse or two
afterward convinced him that he could not drink nor lead an irregular
life with impunity.

There are no cases of convalescence after disease or injury which
require more care than those which follow injuries of the head.
Relapses, from apparently trifling causes, are extremely frequent,
and gradually but certainly undermine the health; they are, in fact,
connected with chronic derangement of the brain, or of its membranes;
and unless successfully met, generally end, after the lapse of a few
weeks or months, in irritative fever and death. In many instances,
particularly among poor people subject to privations and of irregular
habits, in whom an injury of the head has not originally been of any
apparent importance, such a state of irritation, if it occur, combined
with debility, is very difficult to manage; it requires a combination
of local as well as of general means for its cure. A few leeches and
blisters may be applied alternately over the part affected, with great
advantage; and a mild, nourishing diet, with gentle alteratives and
tonics, will expedite the cure, especially when aided by perfect repose
and a fresher atmosphere. An issue in the arm, which establishes a
gentle but permanent drain, will often be found an efficacious remedy.



LECTURE XVII.

WOUNDS OF THE HEAD.


253. Compression of the brain means a diminution of the size of certain
parts of it, resulting from the pressure of an extraneous body, whether
it be fluid or solid, in consequence of which particular symptoms
are generally known to ensue. When they occur, it is said that the
sufferer is laboring under symptoms of compression of the brain, and
apoplexy from the rupture of a blood-vessel may be considered as the
best form or illustration of the complaint. These symptoms sometimes
take place from the presence of a foreign substance, such as a point
or piece of bone, which from the smallness of its size can hardly
compress, although it may displace; and it is then said that the
symptoms arise from irritation of the brain. Many of them have also
been found to occur from loss of blood, or the absence of pressure, or
from insufficient pressure arising from changes in the circulation;
and several different opinions have been entertained on all the points
connected with these subjects. It has been argued that as the brain
is incompressible, no compression can take place. There is no proof,
however, of the fact of its being incompressible as a whole, although
it has been stoutly maintained by Monro secundus, Sir C. Bell, and
others.

The brain is surrounded by membranes capable of secreting a halitus
or a fluid whenever it may be necessary to fill up space; it is
intersected by partitions apparently for the prevention of jar and
pressure, and is permeated in every part by vessels of various sizes,
both venous and arterial. It has been presumed that it contains at
all times the same quantity, or nearly the same quantity, of blood,
in consequence of its freedom from atmospheric pressure, through the
intervention of the bones of the skull. If this conjecture be correct,
the quantity cannot be materially increased, unless something be
displaced to make room for the addition; nor can it be essentially
diminished without something being added to supply its place. The
question turns, however, very much on the words “materially increased
or diminished;” for a very small additional quantity may be the cause
of serious mischief, and the subtraction of even less may give rise
to great cerebral disturbance; but there can be little doubt that the
actual quantity contained in the head is less at one time than at
another, the deficiency being usually on the side of the arteries;
when congestion takes place, it is for the most part venous. When a
person is about to faint on the first passage of a catheter through the
urethra, the blood deserts his face, he feels sick, his pulse nearly
ceases, and he would faint if he were allowed to remain in the erect
position. Let his head now be bent down between his knees for a minute;
his face fills with blood, his brain does the same, and he recovers
almost immediately. Young ladies, when about to faint, are prevented
from doing so by these means being adopted, which they declare,
nevertheless, to be very unladylike, although they may be doctorial and
effective.

254. The motions of the brain covered by the dura mater are but little
observable under ordinary circumstances when a circular portion of bone
has been removed by the trephine; the surface of the dura mater remains
in general perfectly LEVEL; it is of a reddish-silvery color, and is
firmly attached to the cut edge of the bone. The surface is raised,
however, on a full expiration, and it falls on a deep inspiration.
Fluid secreted or placed upon it is seen to move synchronously with
the pulse; but the dura mater never rises up into the hole made by
the removal of the bone, unless some fluid be retained beneath it. If
the quantity of fluid extravasated or collected under it be large, it
rises immediately on the removal of the bone; but the protrusion of
this membrane does not always take place for some hours afterward if
the fluid be more diffused. The motions of the brain, when the dura
mater is thus protruded into the opening, become very indistinct, even
if they can be perceived. These two points, viz., the protrusion into
the opening and the absence of pulsation, are important facts, little
noticed by surgical writers, to be borne in mind in connection with the
practice to be pursued.

If we sometimes see the natural and ordinary size of the brain
diminished under pressure, and that certain symptoms, such as
insensibility, syncope, convulsions, and paralysis, are consequent
on this state, and are relieved by the removal of the pressure and
the restoration of the compressed brain to its ordinary state, we may
safely conclude that some derangement takes place in its integral
parts, which may be best understood by the word compression. If we
further consider that compression can rarely exist without irritation,
and that sometimes of a formidable nature, there does not appear to
be so much difficulty in the subject as is frequently represented,
although the physiological explanation may not be so simple. In the
present state of our knowledge, we apprehend that in many cases
approaching to apoplexy, in which the symptoms are similar to those
arising from compression, all, or nearly all, the vessels, as far as we
can ascertain, are actually full of blood, instead of being partially
empty and containing less than the natural quantity. When we see a
patient, lying in a state of insensibility with a fracture of the
cranium, immediately recover his senses after the application of the
trephine and the removal of a large coagulum of blood, we are apt to
suppose that the coagulum of blood and the insensibility stand in the
relation to each other of cause and effect. It is not unreasonable to
conclude that the pressure of the extravasated blood confined by the
bone had occasioned the insensibility, and that this did not depend
alone upon some few vessels containing less blood than usual; for
the brain must be considered as a whole in all these investigations,
and reference should not be made to its vascular structures only in
explanation of the cause of its derangements.

255. When compression of the brain is caused by an extravasation of
blood, the patient is insensible, breathes slowly, loudly, and in
a heavy, labored manner, or with stertor, and cannot be awakened,
although the noisy breathing may be for a time suspended. The breath is
sometimes emitted from the corner of the mouth, like a whiff or puff of
smoke, and with something of a similar noise: this, when permanent,
is a more dangerous symptom than the common snoring or stertorous
breathing. He sometimes froths at the mouth, and occasionally appears
convulsed, but neither hears nor sees, nor takes the least notice of
those about him. The countenance is generally flushed if the shock
or blow has been slight, pale or livid if it should have been great.
The pulse is usually slower than natural, sometimes irregular or
intermitting, occasionally quick, even from the receipt of the injury.
The pupils of the eyes may be contracted or dilated, being dependent
for their condition more perhaps on the part of the brain affected
than on the degree of injury. They are generally more contracted
in the first instance than dilated; they may afterward pass into a
medium or doubtful state; one may be even dilated, and the other not.
In general, as the mischief is continued and augmented, they become
dilated and immovable. The eyes may be turned upward, or may be fixed
in the center, or be drawn irregularly outward or inward, causing
strabismus, which is, however, a more rare occurrence. If the eyelids
should be partially open, tickling the cilia or the conjunctiva of
the ball with a straw or a feather will cause them to close, if the
spinal cord be sound. The mouth and lips are more or less compressed,
and fluids run out at the corners, unless placed on the very back
of the tongue by a long, narrow spoon, when they are swallowed with
difficulty. Paralysis of one side of the face and hemiplegia are
common; paraplegia is more rare. In both kinds of palsy one part in one
limb may be more completely affected than another, in which convulsive
twitchings are sometimes present, as well as a frequent drawing up of
the limb of the unaffected side. Tickling the soles of the feet or
the palms of the hands will sometimes cause retraction of the toes or
fingers when the limbs are apparently motionless; pricking them gently
with a pin will often give rise to convulsive startings and tremblings
of all the muscles of the extremity when tickling fails, showing that
the capability to move the part remains, although the will to do so
is wanting. The leg or arm is sometimes drawn toward the body when
separated from it; it more often falls from the hand as if it belonged
to the body of a dead person; the muscles are occasionally more stiff
and rigid, and some power of motion remains, although but little of
sensation; sometimes sensation is perfect when motion is lost, and
sensation may be lost on one side and motion on the other. The urine
at first retained may ultimately pass involuntarily, as well as the
feces; nevertheless, irritating the verge of the anus will excite
motion and contraction in the sphincter ani, if the functions of the
spinal cord be not destroyed. The action of the involuntary muscles
is little impaired in general, and the secretions are but slightly
affected; when it is otherwise, the injury must have extended to
the ganglionic system, and the whole of the nervous centers must be
materially implicated.

The loss of motion, or of the power of moving parts of the body, is
either perfect or imperfect according to the degree of injury which
has been inflicted, varying from a sense of feebleness to an almost
utter incapability of moving the part. It is accompanied in general by
defective sensation, or numbness, or by the complete loss of sensation
and of the power of resisting heat and cold; the whole side, or one
extremity, or a part only of an extremity may be affected, and not the
whole. The mischief which gives rise to the loss of motion usually
occurs on the side of the brain opposite to that part of the body
which is paralytic. This was known and stated by Hippocrates, and the
subject has been pursued to the most complete demonstration by modern
anatomists.

The pathological proofs are not less complete. Desault and Bichat
were by no means satisfied that the paralysis which followed an
injury always took place on the opposite side; and some pathologists
since their time, while admitting the fact, have shown that there may
be exceptions. It is acknowledged, although it is not clearly and
satisfactorily accounted for as to the face, that an extravasation of
blood into one hemisphere of the cerebrum, or even of the cerebellum,
can cause paralysis of the complete half of the body on the opposite
side. It has been demonstrated that the right side of the body and
the left side of the face may be paralytic at the same time and from
the same injury apparently of the left side of the head, the mischief
which caused the paralysis of the right side being found, in by far
the greater number of instances, on the left side of the brain, and
that which gave rise to the paralysis of the left side of the face to
have been caused by an injury in the course of the portio dura of the
seventh pair of nerves when about to leave, or after it had left, the
brain.

Burdach found, in 268 cases of lesion of one side of the brain, that
10 presented paralysis on both sides of the body, and 250 of one
side; in 15 of these the paralysis was on the same side as the injury.
Convulsions took place in 25 cases on the same side as the disease; in
3, on the opposite side. In cases of lesion of one corpus striatum,
there were, in 36 instances, paralysis of the opposite side, and 6 with
convulsions of the same side, and in no instance convulsions of the
opposite side. In 28 cases of cerebral lesion of one side, the muscles
of the opposite side of the face were paralyzed; in 10, those of the
same side. Paralysis of the eyelid was in 6 cases on the same side,
in 5 on the opposite side. Paralysis of the muscles of the eyeball
occurred in 8 cases on the same side, in 4 on the opposite; paralysis
of the iris, in 5 cases on the same side and in 5 on the opposite, the
tongue being generally drawn toward the paralyzed side of the face.

A man fell down stairs and received an injury on the head from the fall
which rendered him nearly insensible at the moment. There were no signs
or appearances on the outside of the head indicative of any serious
mischief, nor were any found on examination after death. The pulse was
quick, and rose to 140; the left side was paralytic; the breathing not
stertorous, but accompanied by a little puff on the right side of the
mouth; the pupils somewhat dilated; he could not speak, convulsions
supervened, and he died the day afterward. On dissection, the peculiar
flatness of the convolutions of the brain on the right side was so
remarkable, when compared with that of the left, as to leave little
doubt of its having been occasioned by something which had pressed them
forcibly upward against the inside of the cranium; and, on slicing off
a portion of the brain, a larger coagulum of blood was found below
than is usually observed to exist without the almost immediate death
of the patient. The same thing has been so distinctly marked in other
instances that no doubt can be entertained of those convolutions of the
brain which were situated between the coagulum and the cranium having
undergone a considerable degree of compression. It is worthy of remark
that the pulse of this person was always regular and remarkably quick
from the first examination after the receipt of the injury until the
period of his death, showing, perhaps, that the action of the heart is
not affected directly by pressure acting only on the upper surface of
the brain.

256. Convulsive actions of the muscles, or positive convulsive fits,
are always important symptoms; yet they seem in some persons to be
dependent on idiosyncrasy, particularly when they appear early, and
after the loss of blood, in which case they are less dangerous. They
occur at different periods after the receipt of the injury, and have
been supposed to depend in general upon laceration of the substance of
the brain, although experiments on animals would seem to show that they
may be caused directly by irritation of the cerebro-spinal axis within
the skull, in which case the patients are more likely to recover. They
have been observed particularly on the side opposite to that which
is paralytic, so as to give rise to the idea that the paralysis is
dependent on injury of one side of the cerebrum, and convulsions on
injury of the other. When the effect of the mischief is so great as
to cause complete paralysis, convulsive twitches do not take place,
although they frequently precede, and may in many cases be considered
as premonitory signs, while the evil which gives rise to the paralysis
is gradually accumulating. When the paralysis is not complete, the side
so affected suffers sometimes from slight convulsive twitches, while
well-marked spasms prevail in the other, leading to the belief that,
while paralysis is an affection of only half the brain of the opposite
side, or of half the spinal marrow of the same side, convulsions are
the effect of a more general irritation, capable, however, of being
confined to a part; for partial convulsive motions do very frequently
occur without any paralysis accompanying them on the opposite side.
Several cases have occurred in which the convulsions have ceased, and
the patients recovered after the removal of a portion of bone which
was irritating the brain; but convulsions have generally been the
forerunners of death when the seat of injury was unknown and effective
relief could not be given. When they occur in cases apparently of
pure concussion, accompanied by inflammation of the brain or of its
membranes, and the patient recovers after many days of the strictest
antiphlogistic treatment, it is possible that the brain may have been
lacerated, and the cure have been effected by adhesion. Convulsions, it
must be remarked, are among the most common symptoms of inflammation of
the membranes of the brain, without any such lesion of its substance,
although they are frequently wanting. They may be expected to take
place about and after the fifth day in injuries of the head, when
inflammation of the brain or of its membranes is about to extend to
or to become continuous with the neighboring parts, and may be more or
less severe, varying from a state of partial trembling of a limb to
that of general agitation and restlessness of the body generally--from
a slight, irregular movement of the eyelids, or of the muscles of
the face, to the more marked spasmodic startings of the whole of one
side, grinding of the teeth, and contraction of the limbs. It is far
different with those convulsive movements which, at a late period,
become nearly permanent, or with rigid spasms, resembling tetanus, in
which the body is drawn in different directions, forward, backward,
or to one side. These are for the most part forerunners of death.
Examination after death, in such cases, has frequently shown nothing
discoverable beyond inflammation of the pia mater, and an effusion
of fluid, generally purulent, on the surface of the brain, or in its
ventricles, or between the pia mater and the tunica arachnoides.

The three following cases are intended to show the different forms
of paralysis that ensue after injuries accompanied by compression or
irritation of the brain:--

Charles Murray, private in the 2d battalion of 1st Foot Guards, aged
thirty-three, was wounded on the 18th of June, at Waterloo, by a piece
of shell which struck him on the superior part of the _left_ parietal
bone. He remained insensible about half an hour, and on recovering from
that state, was affected with nausea and some bleeding from the left
ear, and found himself unable to move his _right_ arm and _right_ leg,
which hung as if they were dead, and had lost their feeling. Admitted
into the Minimes General Hospital at Antwerp on the 29th; he suffered
much from pain in the head, which was relieved by his being twice bled.
The paralytic affection having remained without change from the moment
he was wounded, a piece of the parietal bone, about three-fourths of
an inch long, and several smaller fragments, were extracted four days
after admission into the hospital, two perforations with the trephine
having been necessary. Immediately after the removal of the bone he
recovered the use of his right arm and leg, so far as to be able to
move them, and to be sensible of their being touched. He gradually
recovered by the 14th of August, so as to be sent to the General
Hospital at Yarmouth, never having had a bad symptom, the only defect
remaining on the right side being an inability to grasp anything in
his hand with force. The pulsation of the brain was still visible at
the bottom of the wound for about the space of half the circumference
of the crown of the trephine. September 16th, 1815: the wound has
filled up with healthy granulations, and has nearly cicatrized. A small
sinus remains at the superior part, through which the edge of the bone
can be felt. His health has been invariably good, although he has
suffered a good deal of pain twice previously to the coming away of
little pieces of bone, and toward evening he has been generally subject
to slight vertigo. Discharged cured.

William Mitchel, of the Royals, aged forty, was wounded by a
musket-ball on the 18th of June, at Waterloo; it struck the side of the
head near the vertex, and, passing across through the sagittal suture,
fractured and depressed _both_ parietal bones. When he had recovered
his senses he suffered great pain in the part, and found that he had
lost the use of BOTH his legs, and was benumbed even from the loins and
lower part of the chest; he was often sick, and felt low and ill. On
the 28th, ten days after the battle, the trephine was applied in two
places, and the whole of the detached and depressed portions of bone
were removed. The sickness, lowness of spirits, and general illness
immediately subsided, and the loss of power in the lower extremities
gradually began to diminish, but he was not able to walk without
assistance until the first week in August. On the 10th he arrived at
Yarmouth, not having had a bad symptom after the depressed bone had
been removed; and by the end of September he was discharged, able to
walk well with the assistance of a stick.

Mr. Keate has mentioned to me a case, in which the injury and the
paralysis were apparently on the same, or the right side. The
paralysis, although positive, was not so complete as to render
the patient quite incapable of moving the arm and leg, which were
frequently convulsed, but the convulsions, which were observable in
both, were more marked on the opposite or left side. On examination
after death, the most serious injury was found to be a fracture of the
right parietal and temporal bones, extending to the petrous portion
of the latter, and beyond it; this, with a rather large extravasation
of blood under and in the course of the fracture, appeared to be
sufficient not only to destroy life, but to have caused paralysis of
the left side, which, however, it did not do. Another extravasation,
rather less in quantity, had, however, taken place under the upper and
anterior portion of the left parietal bone, which enabled Mr. Keate
fully to account for the paralysis which took place on the right side.
According to the surgery of the French Academicians of the beginning
of the eighteenth century, this man would have been trephined or
trepanned on the left side of the head in search of an extravasation by
contre-coup; but accident or chance alone could have led to the right
spot, as it was by no means opposed to that on the other side.

257. A simple fissure or fracture of the skull is of no more importance
than a fracture of any other bone in the body, unless it implicate the
brain; it should be managed according to the ordinary principles of
surgery. These principles, however, involve a treatment diametrically
opposite to that practiced by many surgeons, almost unto the present
day.

If the integuments or scalp be divided, and the bone fissured, these
principles should be carried out, by endeavoring to procure the union
of the divided parts, as was generally done during the war in all
such injuries from sabre-cuts as did not quite penetrate the skull--a
practice that was found to be eminently successful, even when union
did not take place. The general treatment should be similar to that
insisted on in concussion, of which the following may perhaps be
considered a sufficient example:--

A soldier in Lisbon, partly in liquor, received a blow from a spade
which cut the upper part of the head across the sagittal suture, and
rendered him senseless. He soon got better, and a slight fissure or
fracture without depression was discovered. His head was shaved,
kept raised, wet and cold, and the divided parts brought together by
sticking-plaster; he was bled to twenty-four ounces, purged, starved,
and kept quiet in a dark room. Slept well, but said that his head felt
painful, as if something tight was tied around it. Pulse 96, small
and hard; bowels not open. Blood was taken from the arm to the amount
of forty ounces, when he appeared about to faint. Calomel and jalap,
followed by infus. sennæ cum magnes. sulphate, were given, and acted
well, and he was greatly relieved. The calomel was continued every
six hours. In the evening, however, the pain and tightness of the
head returned, with a pulse of 110, hard and full; these symptoms
were removed by the loss of twenty-four ounces of blood. He remained
easy until the evening of the next or the third day, when the pulse
quickened to 120, became small and hard, and he complained of severe
pain in the head. It was evident that inflammation of the brain or
of its membranes had commenced, and that it must be subdued; he was
therefore bled until he fainted, forty ounces having been taken away.
This entirely relieved him, and calomel and jalap, senna and salts were
again administered with great effect. On the fourth day he was easy,
the pulse 94, soft and full, the mouth being tender from the mercury.
The wound did not heal by adhesion, but by granulation; and under the
continuance of the starving and purging system he gradually got well
without any more bad symptoms, having been saved by the loss of one
hundred and twenty-eight ounces of blood in three days.

The vigorous and decided abstraction of blood saved the man, and, with
the mercury, in all probability prevented the occurrence of those evils
which our predecessors sought to obviate by removing a portion of bone.
They believed the bone could not be fractured without an extravasation
taking place beneath; and some took credit to themselves for placing
wedges between the broken edges, in order to allow the escape of the
blood or of the matter which might be formed below it. That blood may
be effused, and matter may be formed, is indisputable, even under
the most active treatment; but that an operation by the trephine
will anticipate and prevent these evils, cannot be conceded in the
present state of our knowledge; and the rule of practice is at present
decided, that no such operation should be done until symptoms supervene
distinctly announcing that compression or irritation of the brain has
taken place. It is argued that when these symptoms do occur, it will
be too late to have recourse to the operation with success. This may
be true, as such cases must always be very dangerous; but it does not
follow, and it never has been, nor indeed can it be shown, that the
same mischief would not have taken place, if the operation had been
performed early.

258. When a simple fracture, which in its slightest form is called
a capillary fissure, takes place, the dura mater must be separated
from it at that part to a certain extent, and some small vessels
must be torn through. It does not follow, however, that blood must
necessarily be poured out in such a quantity that it will not be
absorbed. Dissection, on the contrary, has established the fact that
it will be absorbed even in cases of fracture of greater extent, where
it has been seen that a larger quantity had been extravasated. As the
effusion of a larger, or of so large a quantity of blood as to prove
eventually mischievous, does not _usually_ take place, except under
other circumstances than those of a simple fracture, the ordinary
practice ought not to be to seek for that which is not likely to be
found. The dura mater is rarely separated beyond the limits of the
fracture, and it is more likely to recover without any further exposure
or interference than with it. The dura mater, however, may be separated
to a considerable extent from the bone in more severe injuries, and a
quantity of blood is often extravasated upon it. When this does occur,
the commotion or shock which occasioned the fracture, the separation
of the dura mater, and the extravasation will generally have caused
other more important although less perceptible derangements. These
show themselves after the lapse of a few days, by giving rise to
inflammation of the brain or of its membranes, of which such patients
more usually die, than of the separation of the dura mater, or of the
extravasation of a small quantity of blood. The case is no longer
one of simple fissure or fracture of the cranium, and the nature and
severity of the symptoms which have supervened must regulate the
practice to be pursued.

259. After the receipt of a severe blow, or of a gunshot fracture of
the head, which has not even stunned the person at the moment, he may
walk to the surgeon, the wound be dressed, and he may converse with
his fellows as if nothing had happened; yet in a short time he may
become heavy, stupid, drowsy, and unwilling to move, with a slow pulse
and a pallid countenance. Inflammation has not yet had time to set
in, and extravasation has not always taken place. If the loss of a
moderate quantity of blood should relieve such a person, it shows that
congestion had occurred, perhaps on the surface of the brain under the
injured spot, on recovering from which, by the unassisted efforts of
nature, he would still be liable to inflammation. I have repeatedly
seen a sharp bleeding from an incision made to allow a complete
examination of the part in such a case, cause the restoration of the
patient to his natural state. A return of untoward symptoms during the
progress of the case does not always indicate essential mischief;
they will be removed, if of a temporary nature, by a further moderate
bleeding, by purgatives, and by greater restriction in diet, through
irregularities in which these secondary attacks most usually occur. If
the loss of blood should not relieve the symptoms, the case is probably
complicated by a separation of the dura mater, or by an extravasation
having taken place between the dura mater and the bone, or even in or
on the surface of the brain.

260. When a fracture takes place at the anterior inferior angle of the
parietal bone, or in any part of the course of the middle meningeal
artery, it often gives rise to a more serious injury, which nothing
but an operation can remove. The artery is always in a groove, and is
often even imbedded in the bone at its lower part, and may be torn
at the moment of fracture, giving rise to a gradual extravasation of
blood on the surface of the brain, which can be borne to a considerable
extent without causing any particular symptoms, although a sudden
and considerable effusion causes immediate insensibility. When the
extravasation is gradual, the patient walks away after the accident,
and converses freely, becoming oppressed slowly, and in the end
insensible, as the last drops of blood which are effused render the
compression effective. When these symptoms occur after a wound in this
particular part, the bone should be immediately examined; if there be
no obvious fracture, and relief cannot be obtained by the abstraction
of blood, the trephine should be resorted to as a last resource; for
if there be truth in the statements so confidently made of fracture
of the inner table of the bone from concussion of the outer without
fracture, it is here especially that we may be permitted to look for
it. The hemorrhage in the greater number of these cases takes place
slowly, and the effused blood depresses the brain by separating the
dura mater from the neighboring bone--a process, however, which can
hardly occur unless the injury has been so violent as to rupture its
attachments to the bone; for the brain generally yields rather than the
attachments of the dura mater, and is depressed, the hollow or cavity
thus formed being filled up by the coagulum, which becomes thicker
and thicker until insensibility is induced. Blood effused between the
dura mater and the bone readily fills up in the first instance all the
space formed by the disruption of the membrane; for the force with
which the blood is poured out from the artery overcomes the resistance
offered by the brain, which gradually yields and sinks unto that point
at which its natural functions can no longer be carried on. If the
attachments of the dura mater be strong, and the separation which has
taken place between it and the bone be small, the blood effused is
compressed by the bone on one side, on which it can exert no influence,
and is resisted by the dura mater, which will recede no further on
the other. The wounded artery in such a case is soon compressed by
its own coagulum, and the effusion is comparatively trifling, giving
rise, according to its nature, either to the primary symptoms of
compression from extravasation, or to the secondary ones dependent in
all probability on inflammation and suppuration of the part, and of
irritation and compression of the brain beneath. If, on the contrary,
the separation of the dura mater from the bone be extensive, the
quantity of extravasated blood may be considerable and the brain will
be greatly depressed. Experience has demonstrated that persons have
recovered after large coagula have been removed; but in all these cases
the brain had not lost its resiliency, and was seen to regain its
natural level on the removal of the depressing cause, the person often
opening his eyes and recognizing and speaking to those about him; but
this does not take place when the brain remains depressed after the
blood has been removed.

A French artillery driver was knocked off his horse by a musket-ball,
which struck him on the anterior and inferior portion of the right
parietal bone, during a charge made by General Brennier, at the battle
of Vimiera, on the British infantry under the command of the late Sir
Ronald Fergusson. I took him under my care, thinking from his freedom
from bad symptoms and the slightness of the fracture that he would
probably do well. The next morning I found him apparently dying. A
portion of bone being removed, a thick coagulum of blood appeared
beneath, apparently extending in every direction. Three more pieces of
bone were taken away and the coagulum, which appeared to be an inch in
thickness, was removed with difficulty with the help of a feather. The
brain did not, however, regain its level, and the man shortly after
died. The middle meningeal artery was torn across on the outside of the
dura mater; the wound did not pass through to the inside, and there
was no blood beneath the dura mater. The convolutions of the brain
were depressed and flattened by the pressure.

A soldier of the 29th Regiment was struck on the right parietal bone in
a similar manner, shortly after daylight, at the battle of Talavera,
during the first attack on the hill, the key of the British position.
He walked to me soon afterward to the place where the wounded of
the evening before had been collected in the rear. Being otherwise
employed, I heard his story but could not attend to him at the moment,
and found him some time afterward insensible, with a slow, intermitting
pulse, breathing loudly, and supposed to be dying. The fractured parts
were sufficiently broken to admit of the introduction of two elevators,
by means of which they were gradually removed, together with a large
coagulum of blood which had depressed the brain. When this had been
done the brain regained its level, the man opened his eyes, looked
around, knew and thanked me. The pulse and breathing became regular; he
said he suffered only a little pain in the part, and should soon get
well. He died, however, on the third day.

During the battle of Salamanca a soldier of the 27th Regiment was
brought to me, who had walked to the rear, and had fallen down
insensible within a few yards of the hospital station. I found a
considerable fracture, with depression at the inferior part of the
parietal bone before and above the ear. The end of the elevator
having been introduced, a small piece of bone was first raised, then
another, and a third, when a thick coagulum was exposed and removed.
The dura mater was not separated from the bone around to any extent,
and the coagulum, although thick, was not large. The brain, which had
been depressed, regained its level immediately; the man recovered his
senses, and was cured of his wound, but remained unfit for service. The
artery did not bleed after it had been exposed.

The rule in surgery, to remove the bone in such cases, is absolute.

261. Fractures of the skull are stated, from almost the earliest
records of surgery, to occur on one _side_ of the head in consequence
of blows received on the _other_. The facts which ancient authors
have collected and related on this point are so numerous and so well
attested that it appears almost more than skeptical to doubt their
accuracy, however seldom they may be now observed.

A counter-fracture or fissure of one parietal or temporal bone, caused
by a blow on the opposite one, is of such rare occurrence that it is
in general unnoticed by later writers on injuries of the head. It is
not so, however, with respect to a fracture at the base of the cranium
from a blow on the vertex, or on the back part of the head--a kind
of accident which occurs more frequently perhaps than any other in
civil life--because persons who suffer from fractures of the skull do
so more generally by falling from a height, or from being pitched on
their heads, than by direct blows or other injuries. This accident
principally depends on the superincumbent weight of the body pressing
on the unsupported flat and thin base of the skull, and is but little
connected with the unyielding nature of the spine; for it occurs to as
great an extent in consequence of falls from a short distance without
any impetus, as from falls from a great height. Some of the worst
cases take place by the sufferer having been thrown from the back of a
horse by the sudden starting of the animal, without any running away.
Although in these cases a fissure may often be traced to the foramen
magnum, the great fracture is essentially distinct, extending from the
petrous portion of the temporal bone on each side, across, and between
the sphenoid bone and the os frontis, and even separating the edges of
the coronal suture nearly to the opposite side.

A noted gambler was thrown from his horse, and pitched on the top of
his head at the door of the Westminster Hospital, late at night; he
was taken up insensible, and died shortly afterward. The skull was
fractured quite round from the vertex to the base, and from side to
side, so that the fore and back parts might have been easily separated
into halves, if the soft parts had been removed. Fractures of the base
of the cranium are generally fatal, but not always so; for some persons
live a considerable time afterward, and appear to die from other
causes; so that partial, if not perfect recovery is possible.

H. Cochrane, forty-five years of age, fell a distance of twenty feet
upon his head, and was taken up apparently lifeless, bleeding largely
from the ears, nose, and mouth, but more particularly from the ears.
He was seen within half an hour of the accident. He was then quite
insensible; the surface of the body cold; pulse about 68, and very
feeble; in three hours after the accident he was bled to sixteen
ounces, when his pulse rose to 76, and the breathing, which before
was rather oppressed, became more free. He was ordered six grains of
calomel, followed by moderate doses of senna, till the bowels should be
relieved.

He continued progressively mending, but in a state of stupidity,
accompanied by extreme listlessness; answered questions sullenly, and
frequently rested upon one arm without appearing conscious of pain;
the mouth was drawn to the left side, to which there had been a slight
tendency for some days; the tongue not at all affected.

He continued under treatment for three weeks longer, soon after which
he was permitted to resume his employment, the mouth being still
drawn in some degree to the left side. His habits became silent and
solitary, but he performed his task with the greatest exactness. He was
occasionally subject to vertigo, particularly in hot weather, after
any violent exertion or taking a small quantity of beer; a pint of ale
would render him stupid or insensible. Six months afterward he was
found dead, lying in a ditch.

_Sectio cadaveris._--The nasal bones were fractured by a blow which
had made a transverse incision in the upper part of the face. The
femur was found fractured upon the right side, and the scalp puffy
and ecchymosed on the left. On removing the skull-cap, the dura mater
appeared perfectly healthy, without any sign of extravasated blood upon
the surface. Beneath the pia mater on the left side the sulci of the
brain were filled with black blood, apparently very recently effused.
The brain was removed without the least violence, when a lesion was
found upon its inferior surface, corresponding to the petrous portion
of the right temporal bone. The dura mater in this situation was
externally of its natural structure, and adhered with its usual degree
of firmness to the bone beneath. The arachnoid and pia mater were here
deficient; the lesion consisted of a cavity about fifteen lines in
length, nine in breadth, and three in depth, coated with a light-yellow
lining, which also adhered to the corresponding portion of the inner
surface of the dura mater, which completed the walls of the cavity
inferiorly; it contained a turbid serum, in which were seen floating
numerous but exceedingly minute white globules. The portion of the
brain in this situation did not appear to have been disturbed by the
recent violence, except that from the upper part of the cavity a probe
was admitted without any resistance into the descending horn of the
right lateral ventricle, which, with the one on the opposite side, was
filled with a large quantity of bloody serum, none of which, however,
had escaped into the cavity beneath. The brain generally appeared
perfectly healthy, and not more vascular than usual. Even within a line
of the yellow deposit above mentioned there appeared not the slightest
change of structure. On removing the dura mater from the base of the
skull, indications of a former fracture were discovered, leading
vertically down through the squamous portion of the temporal bone,
whence it appeared to have been continued along the anterior part of
the petrous portion into the Vidian canal; the edges of this fracture,
both internally and externally, had been rounded by absorption; it was
met at right angles by another which ran across the base of the petrous
portion of the temporal bone. The direction of the last fracture was
marked by numerous small, rough particles of bone, which adhered so
slightly to the rest that they separated on maceration. The transverse
ligament of the second vertebra was ruptured, and the atlas forced
forward. The connection between the articular processes of the second
and third cervical vertebræ on the right side had also been separated
by the fall which had caused death.

William Clayton, forty-four years of age, was admitted on the 31st of
July, 1841, into the Westminster Hospital, having received a blow on
the RIGHT side of his head from the handle of a windlass, by which his
skull was fractured. The fracture extended downward from the parietal
bone across the temporal, and in all probability through its petrous
portion, as blood flowed freely from the ear for the first six hours;
he was stunned for a few minutes at first, but became sensible by the
time he was brought to the hospital. The bleeding from the ear was
followed by the discharge of a fluid resembling water--which is a very
dangerous symptom, as it usually flows from the sac of the arachnoid
membrane--and afterward at intervals by a discharge of blood and
matter, particularly, he said, on coughing; he was also quite deaf,
with a little pain on the right side of the head. The bowels were well
opened, and he lost sixteen ounces of blood. On the evening of the
third of August, the fourth day after the accident, paralysis of the
muscles of the RIGHT side of the face supplied by the portio dura came
on, or was first observed. Pulse 80. He was well purged, but lost no
blood, as he was apparently weak and the pulse soft; it fell next day
to 72. Mercury was now administered twice a day until the mouth became
sore. On the eighteenth of September he was discharged, cured of the
paralysis, the wound on the head being open, and a piece of bone bare
and likely to exfoliate. October 8. Readmitted in consequence of great
headache after drunkenness, with numbness of the toes and fingers; he
was well purged, and felt relieved. He remained in the hospital for a
month, his mouth being again slightly affected, occasionally drinking
in spite of all remonstrance; he then returned to his work on the piers
of Westminster bridge. On the eighth of June several small pieces of
bone came away; and the wound nearly healed. The course of the fracture
can be traced, in consequence of the scalp having adhered to the bone,
causing a slight depression and hardness, which can be felt by the
finger, extending down to the ear.

An hostler was thrown on his head from a horse, and was carried to
the Westminster Hospital late at night in a state of stupefaction; no
other injury could be discovered. The next morning he could answer
questions, although not always correctly; complained of pain in his
head, had bled from the ears all night, and had vomited some blood
two or three times. Pupils dilated, but they contracted on bringing a
lighted candle near them; the left eyelid more open than the right;
pulse 52; very restless, and constantly turning in bed. V. S. ad ℥xxiv.
Calomel and colocynth: salts and senna. Cold to the head. The pulse
rose to 60 after the loss of blood. 2d day. Is delirious; bleeding from
the ears but trifling; complains of pain in the head; bowels open;
passes urine freely; pulse 54, a little irregular. Y. S. ad ℥xvj gave
relief. Continue calomel, and salts and senna. 3d day. Restless all
night; headache and thirst; bowels open. V. S. ad ℥xiv relieved the
pain in the head. Pulse 56. 4th day. Restless and delirious at night;
pulse 60, regular; bowels open; headache. V. S. ad ℥xiv. No discharge
from the ears. 6th day. Slightly paralytic on the left side of the
face, tongue drawn to that side; headache, restless, delirious; feces
and urine passed unconsciously; pulse 80. V. S. ad ℥xx. Pulse rose to
100, and was weaker. Calomel, gr. iii every six hours. 7th day. Pulse
88, compressible; restless at all times, delirious at night; bowels
open, but he is more conscious of everything. 8th day. Pulse 80, small,
intermitting; occasionally slept a little, and is generally better;
bowels well purged; paralysis of the face continues. Has taken a little
farinaceous food. Continue calomel and inf. sennæ. 10th day. Improved;
slept tolerably well. 12th day. Continues to improve. Omit the calomel,
but continue the infus. sennæ. 16th day. Is better. Paralysis lessened.
Recollects he was thrown from a horse, but nothing else. Is free from
pain, but very weak. Mouth a little sore.

After this time he gradually recovered, but was for a long time unable
to work, or to undergo any exposure. A very little more mischief, and
he would have gradually sunk, and died after the seventh day, instead
of slowly recovering.



LECTURE XVIII.

INJURIES OF THE HEAD.


262. A fracture of the inner or vitreous table of the skull, as it has
been termed from its peculiar brittleness, as opposed to the greater
toughness of the outer, is a rare occurrence without some signs of
depression or fracture of the outer table, or detachment of the
pericranium.

Mr. S. Cooper says: “One case of this kind, attended with urgent
symptoms of compression, I trephined at Brussels. A large splinter of
the inner table was driven more than an inch into the brain, and on its
extraction the patient’s senses and power of voluntary motion instantly
returned. The part of the skull to which the trephine was applied did
not indicate externally any depression, although the external table
came away in the hollow of the trephine, leaving the inner table
behind.”

The records of eighteen centuries have produced but little information
on this most interesting subject: and if the cases were collected
which have been overlooked by authors, as well as those which have
been altogether omitted, little would be gained; it may be concluded,
therefore, that although such things have happened, they are of rare
occurrence. 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.
Although it is not possible to doubt the fact of fracture of the
inner table having occurred, without apparent injury to the outer,
it is very desirable in a practical point of view not to bear it too
strongly in mind; for if a surgeon should be prepossessed with the
idea that the inner table may be so readily fractured and separated
from the diploe placed between it and the outer table, and thus cause
irritation or pressure on the brain, few persons who had received a
knock on the head, followed by any serious symptoms, without fracture
or depression, would escape the trephine, and the worst practice
would be again established. An operation should never be performed
under the expectation that such an accident may have happened, unless
it be apparently required by the urgency of the symptoms indicating
compression or irritation of the brain, which cannot be relieved by
other means, and are about to prove fatal.

It is by no means intended to imply by these remarks that a blow on the
head will not frequently detach the dura mater from the inner table by
rupturing its vessels, and thus give rise to compression or irritation
of the brain from the effusion of blood or the formation of matter;
or that the inner table may not from the same cause become diseased,
and thus lead to ulterior mischief; but these are altogether different
states of injury, and require a different consideration.

Mr. Deane, of Chatteris, in Cambridgeshire, had occasion to examine
the head of a young man after death from a blow on the left side, just
below the parietal protuberance, there being only a _slight detachment_
of the pericranium, but no fracture. On removing the skull-cap, a very
distinct fracture of the inner table, about three-quarters of an inch
long, was seen corresponding to the external part injured, extending
outwardly as far as the diploe, but no farther. The dura mater adhered
firmly everywhere, except at this part, and for some distance around,
a quantity of fluid blood being interposed between it and the bone.
If this man had outlived the first symptoms, he would not, in all
probability, have recovered without an operation for the removal of the
extravasated blood.

263. Severe effects do not always take place in such cases in the
course of the first treatment, but occur afterward; or the unfavorable
symptoms, never having been entirely removed, increase so much at a
later period as to render the aid of operative surgery necessary for
the removal of the bone, in order to save life.

M. A. Farnham, aged twenty-three, a stout, healthy-looking girl,
received a blow, two years before, from a stone falling from a door-way
under which she was passing; it struck her upon the left side of
the head at a spot an inch anterior to the parietal prominence, the
weight of the stone and the space through which it fell making the
estimated force with which it struck the head equal to sixteen pounds.
The immediate effect of the blow was insensibility, followed by acute
fixed pain in the head, which has ever since continued to mark the
seat of injury. A week after the receipt of the blow she began to lose
the power of moving the right arm, there being, however, no loss of
sensation or any disturbance of the cerebral functions.

During the following twelve mouths the symptoms remained unchanged;
this period was spent in several London hospitals; not having
derived any relief while in any of these institutions, she became an
out-patient of the Westminster Hospital.

The arm and leg of the right side were quite paralytic, the former,
which had previously been flaccid, having now become remarkably
rigid, its temperature being below that of the opposite side; vision,
particularly of the left eye, imperfect, the pupils, however, acting
naturally; hearing on that side also affected; memory bad; respiration
frequently slow and almost stertorous; the countenance had assumed a
dull, heavy expression, and she manifested an unusual tendency to sleep.

April 1st, 1841.--Mr. Guthrie this day removed a disk of bone from the
exact point in the parietal region to which she referred the pain. The
portion of bone presented no evidence of disease; its thickness varied
from two and a half to four lines, the latter measurement corresponding
to the part most distant from the sagittal suture; the vessels of the
diploe bled freely, the dura mater was quite healthy, and without any
very evident motion.

On visiting her _an hour_ after the operation, she raised the
previously paralytic arm several inches from the bed, and was able to
bend and extend the fingers. The pain in the head was considerably
less, and her countenance, before dull and heavy, was now remarkably
animated. Sensation had returned in the arm, and partially in the leg.
Her pulse was calm, and the skin cool.

Ten hours after the operation she was attacked with rigors, followed by
pyrexia and all the symptoms of commencing inflammation of the brain.
By the immediate abstraction of blood, which was three times repeated
during the succeeding twelve hours, whenever the pain in the head or
the force of the circulation increased, every bad symptom was removed.
In the course of three days the paralysis had completely disappeared,
sight and hearing again became perfect, and after passing through a
speedy convalescence, she quitted the hospital completely recovered.

She has since had some relapses of pain and uneasiness in the head,
but is altogether a different person, although of a very hysterical
temperament. The cicatrix on the head is firm, and she considers
herself to have been cured by the operation.

264. The inner table is sometimes broken in a peculiar manner, and to
this attention was first drawn in my lectures, since trepanning has
ceased to be the rule of practice in all cases of fractures. It occurs
from the blow of a sword, hatchet, or other clean-cutting instrument,
which strikes the head perpendicularly, and makes one clean cut through
the scalp and skull into the brain. This kind of cut is usually
considered as a mere solution of continuity, and not as a fracture, the
bone being apparently only divided, with scarcely any crack or fissure
extending beyond the part actually penetrated by the instrument. When
the outer table alone has been divided, the wound in the scalp should
be treated as a simple incised one, and united as quickly as possible,
a practice of which I have seen several successful instances. When the
instrument even penetrates to the diploe, the same course should be
pursued; for although the external wound may not unite by the adhesive
process, and some small exfoliations may occur, it is not common for
serious consequences to ensue under that strictly antiphlogistic
plan of treatment to which all persons with such injuries should be
subjected.

265. When the sword or ax has penetrated the inner table, the case is
of a much more serious nature; for this part will be broken almost
always to a greater extent than the outer table. It may be separated
from it, and driven into the membranes, if not into the substance of
the brain itself, the surface of the bone showing merely a separation
of the edges of the cut made into it. These cases should all be
examined carefully. The length of the wound on the top, or side, or any
part of the head which is curved and not flat, will readily show to
what depth the sword or ax has penetrated. A blunt or flat-ended probe
should in such cases be carefully passed into the wound, and being
gently pressed against one of the cut edges of the bone, its thickness
may be measured, and the presence or absence of the inner table may
thus be ascertained. If it should be separated from the diploe, the
continued but careful insertion of the probe will detect it deeper
in the wound. A further careful investigation will show the extent
in length of this separation, although not in width; and will in all
probability satisfy the surgeon that those portions of bone which have
thus been broken and driven in are sticking in or irritating the brain.
In many such cases there has not been more than a momentary stunning
felt by the patient; he says he is free from symptoms, that he is not
much hurt, and is satisfied he shall be well in a few days.

An officer was struck on the head, in Halifax, Nova Scotia, by a
drunken workman with a tomahawk, or small Indian hatchet, which made a
perpendicular cut into his left parietal bone, and knocked him down.
As he soon recovered from the blow, and suffered nothing but the
ordinary symptoms of a common wound of the head with fracture, it was
considered to be a favorable case, and was treated simply, although
with sufficient precaution. He sat up, and shaved himself until the
fourteenth day, when he observed that the corner of his mouth on the
opposite side to that on which he had been wounded was fixed, and the
other drawn aside; and that he had not the free use of the right arm
so as to enable him to shave. He was bled largely, but the symptoms
increased until he lost the use of the right side, became comatose, and
died. On examination, the inner table was found broken, separated from
the diploe, and driven through the membranes into the brain, which was
at that part soft, yellow, and in a state of suppuration.

Mr. B., of the 29th Regiment, when in Halifax, Nova Scotia, was struck,
in a drunken frolic, on the anterior part of the left parietal bone,
with his own sword, which was a straight, heavy one, and a wound
about two inches long was made in the side of his head through the
bone. His little finger was cut at the same time, and it was not until
the finger had been dressed that I was asked to look at the head,
which he declared had nothing the matter with it. He was vomited, and
purged, and the next morning bled, and as symptoms of inflammation of
the membranes of the brain came on or increased, the bleedings were
repeated, the quantity taken at each time being gradually diminished.
He lost 250 ounces of blood in five days, after which he gradually
although slowly recovered, some small spiculæ of bone coming away
during the cure. Returning to England, the vessel was taken off the
Scilly Islands, and he was sent to Verdun, where he remained several
years, until liberated by the peace of 1814, when he rejoined his
regiment, which had served in the Peninsula, and had returned to North
America. It was soon found that he became outrageous on drinking a very
little wine, and was odd in his manner, and had a great propensity to
set out walking for hours without apparently knowing what he was about,
or where he was going. When his regiment came immediately in front of
the enemy, he was found going over to their lines, without being aware
of what he was doing; and he was at last obliged to be sent to England,
having evidently become deranged. This gentleman has ever since been
confined in a private mad-house. His brother offered to allow the bone
to be removed; but after thirty years of derangement a recovery could
not be expected, and it was declined. If the examination I have since
learned to be proper in such cases, had been made at the time, the
inner table of the bone would have been found broken and depressed; and
he might now have been in health both of mind and body.

I removed, in Lisbon, in the hospital appropriated to the wounded
French prisoners in 1812, a portion of bone by the trephine, which had
been fractured by a sword some months before: the wound had not healed,
and some pieces of bone were depressed. One piece, in particular, of
the inner table, was sticking in and irritating the dura mater, and
was in all probability the immediate cause of the fits from which the
patient had been suffering. He recovered.

A British soldier received a wound at the affair of El Boden, in front
of Ciudad Rodrigo, from a sword, on the top of the head; he accompanied
me to Alfaiates, on the retreat of the army. The bone was apparently
only cut through, yet the inner table was depressed, and felt rugged
when examined with the probe. The symptoms of inflammation increasing
on the fourth day, and not being relieved by copious bleeding, I
removed a central portion of the cut bone by one large crown of the
trephine, and took away several small pieces which were sticking into
the dura mater, after which all the symptoms gradually subsided.

266. The whole of the French wounded, who remained on the ground or
were taken prisoners after the battle of Salamanca, were under my
care, and among them there were several severely wounded by sword-cuts
received in the charges of heavy cavalry made by Generals Le Merchant
and Bock. The cerebellum was laid bare in two cases without any
immediate bad effect. In one particular case, which recovered, (after
the battle of Waterloo,) the brain was seen pulsating for several
weeks; and the statements made to me by the different officers at
Brussels and Antwerp, and afterward at Yarmouth and Colchester,
entirely confirmed the observations I had made, and the recommendations
I have inculcated on this particular point as resulting from the
practice of the Peninsular war.

267. It would appear that too much stress is laid upon a difference
which is supposed to exist in the danger of trephining a man on the
first or on the seventh day after an accident; and that an error may be
committed in believing that the trephine is a more dangerous instrument
on the first day than on the seventh. The question is not whether the
man is to be trephined or not, but which will be the best and safest
day or time to do the operation. I do not hesitate to say the first,
believing the violence to be greater when done on parts already in
a state of inflammation, than when they are sound. When the inner
table has pierced the membranes and gone into the brain itself, the
individual will in most cases ultimately die miserably of the accident
if not relieved by art. It is less safe to let him designedly run the
certain risk of cerebral irritation, which when once excited is often
indomitable, than to remove the cause, and endeavor to prevent the
evil. If the cerebral irritation only manifested its effects on the
surface of the dura mater by causing suppuration there, delay might
be admitted; but as it usually gives rise under these circumstances
to the formation of matter on the surface, and even in the substance
of the brain, where it is deadly, “la chirurgie expectante” cannot
be allowed. Lastly, there is not more danger of a hernia cerebri, as
has been supposed, when the operation is done early, than when it is
done at a later period; on the contrary, the patient has a much better
chance of escape from hernia cerebri, and from all other evil, when the
local and the general treatment are decided and efficient.

If, on attempting to remove a fragment buried in the brain, serious
convulsive movements should be excited, it would be proper to desist
from all further attempts to extract the splinters until the brain has
become more quiescent.

It is necessary to recollect that the brain appears to be insensible,
or nearly so, when first exposed; and it has rarely occurred that a
serious convulsion or anything beyond vomiting has taken place on the
removal of a piece of bone from the brain; nor will any difficulty be
found in removing such small fragments as can be seen with a pair of
forceps duly adapted for the purpose. It is impossible to say at what
period of time the brain may become irritable, and no longer admit of
its being touched without convulsive movements ensuing; but when this
state of irritation has commenced, and its existence is proclaimed by
the excitement which takes place on touching the fragment of bone, the
surgeon should at once desist from all attempts to remove the foreign
body. The brain under ordinary circumstances is much more likely to
recover from an injury, all foreign or irritating matters having been
removed, than when suffering from their presence.

268. The establishment of the principles which ought to regulate the
practice of surgery in cases of fracture with depression of the inner
table of the skull, is of the greatest importance. The principle being
laid down that it is right and proper to examine all such wounds with a
blunt, flat probe, in order to ascertain if possible whether the inner
table be depressed and broken, the question necessarily arises, what is
to be done when such depression and breaking down of the inner table
have been ascertained to have taken place? There can be no hesitation
in answering, that in all such cases the trephine should be applied,
although no symptoms should exist, with the view of anticipating them.
The old doctrine, it may be said, in regard to fractures generally, is
revived in these cases, but on a principle with which our predecessors
were not sufficiently acquainted. A patient very often survives a
mere depression of the skull; he may, and occasionally does survive, a
greater depression of the inner than of the outer table; but it has not
been shown that he ever does survive and remain in tolerable health,
after a depression with fracture of the inner table, when portions of
it have been driven into the dura mater. If cases could be advanced of
complete recovery after such injuries, they would not supersede the
practice recommended, unless they were so numerous as to establish
the fact that injuries of the dura mater and brain by pieces of bone
sticking in them are curable without an operation, and without leaving
any serious defects. There are great objections to the trephine being
applied in ordinary cases of fracture, not attended by symptoms of
further mischief; but the nature of the cases particularly referred to
having been ascertained, the practice should be prompt and decisive
in every instance in which the surgeon is satisfied that there is
not merely a slight depression or separation of the inner table, but
that several points of it have been driven into the dura mater. If
one trephine will suffice, the central point being applied close to
the edge of the middle of the wound in the bone, it should be applied
there; but if the cut be longer, and the spiculæ of bone extend upward
and downward in its length, a small trephine should be applied as near
each end as may be judged advisable, and one edge of the cut bone
should be removed by the straight saw, of which Paré and Scultetus made
such use in ancient times, and which Mr. Hey of Leeds revived in modern
surgery; or the small straight saw may be used alone, if the object
of removing a portion of bone can be attained without the trephine.
By these means sufficient room will be obtained to remove the broken
pieces of bone which are irritating the dura mater and brain. The
danger resulting from the application of the trephine, in such cases,
bears no proportion to the risk incurred by leaving the broken portions
of bone as a constant cause of irritation.

269. There is an essential difference between a depression of the
skull in a CHILD and in an ADULT. In the child the inner table is not
brittle--it bends equally and does not break; it very often does little
mischief when depressed, and gradually recovers its level. The brain
in young persons is softer and less consistent, and can accommodate
itself more readily to pressure for a limited time, without ultimate
mischief, than the brain of an adult; so that a continuance of the most
urgent symptoms can alone authorize the application of the trephine in
children, and in young persons under fifteen or sixteen years of age. A
similar bending of the long bones in young children is often observed
at an early period in life.

270. The propriety of dividing the scalp in an adult, in order to
examine the state of the bone beneath, when evidently depressed, thus
rendering a simple although comminuted fracture a compound one, is
a matter of very great importance, the decision of which rests upon
the still more essential point--viz., whether a depressed portion of
bone ought or ought not to be removed? This again must depend upon the
nature and extent of the depression, for many persons who have suffered
from such a misfortune have recovered without the depressed portion
being raised. It is a question of degree or extent, upon which every
surgeon must form a judgment from his own observation and experience.

The difference between a simple and a compound fracture of the leg is
often considerable; it is more often dependent on degree. When the
fracture is nearly transverse, and the skin is cleanly divided, the
difference between it and a simple fracture of the same part is little
more than one of time. This may be the case with an injury of the head;
the difference between the two states in fractures of the skull has,
however, been much exaggerated; so much so, that no reliance can be
placed on the supposition that there is more real danger in a case of
fracture with depression in which the scalp has been divided, than when
it has been only bruised, and not divided. I admit that theoretically
it ought to be otherwise, but theory and practice do not always
correspond. In all cases in which a fracture with _marked_ depression
is known to have occurred in an ADULT, it is good practice to ascertain
the nature and extent of the depression. It is imperatively necessary
if accompanied by symptoms of compression.

If the result of a great number of comparative trials should be in
favor of never, under any circumstances, raising a depressed portion
of bone in an adult, but of leaving it to the efforts of nature, an
incision in order to ascertain the state of parts below ought not to be
made; but as such a result is not likely to be obtained, the practice
recommended appears to be the best.

The scalp should be divided, in such cases as may require the
operation, by a straight, crucial, or such other shaped incision as may
be found most convenient to the surgeon; but no part should be removed
which can be preserved with the hope of maintaining its life.

271. The cranium, together with the fracture and depression, being
exposed, the question whether the trephine should be applied or not is
next to be determined. If the operation by the trephine, or that of
sawing a piece of bone out of the head, were not in itself dangerous,
there could be no hesitation about its use; but it is a dangerous
operation, especially in crowded hospitals, and ought not to be
resorted to when it can be avoided. If any ten healthy persons were
trephined in a hospital, one would in all probability die from the
effects of the operation, and three or four more might have a narrow
escape from the inflammation of the brain and its membranes, or the
other consequences which would probably ensue. It is not the admission
of air, which has been even lately supposed to do mischief, that is
to be dreaded in these cases, but the same kind of irritation which
often follows the abstraction of a piece of bone under other and more
ordinary circumstances at a later period of time.

The following cases are illustrative of many important points:--

William Rogers, aged nineteen, of the 32d Regiment, was wounded on the
16th of June by a musket-ball, which entered at the inferior angle
of the left parietal bone, knocked him down, and for a few minutes
rendered him insensible. On recovering his mental powers, he found
that he was unable to speak, not so much (as he said afterward) from
the want of power to form words, as from the incapacity of giving them
sound. He was conscious of everything passing around him, and reasoned
correctly. He retired out of the reach of shot, and then lay down for
the night. On the following morning, he went to Brussels, where he was
examined and dressed. On the morning of the 18th he reached Antwerp
on horseback, very giddy, and overwhelmed with fatigue, fasting, and
watching; he was admitted into the Minimes General Hospital and put
to bed, when he soon fell into a sound sleep, which with some tea
refreshed him much.

June 19th. The ball was found to have passed obliquely upward and
backward at least two inches, and could be distinctly felt with a
probe. It gave more the idea of having raised the outer table than
that of having depressed the inner. The defect in speech was in some
measure diminished, and this with giddiness were the only symptoms of
compression. A poultice was placed over the wound, a brisk purgative
given, and spoon diet ordered.

20th. The pain and giddiness having increased, with annoyance from
noise and exposure to light, twenty-six ounces of blood were taken from
the arm. The following day the purgative was repeated, and the patient
was much relieved. Everything went on well, the wound was nearly
healed, and he was considered almost fit to be discharged, when, on
the 16th of July, the wound began to open; on the 18th it was dilated
and a portion of the cranium removed by the forceps; this was soon
followed by symptoms of inflammation of the brain; twenty ounces of
blood were taken immediately from the arm, purgatives and diaphoretics
were ordered, and the strictest abstinence enjoined. 23d. Venesection
was repeated, as well as the other means usually adopted to reduce high
action. 24th. Completely relieved. 26th. Another portion of the cranium
removed, the dura mater being fully exposed; the general health in the
best state.

August 3d. Doing remarkably well; the wound healthy; the pulsation of
the brain evident; the power of speech perfectly restored. The ball yet
remains in, according to the opinion of the patient, (who is a fine,
intelligent lad,) and he thinks it has gradually descended toward the
petrous portion of the left temporal bone. Sent to England at the end
of the month, the wound being healed.

When I saw this man at Antwerp I gave my opinion, without hesitation,
that the bone and the ball ought to have been removed in the first
instance, when he would have had a better chance for perfect recovery.
The operation, when afterward performed for the removal of the loose
pieces of bone, placed his life in great jeopardy. He was discharged
the service with the ball lodged, and it is more than probable that he
did not long survive, which he might have done if the ball had been
removed when it was first felt within the skull.

In the following case the ball could not perhaps have been removed in
the first instance with propriety; it might, however, have been lying
on the dura mater, or near it, within reach, and the actual state of
things ought to have been ascertained, the surgeon afterward deciding
whether any further operation were necessary.

Thomas O’Brien, 28th Regiment, aged twenty-three, was wounded by a
musket-ball on the 16th of June at Quatre Bras; the bullet penetrated
the occipital bone below and to the right of the junction of the
lambdoidal and sagittal sutures. On his arrival at Colchester, the
wound was healthy in appearance and healing rapidly. It appeared from
his own account that for some hours after the injury he was totally
deprived of sight; since that time he has been constantly more or less
affected with headaches, for which he has been prescribed occasional
cathartics and low diet. He has also been affected with pain and
weakness in both eyes, but more particularly in the right. While at
Brussels, and during his progress to Ostend, he lived very irregularly,
and was frequently intoxicated. The external wound was entirely healed
on the 20th of July, and no suspicion existed that the ball was lodged
in the brain. On the 25th matter was perceived under the scalp, and
was evacuated yesterday. To-day, the 27th, he complains of increase
of headache; pulse small and quick. V. S. ad ℥vj. Haust. cathart.
statim. 28th. In the course of this day his symptoms have become very
urgent; he is restless, with a very quick pulse; an extensive crucial
incision was made in the site of the original wound, and now for the
first time it was discovered that the ball had penetrated the brain;
several loose pieces of bone were extracted; a considerable quantity
of arterial blood was suffered to flow from the small vessels divided
in the incision. His bowels had been well opened by the cathartic. The
most vigorous treatment was continued, but the symptoms notwithstanding
increased, and he died on the morning of the 29th of July.

The ball was found lodged nearly two inches deep in the substance of
the right posterior lobe of the brain; a considerable quantity of pus
surrounded it; some inflammation of the brain and its membranes was
observed, but much less than might have been expected.

A. Clutterbuck, 61st Regiment, aged twenty-five, was wounded in the
back of the head by a musket-ball at the battle of Toulouse, on the
10th of April, 1814. He felt little inconvenience from the wound during
the first two days. On the 14th he complained of severe pain in the
head, giddiness, and dimness of sight; the face was flushed, pulse
hard and frequent. Twenty ounces of blood were taken from the arm, and
the wound enlarged so as to expose the cranium. The upper part of the
os occipitis was found fractured by the ball, and a circular portion
of it, about the size of a shilling, was depressed and fractured.
15th. Pain in the head much abated; no giddiness, dimness of sight,
or any unfavorable symptom; pulse still hard. V. S. ad ℥xx. To be
well purged. 19th. He was bled again this day to the extent of twelve
ounces, as a matter of precaution. 23d. Continues free from any bad
symptom. May 8th. The wound is now much contracted, and he feels no
inconvenience. A small portion of the bone still feels bare to the
probe, but the greater portion of the depressed piece is covered with
healthy granulations. No exfoliation has taken place. May 24th. The
wound is nearly healed; he is in good health and spirits, and without
inconvenience.

This case may be properly contrasted with that of O’Brien, as showing
by the result the difference between an uninjured and an injured brain.
If the fractured and depressed bone had not been at the back part of
the head, it is probable the depressed portion would have been removed
in the first instance, as it certainly would have been after the 15th,
if the unfavorable symptoms had not yielded to the general treatment;
but the bone would then have been removed under much more unfavorable
circumstances than at first.

The following case is related to show the extent to which blood-letting
may frequently be carried to preserve life. There having been no reason
to believe that the symptoms depended on fractured and depressed bone,
the scalp was not divided; and as the symptoms were coeval with and
not consecutive to the injury, they were therefore supposed to depend
on concussion rather than on compression of the brain. If the trephine
had been applied on the fourth day because the insensibility continued,
the additional injury would in all probability have proved fatal. If
the depletion of all kinds had been less effective, the inflammation
of the brain or of its membranes would certainly have terminated in
the effusion of lymph or the formation of matter, which the use of the
trephine would not have prevented nor removed.

George Mills, an artillery driver, aged twenty-eight, was admitted
into the Dépôt de Mendicité Hospital, Toulouse, May 29, 1814, in
consequence of having been thrown from his horse on his head against
the ground. He had fallen on the right side of the os frontis,
immediately above the eye, where the surface of the skin appeared to
be scratched and bruised, but the bone was not depressed: he was bled
freely, but remained insensible. The next morning he was again bled
to twenty ounces, which operation was repeated in the evening. On the
29th, the temporal artery was opened, and a vein in his arm at the
same time, the breathing being strong and sonorous, the eyes closely
shut, and he lying quite insensible; the pulse before the bleeding was
quick and small; after he had lost about eight ounces of arterial and
eight ounces of venous blood, it became fuller, and the breathing was
somewhat relieved; the slightest touch gave him pain, and he shrunk
from pressure made directly above the eye. The temporal artery was
again opened in the evening, and ten ounces of blood were taken away. A
purgative and a stimulating enema were ordered, and cold was constantly
applied to the head.

30th. He has been freely purged and appears more collected; the pulse
is still quick and small; breathing very free; the irritability
continues and he complains of pain on pressing the head. The purgative
and the enema were repeated, and ten ounces of blood were drawn from
the temporal artery, after which he attempted to speak. 31st. Passed
a good night; the pulse is quick and small; pain in the head still
great; was again bled to twelve ounces, and the purgative was repeated.
June 1st. Pulse quick; there is not so much pain in the injured part,
and he appears more sensible; was bled to twenty-four ounces, and the
purgative was repeated. 3d. Was again bled to ten ounces. From this
time until the 20th, he gradually improved, and was then discharged
cured.

The treatment in these cases was the same, although in one there was
no fracture, and in the other two there was fracture with depression.
The broken portions of bone did not, in Clutterbuck, appear to press
unequally on the dura mater, and it was presumed that the moderate
degree of pressure which ensued from the depression might be borne
with impunity, as it did not seem likely to be accompanied by the
projection inward of any pointed pieces which might irritate the brain.
The result confirmed the supposition and justified the treatment. If
the examination of the depressed part had led to the apprehension that
such points of bone did exist, and were sticking into and irritating
the dura mater or brain, they would have been removed, in the belief
that although they might not at the moment have given rise to any other
symptoms than those which depended on the blow, the time would come
when they would scarcely fail to cause those which usually accompany
the formation of matter within the skull. If this danger should also
be avoided, the subsequent evils which have been noticed as occurring
at a later period, and which ultimately require the same operation
for the relief of the patient after months of acute suffering, might
be encountered; for although a person may temporarily recover from an
injury in which a portion of bone has been allowed to remain a source
of irritation to the brain, it does not follow that such recovery
should be permanent. If there be a doubt on the mind of the surgeon,
whether there be or be not any pieces of bone depressed and irritating
the brain or its membranes, he should wait; this is the real difference
between the surgery of the latter part of the Peninsular war and that
of the olden time.

272. When a fracture is accompanied by depression, and the broken
portion or portions of bone would seem to be driven into the dura mater
or the brain, or to press so unequally upon them that as much mischief
is likely to ensue from leaving as from removing them, especially in
an adult or a middle-aged man, less harm will in general follow from
ascertaining the fact by dividing the scalp and removing the broken
pieces than by doing nothing, more particularly when the presence of a
foreign body has been ascertained. If there be no symptoms indicative
of mischief below the fractured part, the surgeon must then decide,
after the best estimate he is able to make, of the probable evil which
will occur from allowing the broken or depressed portions of bone to
remain.

A French grenadier was brought to the field hospital the second day
after the battle of Salamanca; he had received a blow on the left
side of the head, probably from a piece of shell, which had caused
a contusion and swelling on the left parietal bone, with a graze of
the scalp, but without any opening communicating with the bone. This
swelling, on examination, was so soft, and the feeling of depressed
bone beneath so distinct, combined with the fact of the continued
lethargic state of the patient, that an incision was made into it,
when the bone beneath was found broken into several small pieces. On
clearing away the blood, two pieces which were loose were readily
raised and removed by the elevator and forceps, and egress given to
an ounce or two of blood, which were extravasated beneath, apparently
from the rupture of the vessels passing between the dura mater and the
bone. The patient regained his senses in the course of the night and
morning of the third day, and under a strictly antiphlogistic regimen
gradually recovered, some other small pieces of bone coming away, one
or two others apparently reuniting to the uninjured parts, showing that
it is not always necessary to remove every portion of bone which may be
broken, provided any bond of union remains, and principally that which
exists between it and the dura mater.

These different cases stand out in bold relief as eminently successful
and opposed to those said to have been equally so under _la chirurgie
expectante_. They tend to show that however good a general rule may
be, it may admit of many and important exceptions; and they prove that
experience, aided by sound and correct observation, is essentially
necessary for the formation of a scientific surgeon.

273. In young persons the brain will bear a greater degree of pressure
and of irritation with impunity than it will in persons of mature age.
By far the greater number of cases in which recovery has taken place
after fracture and depression of the skull with injury of the brain,
and even loss of its substance, have occurred in children or in persons
_under the adult age_; greater reliance may therefore be placed on
the powers of nature in them; and recourse may be had less frequently
to the aid of operative surgery in order to prevent mischief than in
older persons, even when the bone is fractured as well as depressed. It
will be found, and the remark is important, that the cases of fracture
and depression reported to have been successfully treated without
operation, have occurred principally in young persons.

The result of my experience has rendered it imperative to remove at
once all portions of bone or foreign substances which have materially
injured the dura mater in adults, although no symptoms of compression
should be observed. If the wound in the dura mater should not be
sufficiently large to allow the offending body to be extracted through
it, the opening must be enlarged to enable it to be withdrawn without
further laceration.

274. Depressed portions of bone, accompanied by fracture at the
_back_ part of the head, need not necessarily be removed in the first
instance. When the fractured and depressed bone is accompanied by
symptoms of compression in an adult, which continue after the usual
antiphlogistic means and remedies have been employed in vain, and
appear to increase rather than to diminish, the broken and depressed
portion should be raised; for although the brain will bear and
accommodate itself to pressure in many persons in a manner which could
not be either foreseen or expected, it will not do so in all; and
the removal of the bone offers the best chance for relief, whether
the mischief has arisen from the pressure made by it or occurs from
the extravasation of blood beneath. When the principal symptom of
compression is a severe fixed pain in the part, although the state of
the fracture and depression would not alone have rendered the removal
of the bone positively necessary, it is advisable to do so when this
symptom is present.

The greatest discrimination is required in cases where the extent of
the injury is not so manifest and in which there is more room for
doubt. In most cases in which a slight or moderate degree of fracture
and depression of the skull has taken place, the symptoms of concussion
are present as well as those of compression. The symptoms of concussion
are, however, coeval with the injury, and although those of compression
may take place almost instantaneously, they more usually occur at a
later period of time. The symptoms of concussion may nevertheless
continue for days, more particularly the insensibility, or that state
which is approaching to it, complicating the case and embarrassing the
practitioner. In a child or young person the symptoms of compression
or irritation, when they appear even at a secondary period, may pass
away under further moderate depletion; but in an adult any undue
delay in giving the necessary relief, by the removal of the depressed
portion of bone, will in general be destructive to the patient. It is
the irritation caused by the depressed bone on the dura mater, and
communicated to the brain, which gives rise to the unfavorable symptoms
and to the formation of matter which follows them.

A gentleman received a blow on the side of the head, which knocked him
down and deprived him of his senses, from which state he partially
recovered, and vomited; some stupefaction, however, remained, although
he could be made to answer by a little importunity. Pulse 62,
irregular, breathing slow, the pupils contracting under the influence
of light; the integuments where the blow was received were soft and
swollen, in all probability from an extravasation of blood beneath.
The next day the pulse was full and regular, the pupils were dilated,
vomiting had taken place several times, and the patient answered
correctly on being sharply questioned. He was bled largely, purgatives
were administered, and cold was steadily applied to the head. He was
bled the next day; on the third the left arm became paralytic, the
pupils continued dilated, and on the fifth day paralysis implicated the
left leg as well as the arm. There could now be no doubt that the brain
was suffering from compression; but as the nerves of the excito-motory
system were unaffected, and the functions of ingestion and egestion
were satisfactorily accomplished, it was thought advisable to trust to
the efforts of nature. The swelling of the scalp was painful.

A week afterward the general symptoms were the same, or only slightly
augmented by fever; but, as the swelling of the scalp was more painful,
it was opened, and a quantity of matter was evacuated, the bone beneath
being fractured and depressed. As this operation gave some relief, it
was thought advisable to wait, with the hope that the benefit thus
obtained might prove permanent. The patient did not improve, however;
and as the symptoms of fever increased, and were accompanied at last
by rigors and great pain in the head, the depressed portions of bone
were removed, and about half an ounce of purulent matter escaped
from between the dura mater and the bone. The relief given this time
was effective, and the patient perfectly recovered. “La chirurgie
expectante” placed this man’s life in the greatest jeopardy. It was
only saved at the last moment by the aid of that surgery which ought
not to have been withheld when the paralysis, by affecting the leg as
well as the arm, demonstrated the extension of the mischief within the
head. In this instance the operation was successful, but it is not in
general so serviceable when delayed to so late a period. It is in cases
of this serious nature often a means of prevention rather than of cure.

275. When a severe blow, accompanied by a shock, as from a fall, has
been received on the head, and the skull is so thick and strong as to
be able to resist the violence thus offered without being broken, or is
only slightly fractured, the vibration or _trémoussement_ is directly
communicated to the brain, giving rise to laceration or bruising of its
structure in various situations, to the rupture and separation of the
vessels of the dura mater from the bone to which they are attached,
and to derangement of other parts, which will in all probability be
followed by inflammation, and may even terminate in the formation of
matter under the dura mater as well as above it, and even in the brain
itself. It is said to take place by “contre-coup” when the mischief
occurs in any other part of the head than that which is struck,
numerous instances of which are given by the older French authors. They
were probably cases of laceration, the consequence of concussion of the
brain, and not relievable by the art of surgery; but the injury which
the older surgeons particularly distinguished as by “contre-coup” was
where the blow was on one side, and a fracture took place or matter was
formed in a circumscribed spot on the other; these cases did sometimes,
they say, although rarely, admit of relief by operative surgery. These
cases, unaccompanied by fracture, do not appear to take place under the
improved method of treatment by larger depletion, by antimony, and by
the early use of mercury. In the event, however, of their occurring,
there is no surgeon of the present day who would attempt an operation
of exploration on the opposite side of the head to the injury, without
some sign of mischief existing at that part; although such operation,
if done, might accidentally be followed by success.



LECTURE XIX.

TUMORS OF THE SCALP, ETC.


276. When the periosteum covering the bone is bruised, or the bone is
merely deprived of this membrane, it does not follow that it should
die or exfoliate. In many instances the wound will gradually close up
and heal, as if no such accident had happened. A blow or bruise on the
head often gives rise to a swelling or tumor, from the rupture of the
small vessels passing into the cellular membrane between the scalp and
the pericranium; the tumor in these cases appears _immediately_ after
the receipt of the injury as a soft swelling, and is usually found
to contain blood, which in most instances is removed by absorption
in the course of from two to three weeks. In some cases inflammation
supervenes, and one part becomes tender and appears to point; into
this a small incision should be made to allow the blood and matter
to escape, when gentle compression should be resorted to in order to
induce the parts to unite. Swellings of this kind in new-born infants,
occurring from pressure during delivery, may be readily mistaken for
deficiencies of the occipital and parietal bones, if it were not for
the absence of all motion, which under such circumstances would be
communicated to them from the brain. The blood effused in the cellular
membrane raises the border of the swelling, which becomes harder than
the neighboring parts, while the center remains soft and yielding,
giving a sensation to the finger as if the bone beneath were wanting,
or, after a blow, the idea that the bone beneath is depressed. If
such a swelling be unnecessarily opened, considerable inflammation
and suppuration will often follow, to the great inconvenience of the
patient; this will in general be avoided by the use of a moderately
stimulating cold lotion.

277. In other cases of tumors, which are called secondary in
contradistinction to the preceding, the patients go on well for eight,
nine, or more days, at the end of which time they complain of headache,
giddiness, nausea, restlessness, thirst, and generally of fever. A
few days more, frequently from the thirteenth to the fifteenth day,
rigors, sometimes severe, are superadded, and a swelling, if not
observed before, is now perceived on the spot where the injury had been
received, if the integuments have not been divided; or, if there be a
wound, it loses its healthy red appearance, and assumes a yellowish,
unhealthy color, which is accompanied by a thinner and more acrid
discharge. From this time the symptoms gradually increase, the patients
become delirious, convulsed, comatose, and die; and matter is found
between the skull and the dura mater, or in or on the substance of the
brain. If this secondary swelling be divided, and the fluid evacuated,
which is not good pus, the pericranium will be found detached and the
bone bare.

It has been stated that a bone so circumstanced would not be found
to bleed on being scraped, and that, by attending to the want of
hemorrhage from the outside of the cranium, the extent of the evil
might be ascertained, and that so long as a denuded, discolored bone
will bleed on being scraped, it may be considered that the dura mater
is attached below, and that no operation should be performed.

The essential difference between the primary and the secondary
swellings is to be found in the fact that, although the bone be
exposed, and even in some degree may have changed its color in the
primary swelling when matter has formed, the febrile symptoms will
subside after its evacuation, healthy granulations will spring up, and
little or no exfoliation will take place. In the secondary swelling
none of these favorable symptoms or appearances will take place, for
the bone is incapable of maintaining its life, and must die. If the
outer table only be implicated, it may exfoliate; but if there be
reason to believe that matter has collected beneath, on the dura mater,
the bone should be removed by the trephine.

Inflammation of the dura mater proceeding to suppuration, or the
formation of matter between it and the bone, appears to have been a
much more common consequence of injuries of the head in former times
than at present. It is not now of frequent occurrence in London
hospitals.

As blows on the head and the structure and functions of the brain are
the same at present as formerly, the difference in regard to such
cases can only depend on the difference of treatment. It is, in fact,
infinitely more depletory now, and therefore less operative. Blood is
taken away in larger quantities, although to this there are exceptions,
depending on the constitution of the patient, which will not always
admit of it, while the potassio-tartrate of antimony and mercury are by
most surgeons administered at an early period.

Suppuration, or the formation of pus on the surface of the dura mater,
not being, under the strictly antiphlogistic and mercurial system, so
common as formerly, sufficient attention has not perhaps been paid
to another evil which frequently accompanied it in former times,
viz., suppuration on the surface and in the substance of the brain
itself; for the greater number of those who died with fracture and
depression of the skull, and whose cases are recorded, suffered also
from alteration of the structure or substance of the brain, and the
formation of matter within it or upon its surface. This termination
might not have taken place in a large proportion of the cases in which
it occurred if the depressed bone had been raised to its level, and the
irritation arising from undue or unequal pressure had been avoided.
It must be admitted, however, that an internal part of the brain may
receive such a shock at the moment of injury, as well as an external
part, that no treatment can arrest the progress of the mischief,
although it may be delayed; and when the patient dies, after four,
five, or more weeks of alternate hope and suffering, matter may be
found in some part of the brain where an injury was not suspected.

Purulent matter may be formed beneath the dura mater in a confined
spot, or it may be diffused generally over the surface of the brain, in
which case the sufferer has no chance of relief.

278. The operation of incising the dura mater, to admit of the
discharge of blood or matter from beneath, and even of puncturing the
brain, has not been much resorted to in England; this may be an error.
The records of surgery supply many cases where it might have been done
with advantage, and some in which it was done with the greatest benefit
to the patient. It is not an operation which ought to be performed
without signs sufficiently demonstrative of the necessity for doing it.

I have seen, on the removal of a portion of bone by the trephine,
the dura mater rise up rapidly into the opening so as to attain the
level of the surface of the skull, totally devoid, however, of that
pulsatory motion which usually marks its healthy state. An opening into
it, under these circumstances, has allowed a quantity of blood or of
purulent matter to escape, proving that the unnatural elevation of the
dura mater was caused by the resiliency of the brain when the opposing
pressure of the cranium was removed. This tense elevation, its abnormal
color, and the absence of pulsation are positive signs of there being
a fluid beneath, requiring an incision into the dura mater for its
evacuation. It is a point scarcely noticed in English surgery--one
which was not in the slightest degree understood at the commencement of
the war in the Peninsula.

A. Monro, of the 42d Regiment, was wounded on the 10th of April, at
Toulouse, by a musket-ball, which fractured the left parietal bone
slightly, without depressing any part of it. No symptoms followed
requiring more than ordinary attention until the 23d, up to which time
he had been kept on low diet, for the most part in bed, and had been
bled and purged. On the evening of that day he became feverish, and
hasty and odd in manner, and the pulse quickened; he declared himself,
however, to be quite well, and submitted to be bled and physicked with
great reluctance, calomel combined with opium being given him at short
intervals. On the 24th he complained of pain in the head, which he
said was very slight, and that upon the whole he was quite well, and
would not be bled nor have anything done. He was bled largely by force,
which lowered the strength of the pulse, but did not relieve any of
the symptoms of irritation of the brain. On the 25th he was evidently
worse, although he declared himself to be quite well; he talked a
little incoherently; the pupils were dilated; the pulse quick but
regular; the countenance was changed; he was sensible, apparently, upon
all points except that of being much worse, which he resolutely denied,
saying he was better and would soon be well. Satisfied that matter was
forming, or had formed, in or on his brain, I desired that the trephine
might be applied on the fractured part and the bone removed. This,
however, he would not permit the officers in charge to do, and they
awaited my return in the afternoon, when, finding him much worse, I
directed it to be done by force, three of his own regiment with others
attending to assist the surgeons. He called upon these men by name not
to allow him to be murdered in cold blood, declared he was getting
well, and would get well if let alone, and prayed them to avenge his
death on the doctors if they meddled with him. The surgeons were
dismayed, and requested that the operation, which they said required
great care, should be performed by me, their chief. I therefore removed
the bone; and the moment it was taken away the dura mater rose up in
the opening to the level of the surrounding bone, and remained without
any pulsatory motion. I had no doubt of matter being beneath, and that,
from his general state, the man would die. I did not therefore think it
prudent, under all the circumstances, to do more than warn his comrades
that, when dead, they would see the whole brain beneath in a state of
suppuration. He died that night; and the next day they saw the whole of
the left hemisphere soft, yellow, and covered with matter, to their
great surprise and satisfaction at the accuracy of the diagnosis.

Absalom Lorimer, of the 42d Regiment, was wounded by a musket-ball on
the 10th of April, 1814, at the battle of Toulouse, which carried away
a small portion of the scalp just above the right temple, fracturing
the bone slightly, but without any depression. No symptoms occurred
demanding more than ordinary attention for the first fortnight, during
which period he had been bled once, purged, and kept on low diet. On
the 25th, he complained of pain in his head around the wound, shooting
to the back part; pulse 60; pupils dilated. An incision having been
made to the bone, the pericranium was found detached, and the bone
fractured, but without any obvious depression. V. S. ad ℥xx, calomel
and colocynth: as the pain continued, the bleeding was repeated in the
evening. 26th. Pain in the head greatly relieved; pulse 60; bowels
torpid. Ten ounces of blood were taken from the temporal artery, and
the calomel and colocynth, salts and senna were repeated. On the
morning of the 29th, the symptoms of compression having increased, the
trephine was had recourse to, and the fractured portion of bone was
removed: a layer of coagulated blood was found on the dura mater, which
puffed up into the opening. In the evening he became convulsed, the
pulse intermitted, and he died. On examination, a large abscess was
found in the right hemisphere of the brain, having the ventricle for
its base, with some matter on the surface of the brain, and between the
dura mater and the bone at the base of the cranium.

On the morning of the day that I performed this operation, I had done
another of the same kind at the Hôpital des Minimes; the dura mater
rose up in a similar manner without pulsation into the opening made
by the removal of the circular piece of bone by the trephine; on
puncturing it a considerable quantity of pus oozed out. The opening
was enlarged; and the flow of matter was daily encouraged, until it
gradually diminished, and ceased with the formation of granulations,
and the drawing in and cicatrization of the part.

279. It has been supposed theoretically that a wound through the
dura mater was particularly dangerous, in consequence of the tunica
arachnoides which lines it being a serous membrane; and that, if the
inflammation which ensued did not cease at the adhesive stage, by the
consolidation of the surface which covered the pia mater with that
which lined the dura mater, a diffuse inflammation would necessarily
follow, which might spread over its whole extent. This has not been
found practically to be the case; and if a simple wound of the dura
mater be a danger that ought to be avoided, the risk run cannot be put
in comparison with that which accompanies the continuous irritation
depending on the presence of a spicula of bone, which has passed
through the dura mater, and is irritating the brain beneath. It has
also been supposed theoretically that the danger would be diminished if
the pia mater were wounded also, as the brain would project and fill
the wound; but the accuracy of this opinion may be doubted. If the dura
mater were injured through error or design, I should not think the evil
lessened by adding to it a wound of the pia mater, and perhaps also of
the brain.

By those who have been accustomed to the terrible injuries which occur
in military warfare, in which large portions of the brain are sometimes
exposed, and even lost, without much inconvenience following, the
exposure of or the opening into the dura mater is not considered of so
much importance as it is by those who have had fewer opportunities of
seeing such awful cases; while the formation and retention of matter
below the bones of the cranium is, on the other hand, more dreaded by
those who have often seen their ill effects than by those who have not
had many occasions for observing them; by whom, however, they are often
considered, when they do take place, to be irremediable by art.

280. Gunshot wounds of the skull are attended by certain peculiarities.
In ordinary circumstances there is usually an external wound and a
fracture more or less comminuted, with depression; this wound will
almost always require to be enlarged by a simple incision, so as
to show the extent of the depression or the size of the broken and
depressed portions of bone. When the bone is scarcely injured, and the
periosteum is only bruised, or when the bone is even deprived of this
covering, it does not follow that it should die or even exfoliate.
In many instances the wound will gradually close in and heal, as if
no such evil had occurred; and in those which do not terminate so
favorably, the cure may only be delayed by the exfoliation of a layer
or scale of bone from its outer surface, unless the mischief should
have implicated the parts beneath.

A musket-ball striking directly against a bone sometimes makes a hole
not larger than itself, with or without any radiating fracture; and
one large trephine, if properly applied, will often embrace the whole
of the mischief, and admit of the removal of the broken pieces. As
a center-pin cannot be used, the trephine may be made to turn very
well in most cases in a flat but thick bar of iron, having a hole in
the middle, of such a size only as will allow the polished outside
of the trephine to turn in it. Sufficient support for the instrument
will be obtained by this means until it has made a groove in the bone
for itself, when the operation may be continued as it would be in an
ordinary case after the removal of the center-pin.

When a musket-ball ranges along the side or top of the head, it
may break the outer, and depress and fracture the inner table to a
considerable extent, for the space even of three or more inches.
The broken portions of bone may in general be removed by means of
good forceps and a straight saw; and no good reason can be given for
delaying the operation unless the nature of the injury be doubtful,
when it may be as well to wait for symptoms. It sometimes happens,
although rarely, that a ball sticks so firmly in the bone that it
cannot be extracted by working round it in any ordinary way with a
pointed instrument. The difficulty usually arises from the ball having
half buried itself in the diploe, so little of it being exposed as not
to admit of a firm hold being taken of it. The large trephine, used in
the way pointed out, has several times overcome this difficulty. The
removal of the outer table has been sufficient where the inner one has
not been driven into the dura mater; when any doubt is entertained on
this point both should be removed.

281. A ball or other foreign substance may penetrate the brain
directly or obliquely. When the ball penetrates the brain directly,
it is not often that it can be removed, and the sufferer very rarely
survives beyond a few days, even if the ball has been extracted; more
particularly if the injury have occurred in the anterior part of the
substance of the brain; several persons, however, have recovered, in
whom the injury occurred toward the back part of the head, the ball
being allowed to remain. It will be better in all such cases to allow
the ball to remain, which it will often do for many days, until
circumstances render it necessary to endeavor to find it. When it can
be felt immediately under the surface of the brain, it ought to be
removed like any other foreign substance.

Dr. Rogers relates the history of an excellent case, in which a young
man aged nineteen received a wound on the frontal bone, just above the
center of the left superciliary ridge, from the bursting of a gun on
the 10th of July. It was not until the 4th of August that he discovered
a piece of iron lodged within the head, in the bottom of the wound,
(from which a considerable quantity of brain had come away,) which he
extracted the next day. It proved to be the breech-pin of the gun,
three inches in length, and three ounces in weight. By the tenth of
December his patient was perfectly cured.

When a ball strikes the head obliquely, it may enter and pass out or
lodge. Nearly all these cases die, but one occasionally escapes, and
none should be allowed to die without assistance. When the entrance and
exit of the ball are obvious, and not far distant from each other, the
splinters of bone should be removed; and if the little bridge between
the openings should be injured, the whole should be taken away by the
straight saw; an operation which cannot, however, be necessary in the
first instance, if the portion of bone be apparently sound.

At the battle of Talavera, a soldier of the 48th Regiment was brought
to me in a state of insensibility; he had received a musket-ball on the
upper part of the right side of the frontal bone, where it had entered,
and had evidently passed backward; it could be followed by the probe
rubbing against the bone for nearly four inches. The scalp over this
point was soft, as if blood were effused below; and on dividing it,
a fracture was seen bulging rather outward. The trephine was applied
forthwith, and the bone removed, together with the ball, which only
wanted a little more impetus to have come through. The brain was
injured, and the man died two days afterward.

A French grenadier was wounded at the battle of Salamanca by a
musket-ball, which struck him on the right side of the head, penetrated
the temporal muscle, and lodged in the bone beneath, giving rise to
symptoms of compression. On dividing the parts, I found that the ball
had fractured and driven in a part of the temporal bone, one portion
of the ball being above, and the other below the broken bone. The
upper half of the ball was readily removed, but several small portions
of bone were raised by the elevator and forceps before the remaining
portion of the ball could be drawn from under the bone, which was not
depressed, the ball having been cut in two by its edge. The dura mater
was bruised, but not torn through. The wound suppurated freely; several
pieces of bone exfoliated, and the patient was ultimately discharged in
progress toward a cure.

A small ball sometimes becomes so flattened by striking against
the skull as to remain undiscovered when care is not taken in the
examination. A soldier was wounded at the storming of San Sebastian
by a ball on the side of the head, which was supposed not to have
lodged. The wound did not heal, a small opening remaining, although
no exfoliation took place, and the bone did not seem to be bare. On
dividing the scalp to ascertain the cause of the delay in healing, a
small ball, quite flat, was found; it had sunk down a little below the
hole left for the discharge to which by its irritation it had given
rise.

When a larger ball or a piece of a shell strikes the head, the fracture
is usually extensive, and portions of bone, or a piece of the shell
itself, are often lodged in the substance of the brain. There is
nothing peculiar in the management of these cases, which are for the
most part unfortunate.

282. A suture may be separated by a musket-ball, which impinges with
a moderate degree of force directly upon it, but not without great
danger. It can, however, only happen in young persons in whom the
sutures are not obliterated as they are in elderly ones; in general it
takes place when the ball happens to lodge as it were between the bones
concerned in the formation of the suture. The first case of the kind
which came under my observation occurred at the taking of Oporto. I
met with a second at Albuhera, a third at Salamanca, and a fourth in a
slighter degree at Orthez.

A heavy dragoon was wounded at the battle of Salamanca by a musket-ball
in the body, which caused him to fall from his horse, injuring the
top of his head. Little attention was paid to him until mischief was
suspected from the lethargic state into which he fell, which could only
be attributed to the blow on the head, where a tumor was observable.
This, on being divided, showed a separation of the edges of the
sagittal suture, from which some blood flowed. Two crowns of the
trephine were applied on the twelfth day, in order to admit of the free
discharge of some blood which had been extravasated from a wound in the
longitudinal sinus, after which the symptoms subsided, and the patient
gradually recovered.

A ball may pass apparently through the fore part of the head from side
to side without doing much mischief beyond depriving the sufferer
of sight. It does not in these cases injure the brain, but passes
immediately below it and through the back part of both orbits. In four
such cases the recovery was rapid, but the blindness was irremediable.

283. The danger of injury to the frontal sinuses has been greatly
exaggerated, and vanishes in a great degree when attention is paid to
their structure. The uncertainty of the depth of the cavity between the
tables of the bone, and the irregularity of the exposed surface of the
inner table, which may through carelessness be mistaken for depression,
should be remembered.

A soldier of the 29th Regiment was wounded at the battle of Talavera
by a ball, which struck him on the lower part of the right side of
the forehead, fracturing the external wall of the frontal sinus. On
examination, the ball could be felt lodged in the sinus, whence it was
readily removed by enlarging the opening, and the man recovered without
any bad symptoms.

At the storming of Badajos, a soldier of one of the regiments engaged
at the little breach was struck by a small ball about the size of a
swan-shot; it penetrated the frontal sinus of the right side, and stuck
in the inner table, the outer being considerably injured and splintered
by the blow. The splinters having been removed, the small ball could
be seen sticking in the inner table of the bone, whence it was easily
extracted, leaving the dura mater bare beneath. He was sent to Elvas,
and recovered with a good and firm cicatrix.

After a wound of the frontal sinus has healed, the air has been known
to raise up the integuments of the forehead into an elastic crepitating
swelling whenever the patient blew his nose, so that a compress and
bandage on the part were required for its relief; but these cases are
very rare.

284. Wounds of the bony parts within the orbit are often attended by
the most serious consequences. A boy, nine years of age, was struck by
his playfellow with the end of a thick iron wire on the right eye,
which blackened it. There was no external wound; but as there was
some bloody chemosis at the upper part and the inside, there was a
probability of the wire having penetrated deeply, although the opening
could not be discovered by the probe. The accident had happened two
days before, but he did not think himself ill. He was well purged, and
cold water was applied externally. Two days after, he complained of
sickness, headache, and some pain over the brow. He was bled freely
from the temple of that side by leeches, and well purged by calomel
and jalap. On the sixth day his mother reported him as having been
delirious and restless all night. He was found stupefied, answering
with difficulty and incoherently; pulse very quick, skin hot and dry,
with some convulsive twitches of the face and arms; pupils slightly
obeying the influence of a strong light, but not dilated. He was again
bled freely from the temple, but his breathing became more difficult,
he fell into a comatose state, and died in the night. On examining the
head, the stiff iron wire was found to have passed under the upper
eyelid, between it and the eye, through the posterior part of the
orbitar plate of the frontal bone and into the anterior lobe of the
brain, which was softened at that part, and bedewed with matter.

A woman, who had been struck by her husband on the left eye with a
tobacco-pipe, while preparing her frying-pan for cooking, knocked him
down with the pan, and ruptured his right eye, which was lost. She then
pulled out a piece of the pipe which was sticking in the orbit, between
the lid and upper and inside of her own eye, which was uninjured. She
complained of little but the bruise, and rather brought her husband
than herself for advice. Bled and purged, she did not complain of
anything for several days, when she said she had been very ill all
night, with nausea, headache, and shivering; with hot and dry skin,
pulse very quick, the upper eyelid paralytic; she looked very ill,
became delirious at night, and died two days after the first complaint
of serious illness. On examination, half an inch of the red waxed end
of the tobacco-pipe was found to have gone through the sphenoid bone,
by the side of the sella turcica, and to have lodged in the brain,
whence it was removed bedewed with pus, the brain being yellow and
softened around it.

A wound of the longitudinal or lateral sinuses, allowing a free
discharge of the blood poured out, is of comparatively little
consequence. It is, on the contrary, a very fatal injury when the blood
is permitted to accumulate.

285. A protrusion of the brain, often improperly called a fungus
cerebri, is of two kinds, and occurs at different periods of time.
The first kind is principally composed of coagulated blood, usually
appears immediately after, or within two days after, the injury,
and is generally fatal. The second takes place at a later period,
although it has occurred on the third or fourth day, and is formed for
the most part of brain. These protrusions rarely take place when a
considerable portion of the skull has been lost or removed, the brain
then being able to expand to such an extent as the inflammatory impulse
from within may render necessary. When the opening is small, and the
dura mater has not been injured, it has seldom been observed. It is
then principally when the opening in the skull has been of greater
extent than the size of one piece of bone removed by the trephine,
the dura mater having yielded either in consequence of the injury or
by ulceration, that this evil takes place; it is not, under proper
treatment, a fatal, although it is always an extremely dangerous
occurrence.

In the first kind of protrusion, the dura mater must necessarily be
torn to some extent, and the tumor which comes through it is of a
dark-brown color, glazed and covered in general by the pia mater.
These protrusions were accompanied, in every case I have seen, by
delirium and other symptoms of inflammation of the brain and of its
membranes, and not by coma, until near the fatal termination of the
disease. I have seen them torn off by the patients themselves during
life, or before death; and satisfied myself that they all arose from
hemorrhage into the substance of the brain, probably immediately below
its surface, which became more elevated as the inflammation proceeded,
and was gradually protruded at the part where there was the least
opposition. When the tumor was torn off, little hemorrhage ensued, but
a dark-brown blood cavity was seen in the substance of the brain; and
when cut off and examined, the protruded part seemed to be covered by
the pia mater, with or without a layer of cerebral matter, and was made
up generally of coagulated blood. No case of this kind recovered.

In the second kind of protrusion, or that which usually although not
necessarily takes place when the first or active inflammatory symptoms
are on the decline, the tumor is formed of the substance of the
brain. It has been supposed that in whatever manner a case of hernia
cerebri may arrive at a favorable termination, there must inevitably
be a loss of brain proportionate to the extent of the protrusion--a
conclusion which the experience of the Peninsular war did not confirm,
while it may lead to the establishment of an erroneous practice for
the too early removal of the protrusion. The loss of a portion of
one of the hemispheres of the brain is now known to occasion little
or no inconvenience in many instances, either to the intellectual or
corporeal faculties; nevertheless, as the precise quantity of brain
which a person may lose with impunity has not been ascertained, it may
be as well not to deprive a patient of any, provided its removal can
be dispensed with; and that it may be so dispensed with, the practice
of that war gave positive proof in several instances, by the protruded
part being gradually withdrawn within the skull, the wound having
afterward healed by the ordinary processes of nature.

There were three cases of recovery from a protrusion of the brain after
the battle of Toulouse.

Bernard Duffy, 40th Regiment, aged twenty-four, was wounded on the 10th
of April, and admitted into the Caserne de Calvete Hospital, on the
13th, with fracture and depression of the upper part of the os frontis.
Some portions of detached bone were removed; he was largely bled and
purged.

On the 14th, he complained of severe pain in the head, giddiness,
dimness of sight, and drowsiness. The pupils were much dilated; pulse
60, and full. An incision was made down to the bone, and the divided
arteries were allowed to bleed freely. One perforation was made by the
trephine, and the whole of the detached and depressed pieces of bone,
which were of considerable size, were removed, one of them having
penetrated the dura mater.--15th. Has less pain in the head; pulse full
and slow; pupils dilated, with a tendency to coma, but he is sensible
when spoken to. V. S. ad ℥xxiv. Continue the purgatives.--18th. Is
less drowsy; pupils more contracted. The surface of the dura mater is
sloughy, and a small, dark-colored excrescence is rising up through
the opening in the cranium.--22d. The fungus cerebri has considerably
increased in size during the last few days; in other respects he is
doing well.--24th. The wound looks clean; the discharge is healthy.
The fungus increases in size, and is rather above the edges of the
wound; some sloughs have separated from it, and it has now a red and
tolerably clean appearance.--26th. The wound granulates regularly;
the excrescence seems to enlarge rather at the base than at the upper
part; it was touched slightly with lunar caustic without any pain
or unpleasant symptom being produced.--30th. Continues doing well.
The pupils are still somewhat dilated, but contract readily on the
admission of light; appetite good; bowels regular; and the patient
says he has no complaint. Discharge from the wound healthy; the fungus
is prevented from increasing by a slight application of the argenti
nitras every second day. He has not required any medicine for some
time past.--May 6th. The wound has closed around the fungus, which is
a little above its edges; it is touched slightly every day with lunar
caustic or the sulphate of copper. The pulsation of the brain elevating
and depressing the fungus is perfectly distinct; no constitutional
derangement. Was discharged cured to Bordeaux.

William Donaldson was admitted, on the 13th of April, 1814, into the
Dépôt de Mendicité Hospital, having received a gunshot wound in the
head on the 10th of April, which fractured the right parietal bone to a
considerable extent. The brain protrudes; pulse quick and small; bowels
open. V. S. ad ℥xvi.--14th. The pulsation of the brain is evident,
and the protrusion increases; he complains of no particular pain; the
discharge is profuse, and of a thin, black, watery quality; pulse 90;
bowels freely open. V. S. ad ℥xvi. Continue the purgatives.--15th.
The pulse and bowels natural, the protrusion has scarcely increased;
discharge profuse, and still gleety; a small compress was laid over
the dressings, and a bandage was lightly applied.--16th. Pulse and
secretions natural; the wound looks more healthy; the discharge
something better in appearance; the fungus does not increase.--19th.
Is doing well, and does not complain of pain; functions natural;
the protrusion somewhat less; discharge good. A small quantity
of cloth has come away.--21st. Discharge improved. Continue the
purgatives.--26th. The protrusion evidently diminishes, and begins
to heal at the edges.--30th. The hernia cerebri has considerably
diminished; secretions natural; a small quantity of bone has come away;
discharge diminished.--May 4th. The wound is healing rapidly; the
patient is now permitted to get out of bed, and has half diet. Another
very small piece of bone has come away.--10th. The wound is now nearly
healed.--Between the 15th and the 25th several small pieces of bone
came away.--On the 26th, on introducing the probe, a small piece of
bone followed it; and on further examination a large piece was felt
quite loose, and was removed by incision. Discharged cured to Bordeaux.

Gentle pressure was made on the protrusions, according to the feelings
of the individuals, in both these cases; when made too firmly, it gave
rise to swimmings and pain in the head, retardation of the pulse,
a sense of sickness and fainting, and on one occasion to syncope.
Pressure could only be borne when very lightly applied while the
protrusion was increasing, but could be gradually augmented when
it became stationary, and during its diminution and secession. The
pressure was continued until after the wound had healed.

I had occasion, at Santander, to remove a portion of bone, including
the upper part of the lambdoidal suture of the right side, from the
head of a soldier of the Light Division, in consequence of symptoms
of irritation having come on after an irregularity in drinking. He
had been wounded by a musket-ball on the heights of Vera, which had
fractured and depressed the skull at that part some weeks before.
A piece of bone was depressed, and had irritated the dura mater at
the part; the membrane had some matter upon its surface, and was
evidently abraded. The operation gave relief, but a tumor soon sprang
up, evidently composed of brain. The patient was again bled, purged,
and starved; calomel and opium were given in moderate doses, and the
protrusion ceased to increase; about the same time it changed color,
became yellow, fetid, softer, and soon wasted away, pieces of dead
matter separating at each dressing, until it sunk within the level of
the skull; after which healthy granulations sprung up, and the wound
healed.

In the fatal cases, paralysis, accompanied by stupor and other symptoms
of compression of the brain, invariably supervened before death.

The preceding cases prove that persons may recover after having had a
protrusion of the brain, without as well as with the loss of a portion
of its substance, the difference in all probability between the cases
being dependent on the degree of mischief which gave rise to them. In
the fatal cases I have seen, the protrusion was manifestly a part of
the substance of the brain, and firmer than the hemisphere beneath,
which was soft, pulpy, and of a yellow and sometimes of a reddish
color, the lateral ventricle being filled with a sero-purulent matter,
pus being also spread over the surface and intermingled with the pulpy
structure, into which the brain had been changed. The protrusion was
the consequence of low inflammation of the brain; and greater caution
had been necessary during the progress of the mischief than had been
enforced. It was the observation of this, and of other circumstances
not less important, which led me to enjoin that rigid system of
management insisted upon in all cases of injury of the head. There can
be no doubt that the formation of many of these protrusions was aided
by the opening made in the dura mater, which would have restrained
their growth if it had been sound. The dura mater therefore should
never be opened if it can be avoided.

It has been proposed to destroy protrusions of the brain with
escharotics, and by ligature; and more faith has sometimes been
placed in the knife for their early removal than in the more deferred
operations of nature. Greater reliance may, however, be placed on
the efforts of nature, assisted by a methodical treatment of the low
inflammatory state of the brain, and by such pressure at a later period
as can be borne with comfort, and persisted in with propriety.

286. It has been supposed that abscess of the liver followed injuries
of the head in a more peculiar manner than injuries of other parts
of the body, an opinion upon which too much reliance should not be
placed; for experience has induced me to think that unless the liver
be really injured by a fall or blow, it only becomes affected in a
secondary manner, in a similar way to the lungs or other viscera, or
to the joints or other parts. The new disease in these cases is always
insidious in its nature and progress, and for the most part fatal in
its result, as has been explained at length, (Aph. 59, p. 62, et seq.)

287. When a person has received a serious blow on the head, which
has given rise to an exfoliation of the bone, or to a very slight
depression of the skull, he is rarely restored to his previous healthy
and natural state. The scalp adheres firmly to the bone beneath,
instead of sliding loosely over it, and a deep hollow is formed, which
would imply that greater mischief had been done and a greater loss of
bone had been sustained than had actually occurred. This is the more
remarkable when pieces of bone have been removed. Major D., of the
Indian army, was wounded on the left side of the forehead, at its upper
part, by a musket-ball, at the assault of Maheidpoor. Several pieces
of bone were removed, and the pulsation of the brain was evident under
the discharge. The point of a little finger passes into the hole left
by the cicatrization of the wound, to a greater extent than might be
expected. This officer suffers from headaches, augmented or brought
on by any exertion of body or mind. He cannot bear exposure to the
heat of the sun. He can scarcely drink three glasses of wine without
feeling their effect. Persons so afflicted can bear no great exertion
of any kind. They fall down under exposure to heat. They are easily
inebriated, rendered furious by a small quantity of liquor, and often
become stupefied, comatose, or even die suddenly. In addition to these
evils, which may be avoided by care, many are subjected to fits, which
are apparently epileptic; and others suffer from such intolerable
pain in the part injured, as well as in the head generally, as to be
desirous of seeking relief by an operation, even at the risk of life.

These injuries are often accompanied during their progress by mental
defects which time does not always remove. The memory is very often
much impaired; it is frequently defective as to things as well as
to persons. The sight of one or of both eyes may be impaired, or
even lost. Ptosis, or a falling of the upper lid, is not an uncommon
although a more curable defect. Speech is not only difficult, but
the power of uttering certain words is often lost; a language is
occasionally for a time forgotten, and a sort of conventional one has
even been adopted, under my own observation. The more serious evils
which befall these unfortunate sufferers are aberrations of mind,
rendering some degree of restraint necessary, or a state of fatuity,
which is not less distressing. These intellectual defects are often
accompanied by various states of lameness or debility, from which
there is but little hope of recovery. Pathologists have supposed that
concussion of the brain is frequently accompanied by, and may indeed
be essentially dependent on, small extravasations of blood in various
parts of or throughout the brain, not larger than the point or head of
a small pin, constituting, in fact, a derangement which, when general,
is destructive of life, and, when partial, may sometimes be the cause
of the various defects which follow injuries of the head.

288. It is an interesting fact that a person who has been shot in
the head, or has fallen from the top of a house, so as to become
insensible, has no knowledge of the circumstance; and when, after
several days or weeks, he regains his senses, he has no recollection
of the injury, or of having received the wound; or if he should have
fallen from a height, he only remembers that he was aware he was about
to fall, but of the actual descent, or of the injury, he knows nothing.

289. The trephine, which is worked by turning the hand, and makes
therefore only a half turn, necessarily saws unequally; but the
operator has the advantage of being able to press with it on any
particular part as the sawing of the bone draws to a close, and can
thus cut any portion of the bone which is thicker than the rest without
wounding the dura mater. The division and yielding of the last layer of
bone is very sensibly felt by the hand, and when sawing, the surgeon
can use the trephine as a slight lever with great effect, by pressing
on a particular part, or from side to side, and the inner layer of the
vitreous table may be in this manner as much broken as sawn through.
The piece to be removed should never be brought away in the crown of
the trephine, but should be raised by the forceps and lever; whenever a
rough edge of the inner table remains, it should be carefully rounded
off with the lenticular or blunt-ended instrument commonly used for
that purpose.

290. Whenever there has been a loss of the integuments or scalp, so
that this part cannot be brought over the opening made by the removal
of the bone, some fine soft cotton should be laid on the dura mater,
so that a slight degree of support may be given to that membrane, more
particularly when it is thought that it may not be necessary to examine
it for two or three days. When circumstances appear to render a daily
inspection necessary, the cut portions of the scalp should be brought
over the opening, and retained by a slight compress and bandage kept
constantly wet and cold. The dura mater usually changes color and
becomes more red; a layer of lymph is seen adhering to it, from which
granulations arise and spring up until they touch the scalp, to which
they unite, or cicatrization takes place. When the patient dies early
from other causes, and the calvarium has been raised, the discolored
spot on the dura mater marks the place from over which the bone was
removed. I have seen this in a state of slough, and the only apparent
discoverable mark of disease.

One of the improvements in modern surgery is to be found in the
restriction which has gradually been placed on the repeated use of the
trephine on the same person, and on the removal of large portions of
the skull. Cases are not, however, wanting in the older authors which
would appear to justify the proceeding, although it may perhaps be said
that they only show how great an extent of injury may sometimes be
committed with impunity.

Saviard trepanned one person twenty times. Russ Martel and Le Gendre,
surgeons to the King of Navarre, say that in the year 1686 they took
away nearly both parietal bones, and the patient recovered and lived
for thirty years afterward, half his body, however, being paralyzed.
Marechal applied the trephine twelve times successfully, Gooch thirteen
times, Desportes twelve times. Saviard says that he had under his
care a woman whose parietal bones, together with a great part of the
occipital and frontal, separated at the end of two years after a
blow; the bones thus separated resembled a calvarium sawn off a dead
person. No fungus or hernia took place, and she lived for several years
afterward.

Dr. Drummond, deputy inspector-general of hospitals, has published
the case of a seaman belonging to H.M.S. “Mutine,” who in 1845 fell
down some stone steps at Sierra Leone, receiving a contused wound on
the scalp, for which he was admitted into the Royal Naval Hospital
at Plymouth in October of the same year. The bone, which was not
supposed to have been injured, was then found to be denuded of its
pericranium to some extent, (left side of occipital.) After an attack
of erysipelas, followed by numerous purulent deposits under the scalp,
necrosis went on rapidly; there was oozing of pus from beneath the
diseased bones, and gaping of the coronal and sagittal sutures, the
brain pulsating very distinctly in the spaces. In July, 1846, he was
removed to Melville Naval Hospital at Chatham. During the six years
he has been under observation, there have been repeated attacks of
erysipelas, followed by profuse suppuration. Both tables of the bones
have suffered in some places; in others only the external. About five
square inches have been lost from the right side of the frontal, right
parietal, and squamous part of the right temporal. The whole of the
occipital to within a short space of the foramen magnum is deficient,
with the exception of about two inches in the center of the bone,
which are now undergoing the process of separation. On the left side,
Dr. Drummond adds, there has been less destruction of the bones, but
extensive caries was going on there, and fetid pus was being discharged
from several openings at the date when the case was reported, (April,
1851.) At no point was there any tendency to reproduction of bone, or
arrest of the disease.

291. The removal of a large portion of the skull may be necessary
where the broken portions are deprived of their natural support and
connections, but as little should be taken away as possible. When the
loss of sense and motion is accompanied by fracture, and continues to
increase rather than to diminish, after the necessary and usual means
have been adopted for its relief, a piece of bone should be removed.
If blood should be found in any quantity on the dura mater, it may be
necessary to take away more bone to admit of its free discharge; for
although the gradual pressure of the brain from within will tend to
expel it, this object may not be attained in sufficient time, and the
patient may be lost. The older surgeons in these cases were anxious to
ascertain how far or to what extent the dura mater was separated from
the skull, and they often removed large portions of bone accordingly;
although their practice should not be implicitly followed, repeated
observation has shown that modern surgeons have often fallen too
much into the opposite extreme of doing nothing. When blood has
been evacuated in this manner, the parts must pass from a state of
inflammation into that of suppuration before the dura mater can again
adhere to the superincumbent bone, and care must be taken that the
matter shall have a free discharge. If symptoms of fever, followed by
those of commencing compression, should supervene from the granulations
arising from the dura mater filling up the opening and preventing
its exit, they should be excised; or if the matter should have
gravitated in a direction which does not admit of its being discharged,
the opening in the skull should be increased so as to remove the
impediment, and thereby lessen the danger.

A layer of blood is often extravasated very thinly over the whole
surface of the brain and cannot be removed, although it may be
absorbed. It is, on the other hand, often collected in larger quantity
on the basis of the cranium, whence it will not be absorbed and cannot
be removed. It may be extravasated without reference to the part on
which the blow has been received, giving rise in the end to symptoms of
epilepsy or apoplexy, for the relief of which no surgical operation can
avail; but when a blow has been undoubtedly received on a part of the
skull, and any sign of mischief can be perceived on or in that part,
the removal of the bone is permissible.

292. The wind of a cannon-ball has been supposed to exert some
influence on the brain when passing close to the head; there is,
however, no valid foundation for the opinion. An officer of the fifth
division was struck by a cannon-shot, during the assault of Badajos,
on the right side of the head and face. It carried away the right
eye and the whole face, the left eye hanging in the orbit, the floor
of which was destroyed. A part of the lower jaw remained on the left
side, but a great part of the tongue was gone. He had lost a large
quantity of blood, but was quite sensible. In the middle of the next
day he suffered much from the want of water to moisten his throat,
which could not be procured. After a distressing delay of three or four
hours under a hot sun, a small quantity was obtained, the arrival of
which he observed; and while I was giving directions relative to its
distribution, I felt a gentle tap on my shoulder, and on turning round
saw this unfortunate man standing behind me, a terrific object, holding
out a small cup for water, not one drop of which he could swallow.
Alone among strangers, he felt that every kindness in our power to
offer was bestowed upon him, and he contrived to write his thanks with
a pencil, which he gave me when he pressed my hand at parting at eleven
at night. I was glad at sunrise to find he had just expired.

293. When a portion of bone is as it were sliced off with the scalp and
adheres to it firmly, the scalp and bone should be reapplied; and the
cure will often be effected without difficulty. When the portion of
bone cut off and hanging to the scalp, which is turned down, has but
little adherence, it should be removed.

A German dragoon was brought to me in front of Madrid, who had
received a slicing cut of this kind on the top and side of the head,
which caused a portion of the scalp and parietal bone to be turned down
over the ear, uncovering the dura mater. Replaced and retained in its
situation, the flap and bone appeared to adhere, and the man recovered.
In the case of a Portuguese soldier cut down by the French cavalry in
a sortie during the second investment of Badajos, a portion of bone
cut off with a flap was quite loose, and was removed. The patient did
equally well.

In the museum of the Royal College of Surgeons there are ten skulls
which have suffered from very severe slicing cuts. They appear to have
been collected from the burial-place of some establishment for invalid
soldiers in Germany. The portions of bone thus sliced, and they are
large pieces, were once detached, and afterward reunited a little out
of their proper places, so that the points of separation and of union
can be distinctly seen. These fissures are all in a certain state of
progress toward being filled up by bone, and the patients must have
lived some months, if not years, after the receipt of their respective
injuries; for bone is deposited apparently with difficulty and most
carefully in all such cases, so as not to irritate the membranes of the
brain. The opening in the first instance is filled up by granulations,
over which a thin skin is formed; this afterward becomes firmer and
harder, being in some cases, where the trephine had been used, a thin
but strong membranous expansion extending from one edge of bone to the
other. In others it is thicker and more solid, and in a few instances
osseous matter is deposited in its circumference, so as in part to
fill up the opening, the edges of the bony circle made by the trephine
becoming gradually thinner as they appear to grow inward. It is common
for an exfoliation to take place in such cases from the edges of
the cut bone, and from the circle made by the trephine. It has been
occasionally observed, after death, that the circular cut edge of the
bone does not become thin in the manner described, but that a sort of
ridge forms around and within it.

When the scalp is torn down without being much bruised, and a large
flap extending from the occiput to the forehead falls down on the
shoulder, covered with blood or dirt, the flap should be cleansed and
restored to its place. When it is large, two or three sutures may be
necessary to keep it in its proper situation. The flap may not entirely
adhere under any management, but it will do so in parts; and care
should be taken to evacuate at an early period any matter which may
form by small but sufficient incisions made where required; this will
in general be above and about the ear. When the flap is much bruised,
the attempt at adhesion by close apposition will be useless until after
suppuration has taken place, when a well-regulated pressure will do
much toward expediting the cure.

294. Erysipelas occurs in two forms: when the skin has the ordinary
redness characteristic of the complaint, and when the color of the
skin is not altered or is whiter than natural, but puffed, tense, and
shining, the inflammation being seated beneath the tendinous expansion
of the occipito-frontalis muscle.

The general treatment should be regulated by the powers of the patient
and the state of the constitution, (Aph. 24, page 39.) The local
treatment of the first form essentially depends on puncturing the red
and inflamed skin all over with the point of a lancet, assisting the
flow of blood by warm fomentations. The punctures should be repeated,
if necessary. The second form is to be treated by incisions, perhaps
the greatest improvement of the surgery of the Peninsular war.

The scalp in such cases is in a state of general puffiness, causing
the head to look considerably larger than usual, but without redness;
it retains the impression of the finger. Incisions are to be made in
the scalp from two to four or six inches in length, united by others,
if necessary. The scalp will often be upward of an inch in thickness,
and filled with a fluid partly serous, partly purulent. The small
arteries bleed freely, and should be allowed to do so as long as may
be desirable, when the hemorrhage should be arrested by pressure.
The head should be fomented. The essential points are, to take off
tension, and to allow the free discharge of any fluid which may be
secreted. The moment the parts around a wound have become puffy, the
surface of the wound changing from a red to a yellowish color, with
a thin discharge instead of good pus, an incision should be made
through them, and repeated, if necessary. It relieves the tension and
the irritative fever, and prevents the delirium which would follow;
which neither bleeding, purging, nor the other constitutional remedies
which the state of fever may indicate will remove. If it should be
neglected, suppuration and sloughing will extend under the tendon of
the occipito-frontalis, or the fascia of the temporal muscle, and the
greatest danger will be incurred from this additional cause.



LECTURE XX.

WOUNDS OF THE CHEST.


295. Wounds penetrating the wall of the chest, and implicating any part
or portion of its cavity or contents, are among the most dangerous of
injuries. They require in their treatment a more careful attention and
a greater extent of knowledge than most others which befall mankind.
The means which the improved methods of auscultation have afforded
cause the progress of the symptoms which follow to be less obscure,
and lead to a less doubtful practice than formerly; while they render
a knowledge of this branch of medical science an essential part of the
education of a surgeon.

296. _Incised_ or _punctured wounds_, from swords, lances, bayonets,
or knives, require a treatment _essentially distinct_ on many points
from that of _gunshot_ wounds, especially in the commencement. On this
early treatment so much depends, that details of the more serious or
more important cases are rarely found among the records of injuries
sustained on the field of battle, where so much is often to be done,
and so few are to be found to do it.

The simplest of the more serious results from injuries not penetrating
the chest is the occurrence of inflammation, either of its lining
membrane, giving rise to what is called _pleuritis_, or of the
substance of the lung, termed _pneumonia_, or of both, constituting
what has been named _pleuro-pneumonia_; but many severe blows on the
chest are not followed by such serious consequences.

On the 17th August, 1808, in the act of leaving the village of
Colombeira to ascend the heights of Roliça, a soldier was shot in the
leg: he jumped up three or four feet, and made a considerable outcry.
A second was struck at the same time by a ball on the shoulder, which
did not penetrate, but gave him great pain. A third received a ball on
his buff-leather belt, on the right breast. The noise made by these
two blows was unmistakable. I saw this man fall, and supposed he was
killed: the ball, however, had only gone through his belt, and made a
mark on his chest, over the cartilage of the fourth rib, the hardness
and elasticity of which had prevented further mischief. He recovered
in a short time, spat a little blood in the night, and after a large
bleeding was enabled to accompany me on the 20th to Vimiera, ready for
the fight next morning.

A soldier was struck on the hill of Talavera,[4] on the breast-plate
by a ball, which, as he believed, had gone through his body. He was
as white as a sheet, and desperately frightened. On opening his coat,
I found the ball had indented the breast-plate, and made a round,
red mark on the skin, without going deeper. I did not see him again
for several days, until after crossing the bridge of Arzobispo, on
the retreat to Truxillo. He was then engaged in disemboweling a fine
fat wild hog, among a herd of which we had, unluckily for them, just
fallen. He recognized me at once; said that, as I told him, he had
been more frightened than hurt; that he had been bled largely and well
physicked, and after two or three days had thought no more of it. I am
bound to add that, in gratitude, he offered me a leg of the pig, which,
having nothing to eat, I could not but accept. It supplied a dinner for
three others who are now no more.

[Footnote 4: The Duke of Wellington received a blow from a spent ball
at the same time, near the left clavicle.]

A soldier of the 40th Regiment slipped from the ladder on which he was
attempting to scale the wall near the great breach of Badajos, and fell
on his cartridge-box, which hurt his left side so much as to render him
unable to move for some time. On the 8th of April he was much worse.
The part injured was painful to the touch; the difficulty of breathing
considerable; cough hard, with little expectoration; pulse 90, skin
hot, appetite gone, tongue white. V. S. ad ℥xvj, and aperients. 9th.
Better; pain less; expectoration more in quantity, and viscid. V. S.
ad ℥xii; antimonials. 10th. Pain still felt on coughing; expectoration
reddish; difficulty of breathing greater. Pil. cal. et antim. c. opio;
V. S. ad ℥xvj. He gradually recovered (his mouth having become slightly
sore) from what was manifestly an attack of pneumonia. A gentleman, in
1835, fell from his shooting-pony on his powder-horn, which bruised his
right side from the seventh to the last rib, and, as he said, knocked
the breath out of his body, and hurt him so much as to render him
incapable of walking from one room to another from pain in the side,
back, and thigh. No bones were broken. The pain, on the second day,
was augmented on breathing and on attempting to cough. The third day
he was purged, and blooded to sixteen ounces, which gave some relief;
but as the symptoms increased on the fourth day, he was more carefully
examined. His right side could not bear pressure. The respiratory
murmur was distinct, but accompanied by a crepitating rhonchus under
the part injured. Cough troublesome; expectoration mucous, viscid,
and of a reddish tinge. Antim. p. tart. and sulphas magnesiæ, every
four hours. V. S. ad ℥xiv. On the fifth day, the symptoms being little
altered, he was cupped on the part affected to fourteen ounces. On
the sixth, the pain was only felt on coughing, or on drawing a very
full breath; expectoration redder and thicker; pulse quicker. The
rhonchus was quite as distinct. V. S. ad ℥xij, and the medicines to be
continued. After this he quickly recovered and the natural respiration
became distinct.

Lieutenant Cooke Tylden Patterson, of the Light Division, was struck
on the left breast by a musket-ball, on the morning of the 15th of
July, 1813, in front of the village of Vera, in the Pyrenees. He fell
on his back breathless, as if he were killed. While waiting the order
to advance, he had been reading Gil Blas in Spanish, and on receiving
it, had hastily put the book in the breast pocket of his coat. The
ball had struck this, but, unable to penetrate it, had fallen on the
ground at his feet, completely flattened on one side, and marked with
the impression of the braid of his coat. A piece of the cover of the
book, about the size of a half-crown, was driven in, and the leaves
throughout were indented by the ball. It was some days before the
effects of the blow entirely subsided.

A soldier of the 97th Regiment was struck at the unsuccessful assault
of Fort Christoval, opposite Badajos, by a musket-ball, which went
through his brass breast-plate and coat, drove his shirt through the
skin, and against the sternum, which it was not able to penetrate. He
fell, and was supposed to be killed, but he soon recovered and ran to
the rear. The ball was found flattened between his shirt and coat. The
part of the chest was very black next day, the spot struck by the ball
being much bruised. It was necessary to bleed him largely. When the
integuments are painful, although merely bruised, the diluted tincture
of arnica is a useful application, and Scheele’s hydrocyanic acid, six
drops to an ounce of water, is said to be efficacious.

Major Lightfoot was struck by a musket-ball on the left breast; it
went through his clothes, the integuments and the outer part of the
great pectoral muscle, and slanted inward for three inches toward
the sternum, to which distance its track could be followed. It was
evident that the ball had neither lodged nor penetrated, for no serious
symptoms ensued. In all probability it had been ejected the way it went
in by the elasticity of the cartilages of the ribs near the sternum.

297. In order to understand, or to become in any way acquainted with
the changes from the natural structure which are going on under
derangement in the chest, even from simple injuries, it is always
necessary to have recourse to auscultation, and sometimes, although
more rarely, to percussion, if the external parts are not too tender.
Under all circumstances both sides of the chest should be examined
by the stethoscope. As the ordinary breathing of an individual is
rarely sufficiently strong to enable the auscultator to hear it with
distinctness, the patient should be desired to inspire fully and
more quickly than usual, without much effort, and without noise from
the mouth or nose, or retaining his breath. The inspiration and the
expiration are both to be carefully observed.

When the ear is firmly and equably applied to the chest of a healthy
young person, a very distinct and long-continued sound is heard at
the moment of inspiration, and another at that of expiration. This
is called the _vesicular_ or _respiratory murmur_, and is dependent
on the air fully permeating and distending the air-vesicles of the
lungs. It has been poetically compared to the sound of a gentle gale
rustling in a thick summer foliage--to the whisper of a retiring wave
on a sandy beach in a calm day. It is soft, scarcely sonorous, equable,
and during inspiration continuous. In childhood it is louder than in
adult persons, arising probably from the greater activity of the lungs
in young than in elderly people. This is called, and especially when
perceptible in adults, _puerile respiration_, as opposed to their
ordinary, or what in old persons may be called _senile_. It is more
marked during inspiration.

When the stethoscope is applied in the situation of the great bronchial
passages, as over the first bone of the sternum, under the clavicle,
in the center of or between the shoulder-blades, a different sound
is usually but not always distinguishable, when the patient breathes
fully, arising from the passage of the air through these bronchial
tubes. It is compared to the noise made on blowing through a reed or
quill, and is called _bronchial or tubular respiration_. When heard
in other parts of the chest, it is a morbid sound. If the stethoscope
be applied over the trachea, the sound is louder, rougher, and more
intense, and is called _tracheal_ respiration. On listening over the
trachea during speaking, the voice sounds as if it were passing into
the ear, and the words are distinct--_tracheophony_. This, if heard in
any other part of the chest, is a sign of disease, for in the natural
state the voice is heard only to resound through the chest, but the
words are not heard if the other ear be stopped. When heard, the sound
has been called _pectoriloquy_, and is supposed to imply the existence
of a cavity at that part; but the word is unnecessary, or, if used, it
means that the cavern or hollow communicating directly with the trachea
gives forth a similar or nearly similar sound, a _natural_ sound in an
_unnatural_ position. The essential difference between _bronchophony_
and _tracheophony_ in the investigation of disease is, that in the
latter the voice apparently speaks through the stethoscope into the ear
of the auscultator, while in the former it is heard with scarcely less
distinctness, but at the distal end of the instrument. Over the larynx
it is louder, hoarser, and rougher.

The length of the sound in inspiration, as compared with that of
expiration, has been said to be as five to two. One is louder
and longer than the other, a difference requiring attention from
the circumstance that morbid sounds of great import are heard in
inspiration, which do not prevail during expiration. When any other
difference is perceptible between them, so that they more nearly
resemble each other in duration or in intensity, or when expiration is
prolonged, some structural alteration may be suspected in old persons,
some disease in young ones. When little or no respiratory murmur can
be heard after symptoms of inflammation have existed for some time,
the case is very serious, implying that effusion into the cavity, or
condensation of the lung, has taken place to a considerable extent.

298. The number of inspirations in a minute in the adult and elderly
persons varies from eighteen to twenty-two in a state of health: from
twenty-two to twenty-six in children. The stroke of the pulse is
generally as four to one. If the inspirations are eighteen, the pulse
will in general be seventy-two. Both may be slower, although they are
often quicker under disease. When the breathing is slower, it commonly
indicates some affection of the nervous system; when very rapid, some
important lesion within the chest.

The theory of percussion is founded upon three elementary sounds, which
are produced when a solid, a liquid, or a gaseous body is struck; all
others are varieties of these. The sensation of resistance which is
experienced at the same time bears an exact relation to the density of
these bodies--hence the resistance when a solid substance is struck is
greater than when a gaseous one is under percussion. The liver, the
thorax in a case of pleuritic effusion, and the distended stomach after
a long fast, afford good examples of these elementary sounds. To employ
percussion successfully, it is necessary that the strokes be uniform in
force and quickness, and that the finger or pleximeter be so applied to
the surface that no space exists between them, otherwise such a sound
will be elicited as may give rise to an incorrect diagnosis.

It having been stated that a sound lung never fills the bag of the
pleura, particularly toward the diaphragm, at least during ordinary
respiration, I requested Mr. Quekett, the Resident Conservator of the
College of Surgeons, to ascertain this by experiments on some sheep at
the moment of their being killed; and it appeared from them that the
base of the lung is always in contact with the surface of the diaphragm.

299. In ordinary expiration the chest diminishes in size. The ribs
which have been raised recede, by the elasticity of their cartilages,
and by the return of the ligaments, to their state of rest; the
elevated muscles become relaxed, while others belonging to the lower
part of the trunk and abdomen contract. The diaphragm is relaxed,
and pushed upward by the viscera of the abdomen, pressed upon by the
muscles of its wall, if it should not be drawn upward by the attraction
of the lung, which when distended endeavors by its elasticity to
return upon itself, and to occupy less space than the capacity of
the chest will afford. The lung, invested by an elastic, special,
and transparent membrane, and covered by the pleura pulmonalis, is
composed of an immense number of air vesicles, the largest being equal
in size to the fourth part of a millet-seed. These air vesicles,
crowded together, each communicating with a fine bronchial tubule, are
separated from each other into groups by a condensed cellular tissue,
thicker where it surrounds these lobules, which alternately form, when
aggregated together, a lobe, whence it is called interlobular tissue.
An artery and vein form a very minute net-work around each vesicle.
These vesicles may become filled with water; when dilated by air, they
constitute what is called emphysema of the lung. The lung in man is
constantly applied to the internal surface of the chest, the pleura or
serous membrane covering the lung being closely applied to the pleura
lining the wall, and one surface glides upon the other, moistened by
a secretion in just sufficient quantity to effect this object. If the
lower intercostal muscles of a young animal be removed to a sufficient
extent, the lung and the diaphragm may be seen applied to the inside
of the pleura lining the rib, and _ascending_ and _descending_ in
concert, the lungs moving vertically, not horizontally. The diaphragm
ascending, covered by its pleura, is in a similar manner applied to the
lower part of the wall of the chest, which had been filled by the lung
during inspiration. After death the lung remains closely applied to the
pleura, recedes on an opening being made into that membrane, and may
collapse, provided no adhesions exist to prevent it.

300. When inflammation of the pleura takes place, the gliding motion
is not effected silently, but with a peculiar noise, called by the
French _frottement_. When the lung is inflamed, the respiratory murmur
is changed in that part, or is overcome by a peculiar sound, which can
be distinctly investigated by the ear--_rhonchus crepitans_. Hence the
great value of auscultation.

In the following observations it is not intended to give a history of,
or even the whole of the symptoms and consequences of inflammation
of the pleura and the lungs; but only to draw attention to such of
the principal facts as it may be necessary to consider when these
inflammations and their consequences are caused by external injuries.

Acute idiopathic inflammation of the pleura usually commences by
rigors, preceded perhaps by some signs of general uneasiness, which
soon become those of great febrile excitement. Pain is early felt in
the side in the course of the sixth, seventh, and eighth ribs, or at
the point corresponding generally to the seat of the inflammation.
It is usually sharp and darting, is called a stitch, occupies rather
a small space, (the _point de côté_ of the French,) and is always
increased by drawing a full breath or by coughing. The breathing is
short, from the disinclination to fill the chest, by which the pain
would be increased; it is hurried, and sometimes takes place as if
by jerks, from the necessity for its repetition, in consequence of
the smallness of the quantity of air admitted at each attempt. When
the attack is very severe the patient tries to breathe with the
healthy side only, the lower ribs of the affected side being moved
but slightly, and with evident caution. If the inflammation have been
caused by extreme violence, pain will also be felt, particularly at the
part injured.

When inflammation has affected the pleura covering the diaphragm,
especially when caused by external violence, the pain will be felt
lower down, so as to lead to the suspicion that it is also abdominal.
When jaundice supervenes, it occurs from the extension of disease
through the substance of the diaphragm, as is occasionally seen in
wounds implicating the chest, the diaphragm, and the liver.

A cough is not a constant accompaniment of the first stage of disease;
when present, it is usually dry, slight, infrequent, and does not
attract attention, unless accompanied by a thin, frothy mucous
expectoration, indicating the presence of bronchitis; of pneumonia, if
reddish. The patient usually lies on his back while the pain is severe,
and has a great indisposition to turn fully on to the affected side.
At a later period, when effusion has taken place, the pain usually
subsides, and he turns on the side affected to relieve the difficulty
of breathing, caused by the pressure of the fluid on the sound lung
through the bulging of the mediastinum; but the manner of lying, or
_decubitus_, is of little importance, and should be subservient to the
feelings of the patient, who is sometimes comfortable only when raised
to nearly an erect position.

When the complaint is not subdued at an early period, an effusion of
serous fluid, more or less in quantity, takes place. The whole cavity
of the side affected has been known to be filled in from twenty-four
to forty-eight hours, giving rise to symptoms dependent on the degree
to which the effusion has taken place; _this_ is the evil which in
injuries penetrating the cavity of the chest is most to be feared. When
the external wound has been closed, or is so partially closed as not
to allow the escape of the effused fluid, it is commonly the immediate
cause of the death of the patient. Its secretion and early evacuation
are therefore the most important points to be attended to in wounds of
the chest.

The respiratory murmur becomes less distinct as soon as the pain
prevents the ordinary distention of the affected side of the chest,
and diminishes the quantity of air which usually penetrates the lung
in any given time. As soon as a thin layer of fluid commences to be
thrown out between the pleuræ, this murmur becomes fainter, and when
it is complete, it ceases. If the patient can bear percussion, the
side affected yields a dull, dead sound instead of the ordinary clear,
sonorous one of health. The position of the patient when erect, by
causing the fluid to descend, may allow of the respiratory murmur being
heard at the upper part of the chest; and it may be perceived in front,
but not behind, when he lies on his back, until the cavity is filled,
when the sound altogether ceases. At the spot in the back corresponding
to the root of the lung, or at any other point at which a previously
formed adhesion may retain the lung against the wall of the chest, some
respiratory murmur may yet be distinguished, until this part of the
lung shall also have yielded to the general compression, so as to be
temporarily impervious, or have become solidified under the continuance
and extension of disease. While this is taking place in the affected
side, the other lung is called upon to make up the work of aerification
of the blood; it labors harder, its functions become more energetic,
and that side of the chest is more distended; the respirations become
quicker, fuller, and louder, and the vesicular murmur is said to
resemble that of a child--in fact, to be _puerile_.

When the lung begins to be compressed by the circumambient fluid
and the respiratory murmur ceases, a peculiar modification of
the respiration through the large bronchial tubes may be heard,
constituting _bronchial_ respiration. It occurs in pneumonia, in
pulmonary apoplexy, and in tubercular disease when the lung is
solidified. When the voice is heard through the stethoscope in these
complaints, the peculiar sound emitted is called _bronchophony_.

In pleuritic effusion, the voice, when carefully examined, sometimes
obtains a character not previously noticed, but of comparatively little
importance, called _œgophony_, a sound which may be easily confounded
with bronchophony, of the latter of which it is a modification more
often alluded to than observed. Laennec says: “Simple œgophony consists
in a peculiar resonance of the voice, which accompanies or follows the
articulation of words. It appears to be sharper than natural, more
acute and somewhat silvery, vibrating, as it were, on the surface of
the lung more as an echo of the voice than as the voice itself. It
rarely enters the tube of the stethoscope, less frequently traverses
it completely. It has besides another peculiar character, which is
constant, and from which I have taken its name. It is a trembling,
bleating, or shaking sound, like that of a goat, the tone of which
animal it greatly resembles. When it occurs near a large bronchial
tube, as in the root of the lungs, a more or less marked bronchophony
is often superadded.” This sound may pervade the whole side; it is
usually, however, most distinct near the inferior angle of the scapula,
the patient being erect. It only exists where the effused fluid is
small in quantity, and is never a dangerous symptom; its return,
after it has been present and has disappeared, is a sign that a part
of the effused fluid has been removed. It is a sign principally of
value in distinguishing between pleuritis and pleuro-pneumonia and
pure pneumonia, in which latter disease it is not heard, as in that
complaint fluid is not thrown out into the cavity of the pleura.

301. In pneumonia or inflammation of the substance of the lung, as
distinct from any implication of the pleura, which, however, most
frequently obtains after blows on, and in cases of penetrating wounds
of, the chest, the symptoms differ. The ordinary febrile symptoms are
similar to those of pleurisy, only more intense; they usually precede
for a day or two the local symptoms of difficult respiration, pain,
and cough. The dyspnœa varies in different people. In some it is only
a slight embarrassment of breathing, admitting of partial removal
by accelerating the number of the respirations, which are augmented
from twenty to thirty, forty, and upwards, and in children to sixty
and seventy, marking a great degree of distress and of extent of
inflammation, from which, when they are so frequent, persons rarely
recover. The patient can scarcely speak or lie down, and is obliged to
be supported in that which he finds to be the least uneasy position.
Pain is not always present; it is even said to be more frequently
absent when the substance of the lung is affected, and not the pleura.
That pain is not a necessary concomitant of pneumonia, is admitted, but
that it is usually present, and with great intensity in many cases,
cannot be doubted. When present, it is usually an early symptom, deep
seated below the sternum, under the breast, extending to the scapula.
When in the sides it is more acute and fixed, and is probably conjoined
with the pain of pleurisy.

The pulse is quick and sharp, occasionally full and hard, at the
commencement of this complaint in young and healthy persons, although
it is sometimes small and weak from the beginning, where there is
little general power; but this rarely occurs in cases of injury, and is
not to be relied upon in opposition to other symptoms.

The _cough_ is usually dry in the commencement of idiopathic pneumonia,
rarely recurring by paroxysms, and is without any particular
indication; it is soon, however, accompanied with a slight mucous
expectoration, which, after some twenty-four or forty-eight hours,
begins to assume certain and peculiar characters of the utmost
importance as indicating the existence and the different stages of the
disease. On the second or third day the expectoration becomes bloody.
Each sputum, spit, or _crachat_ of the French is composed of mucus
intimately combined with blood--that is, not simple streaks or striæ
of blood, as in catarrh; nor is it pure blood, as in hemoptysis. Each
sputum is either of a yellow, or rusty, or even red color, according to
the quantity of blood intimately mixed with the mucus. These sputa are
at the same time tenacious and viscous, adhering so intimately together
as to form a homogeneous transparent whole, readily gliding, however,
from the basin in which they are held on sufficient inclination being
given to it. At this period or stage of the disease, the sputa adhere
strongly to each other, but the mass is not sufficiently viscid to
stick to the sides of the vessel. When no further change takes place
in the sputa the inflammation rarely passes beyond the first stage of
obstruction or engorgement, or swelling. When they attain to a more
viscous state, and adhere to the inside of the vessel in which they
have been received, the progress of the inflammation to the second
stage, or that of hepatization, may be feared. In almost every case
where the viscidity of the expectorated matter increases, respiration
becomes dull or bronchial, percussion of the chest yields a duller
sound than before, and the inflammation has attained its highest
degree. The expectoration, after being some time stationary, changes
its character. If the complaint is to terminate by resolution, or by
death, or to pass into a chronic state, the redness and viscidity
gradually diminish, and at last disappear. If the rust color and
the viscidity should return, there has been a relapse, which the
reappearance of the other symptoms will show. When the inflammation
is of the most serious nature, and about to terminate fatally, the
expectoration diminishes, and at last ceases. In some cases it only
diminishes because it cannot be discharged; it accumulates in the
trachea, in the larynx, and in the bronchi, until the patient is
destroyed. In some rare cases the matter secreted is spit up nearly to
the last, and in others, still more rare, the approach of death in the
last stage is characterized by a brown expectoration which cannot be
mistaken for either of the others which preceded it. If the pneumonia
pass into the chronic state, the expectoration becomes yellowish, or
somewhat greenish, and at last is purely catarrhal.

Delirium is not an uncommon symptom when the inflammation of the lung
is intense in persons of powerful constitutions, particularly during
the exacerbation of fever in the night. It yields with the other
symptoms when relief is obtained. When, however, it comes on at a later
period of the complaint, or when the accompanying fever is not purely
inflammatory, or in persons weakened by exhaustion and privation, it is
usually a fatal symptom if continued. When mild, it often occurs after
repeated and efficient bleedings, which have subdued, but not entirely
removed the disease; and yields to opiates and gentle stimulants, by
which the pain is removed, although it sometimes remains in a milder
degree than before.

The ear discovers, soon after the commencement of the disease, that
the natural murmur cannot be distinctly heard, it having been at first
partly obscured, and after a time entirely superseded by a peculiar
noise, called a crepitating or crepitous rattle or rhonchus. In its
purest state it has been likened to the sound of a lock of hair
rubbed close to the ear, or to that made by rumpling a fine piece of
parchment; or again, to that which is produced by what under ordinary
circumstances is called the crepitation of salt, when scattered in
small quantities on red-hot coals. This crepitating rhonchus is heard
at first in a small part of the lung, generally at the lower rather
than at the upper part; it marks the first stage of the disease. It
is not of long continuance; the vesicular murmur is either restored,
or the crepitating rhonchus ceases to be heard, in consequence of the
second stage to this, or that of hepatization, having commenced; the
small air-vesicles are no longer pervious; the sound of the breathing,
which is now heard, is that of the air more forcibly driven into the
larger bronchial tubes causing _bronchial respiration_, which is no
longer a vesicular or crepitating, but a whiffing sound, like that
caused by blowing forcibly through a quill, or as if little gusts of
air were blown in or blown out. The voice betrays to the ear of the
auscultator another sign; it descends into the pervious bronchi, and
being conveyed to the ear through the solid lung, gives rise to that
peculiarity of voice called _bronchophony_, a correct knowledge of
which can only be acquired by repeated observation.

When the inflammation of the lung is confined to a small and
deeply-seated spot, auscultation may not at first reveal the evil;
or it may possibly be overlooked, through the sound part of the lung
becoming more active, and giving forth in consequence a stronger and
more puerile breathing, which may mislead the listener.

When the vesicular murmur cannot be heard, when the _rhonchus_ or
_crepitating râle_ or sound is not present, and bronchial respiration
and bronchophony only can be distinguished, the case is one of great
anxiety and danger. The second stage of hepatization is passing into
the third, or purulent infiltration, of which auscultation shows no
further signs, although the matter secreted may be expectorated, in
proof of what has taken place. Pus is thus formed, which it is steadily
maintained by some pathologists is not deposited in the form of
abscess, but is infiltrated throughout the parenchymatous substance of
the lung, finding its way into larger bronchial tubes, or being poured
out from some parts of their secreting surface; the accuracy of this
statement, however, as a rule, may be doubted, from some dissections
having proved the reverse.

302. The effects of inflammation of the pleura are well marked; the
first is to diminish, if not to annul, the secretion of the exhalation,
or halitus, by which it is lubricated; so that its surfaces can no
longer glide without noise upon each other. The patient is often
made aware of the difference by some uneasy internal sensation; the
auscultator, by a rubbing or creaking sound emitted as the inflamed
pleuræ, no longer smooth and polished, rub against each other, and
become covered by a thick, effused matter, although not actually
separated by a liquid. It is a sound which cannot exist after
separation has taken place by the intervention of a fluid, or after
adhesions have formed; it is, therefore, an early and transitory sign,
is frequently interrupted, and returns, as if by jerks, three or four
times repeated in succession. The pleura when inspected, after being
attacked by inflammation, shows at first but little sign of derangement
on its serous surface. It quickly, however, exhibits numberless small
vessels, carrying red blood, which are principally seated in the
sub-serous cellular tissue, reddening the membrane more deeply in one
part than another. These soon begin to take on a new action, leading
to the deposition of coagulable lymph or fibrin, which adheres to the
inflamed surfaces. These deposits soon assume the determinate form
of very thin layers, constituting what are called false membranes;
while a serous or sero-purulent effusion takes place, even to filling
the cavity of the chest, and which may or may not be ultimately
absorbed. When coagulable lymph is first deposited, and about to form
a false membrane, it is soft, of a grayish-white color, and does not
possess any appearances of organization. Red points are, after a
time, perceived in it, which soon become red lines or streaks, on the
surface. This organization of the lymph does not depend on the period
which has elapsed from the commencement of the complaint. It is seen
in the first day of the disease in some cases; it is altogether absent
in others, and depends much on the state and habit of the patient.
The lymph is sometimes deposited in small drops or spots; in others,
in patches of a greater or less size, varying according to the extent
of the inflammation which has produced them. When a false membrane is
once fully formed, it becomes itself a secreting surface, and may go on
augmenting its thickness to so great a degree as materially to diminish
the cavity of the chest. I have seen the pleura with a solid deposit
of this kind much more than an inch in thickness. In general, it is
found in distinct layers, superimposed one upon the other. Whatever may
be their thickness, they commonly admit of being separated from each
other. The false membranes thus formed, resembling areolar tissue in
their properties, may ultimately become cartilaginous, and even bony.
When simple adhesions form between the pleuræ, they become lengthened
with time; and, although they impede the motion of the lung at first,
and may give rise to some uneasy sensations, they gradually become
elongated, and give no further inconvenience. The fluid thrown out
is serous; is often mingled with flocculi or lymph, which are seen
floating in it; it is therefore more or less turbid, resembling whey.
It is often nearly colorless and transparent; when the consequence of
injury, it is often tinged with blood, forced out from the capillary
vessels of the pleura, or of the false membrane, if not caused by the
deposition of the fluid coagulated in the first instance after the
receipt of the injury.

The quantity of fluid thus thrown out varies from an ounce to several
pints; it gravitates according to the position of the patient,
unless, when from old adhesions between the pleuræ, it is confined
to particular parts. When the cavity of the pleuræ is free, and the
fluid is in quantity, it compresses the lung, and diminishes its size
by pressing or squeezing the air out of it; it is thus pressed toward
the vertebral column, and so greatly diminished in size and augmented
in density as to be useless for the purposes of respiration. While the
lung is undergoing this compression to its utmost, the mediastinum also
yields, and bulges into the opposite side of the chest, carrying the
heart more or less with it; so that when the left side of the thorax is
thus affected, the heart is seen and heard to beat on the right. The
diaphragm now yields in turn, more on the left than on the right side,
from the obstacle to its descent afforded by the liver. The intercostal
muscles and ribs resist the internal pressure for a considerable length
of time, even for weeks; they at last, however, yield; the ribs may
even turn a little outward, while the interspaces in thin persons are
said to fill out, so as to render that side of the chest nearly smooth,
the size of that side, when measured, being larger than the other, in
some instances even by two inches, but this rarely occurs unless the
fluid within is purulent, and the disease of long standing.

303. After a time, and particularly in wounds of the chest, the
effused fluid becomes purulent, the lung, compressed to a small,
flattened surface, adheres to the spine by what was its root, if no
adventitious attachments have retained it in a different position; and
the pleura has become a thick, yellowish-white, irregular, honey-combed
sort of covering for it, as well as completely lining the chest.
The serous as well as the purulent effusion are both free from any
unpleasant odor; unless a kind of gangrene has taken place, when the
latter becomes very offensive, and of a greenish-black color, as well
as the substance of the false membranes extending to and sometimes
beneath the pleura covering the condensed lung, into which openings
have even thus been made.

In some cases the surface of the pleura is covered with small
tubercles, some as large as a filbert; in others it appears to have
a reticular or honey-combed appearance; and in particular cases,
large irregularities or excavations may be observed in it when much
thickened, being evidently spots of ulceration, which, if they had
proceeded, would have ended by allowing passage to the matter outward,
until it formed an external abscess, implicating in all probability one
or more of the ribs; thus giving rise to an exfoliation which, by being
separated internally, might in time be the cause of further mischief,
if not previously covered by a thin layer of false membrane. When
chronic pleurisy succeeds to a more acute attack, or they alternate
with each other, particularly after penetrating wounds of the chest,
several layers seem to be laid down one upon the other. This deposit
is never so thick upon the pleura pulmonalis; nevertheless it is thick
enough in most instances to prevent the lung from again dilating,
the substance of it being generally quite permeable to, although so
compressed as to be deprived of, air. It is then flattened, drawn
upward toward its root against the mediastinum and spinal column,
unless by some previous adhesion such a course has been prevented, and
it adheres, as it has been often known to do, to the side of the chest.
As that adhesion may occur in more than one spot, so may the effusions
or deposits take place between them, constituting circumscribed sacs,
and rendering the case more complicated.

304. The changes which take place in the structure of the lung in
pneumonia are three in number: 1. Engorgement. 2. Hepatization. 3.
Purulent infiltration. The formation of an abscess or vomica, and
the occurrence of gangrene, may be omitted, as well as of chronic
disorders, in the views about to be taken of the disease from injury.

In the first stage of inflammatory obstruction, or that of engorgement,
the lung has assumed externally a livid-red or violet color. It is
heavier and firmer than in its healthy state, and the natural feeling
of crepitation, although greatly diminished, is not extinct. The lung
retains the impression of the finger, and pits on pressure as if it
contained a liquid, although air-bubbles can yet be distinguished
in it, and its cellular or spongy texture is still to be observed.
On cutting into it, a quantity of sanguineous or turbid fluid flows
from it, mingled with numerous minute air-bubbles. In some places
the color of the incised surface is darker and more compact, showing
that some progress has been made toward the stage of hepatization. It
nevertheless tears with greater facility than in a healthy state.

In the second stage, or that of the red softening of Andral, the
hepatization of Laennec--the latter term being in most common use,
from the lung assuming somewhat the appearance of liver in solidity
and weight--the lung does not crepitate, no air-bubbles pass out of
it, but a thick, bloody fluid exudes on pressure, and it sinks for the
most part in water. The color is somewhat less red or violet than in
the first stage, and lighter and more varied in color when cut into.
The openings of the larger vessels and of the bronchi, when cut across,
are observed as white specs; the interlobular tissue is thicker and
more marked in lines running in different directions; while many little
granular points can be discovered, especially with a glass, apparently
of a more solid material than the surrounding parts.

The word solidity, or solidification, is sufficiently explanatory in
contradistinction to the naturally pervious and crepitating state of
the lung. Andral believed that hepatization arises from an excessive
congestion of blood, and not from any deposition of lymph. It is not
easy, however, to understand, in the present state of our knowledge,
how acute inflammation can go on for three or more days without
secretion and deposition being added to congestion. That hepatization,
or impermeability to air, may take place in the typhoid pneumonia in
twenty-four hours, and that it as suddenly seems to be removed, is
hardly conclusive, as it shows merely that a thoroughly well-loaded
lung ceases to be permeable to air until a part of the load shall have
been displaced.

When the lung, inflamed to the second stage, or that of hepatization,
is about to be restored to a state of health, a slight crepitation or
crackling begins again to be heard at the end of each inspiration;
and as this increases, (the rhonchus crepitans redux of Laennec,) the
bronchial respiration and voice gradually, or after a time, diminish,
until they entirely disappear; while a mucous râle or rattle commences,
the index of that free expectoration by which pneumonia usually
terminates.

In the third stage of morbid change, or that of purulent infiltration,
the lung is of a lighter color, from the intermixture of a new matter
in its substance, although in the first degree it preserves its
firmness and granular structure. The new secretion is of an opaque,
straw or yellow color, and puriform in its nature. This is discoverable
more particularly in spots; but as the disease proceeds, it pervades
the whole substance of the lung, which becomes softer and more moist,
and is easily broken down by the fingers, the granular structure having
disappeared. It is more or less a purulent sort of sponge, in which all
of the lung that can be perceived under a strong light may be resolved
into small blood-vessels, bronchial tubes, and interlobular septa.

These three degrees or stages of inflammation may be met with in the
same lung, for the most part gradually intermingling one with the
other. The lower part of the lung being ordinarily first affected,
is usually the seat of the purulent infiltration of the third stage;
while in the tubercular affection, which ends in phthisis, the disease
commonly begins in the upper part.

Resolution or recovery from even this, the last of the morbid changes
which have been observed, may take place, although it is less likely to
do so after idiopathic than traumatic inflammation, in which the lung
was previously healthy, and the constitution unimpaired.



LECTURE XXI.

GENERAL BLOOD-LETTING, ETC.


305. The first and most essential remedy in the treatment of pleuritis
and pneumonia from injury is bleeding, which should be resorted to in
every case, whenever the febrile excitement is really inflammatory.
All old people, under such circumstances, unless in a cachectic state,
bear at least one bleeding well; they often bear more; and no fact is
more important, in opposition to the opinions commonly entertained on
this subject. In young people, who have not been reduced in health
and strength by privations and hard service, the bleeding should be
repeated until the desired object has been effected; the quantity
required to be drawn in inflammation, particularly after _injuries_,
is often very great. It may almost become a question, in some cases,
whether a patient shall be allowed to die of the disease, or from loss
of blood; for convalescence is rapid in proportion as the inflammation
is of small extent, and has been early subdued. As the first stage
of pneumonia only lasts from twelve hours to three days before it
passes into the second, and the second from one day to three before
matter begins to be deposited, no time should be lost to prevent these
evils taking place, if the patient is to be saved, without incurring
a risk, from which few escape with health, even if life be ultimately
preserved. Bleeding in inflammation of the pleura, in _young_ and
_healthy_ persons, should therefore be effected with an unsparing
hand, until an impression has been made on the system--until the
pain and the difficulty of breathing have been removed--until the
patient can draw a full breath, or faints; and the operation should be
repeated, from time to time, every three or four hours, according to
the intensity of the recurrence, or the persistence of the essential
symptoms. The pulse does not often indicate the extent or severity
of the inflammation, although it often expresses the amount of the
constitutional irritability of the person. It is sometimes exceedingly
illusory as a guide, and is never to be depended upon in the earlier
stages of disease, when accompanied by pain and great oppression of
breathing. Whenever the pulsations of the heart are proportionally
much stronger than those of the arteries, we may bleed without fear,
and with the certainty of finding the pulse rise; but if the heart
and pulse are both weak, the abstraction of blood will almost always
occasion complete prostration of strength, and may be fatal.

306. When many years ago in charge of a regiment of infantry, on the
top of the Berry Head, the outermost point of Torbay, the men thus
greatly exposed were attacked by pneumonia. According to the practice
taught in London, I bled my patients three and four times in the first
forty-eight hours. I first drew sixteen ounces, then fourteen, then
twelve, then abstracted, as the complaint continued, eight ounces; gave
tartar emetic, so as to keep up nausea; then calomel, antimony, and
opium, and lost my patients. I examined the bodies of all, and found
that they had lived to what is now called the third stage of pneumonia,
combined in almost all with pleuritis, with effusion, and the formation
of false membranes. The disease was essentially a pleuro-pneumonia,
varying in different degrees, as the pleura or the lungs were
principally affected; and I saw with regret that the disease had not in
any way been arrested; that the means employed had been insufficient.
What was to be done? My sixteen ounces of blood were increased to
thirty, but it would not do. It was evident that, to succeed, no limit
should be placed to the abstraction of blood in the first instance, but
the decided incapability of bearing its further loss. Every man was
therefore bled, when he came into the hospital, until he fainted, and
the bleeding was repeated every four hours, or even oftener, as long as
pain or difficulty of breathing remained; under this improved practice
all recovered.

The lesson learned at Berry Head was not forgotten during the five
subsequent years passed in British North America. The men were as
healthy, the winds were sharper and colder, the vicissitudes of all
kinds greater. Rum was cheaper, newer, and stronger than the gin of
Torbay. The local inflammations were often as severe, whether of the
pleura or of the lungs, and by no means less so of the bowels. A
grenadier, some six feet three inches high, broad, and well framed
in proportion, had drank a gallon of rum during the afternoon, and
very narrowly escaped, even with the loss of nearly as much of his
blood, abstracted in a few hours. His first bleeding was into the
washhand-basin, until he fainted, lying on his back, and the bleedings
were repeated as soon as he began to feel pain, and whenever he felt
a return of the pain he used to put his arm out of bed to have the
vein reopened, for Jack Martin was a very gallant fellow. This is
given as an extreme case, to be borne in mind under circumstances
somewhat similar, particularly after injuries. In common cases of
well-marked pleuritis from injury in strong and _healthy_ persons,
it is now not unusual to abstract blood by those who rely on its
efficiency, until the pain and difficulty of breathing are relieved,
or fainting is about to take place. The patient should be raised in
bed, the opening in the vein should be large, the flow of blood free.
The quantity will vary from sixteen ounces to three times that amount
in different people; but the important point is to repeat it as soon
as the pain or difficulty in breathing returns. It rarely happens that
one bleeding, to whatever extent it may be carried, will suffice to
remove the symptoms; and recurrence should be had to this remedy as
often as the pain and oppression require, and THE FORCE OF THE HEART
will bear it, especially during the first two or three days. It will
often be necessary to have recourse to it in smaller quantities for
the next four or six days, and again in less quantity on any return of
the inflammatory symptoms. Where the patient is likely to faint, he
should be bled in the recumbent position; and as it is advisable to
take away a sufficient quantity of blood, great care should be taken,
by arresting its flow for a time, by giving stimulants, by admitting
fresh air, and by sprinkling with cold water, to prevent syncope,
which is sometimes dangerous in elderly persons, who may be subject to
and who are not readily recovered from it. In the second stage of the
complaint, profuse and repeated bleedings do not answer as well; they
do not remove the evil which has occurred, although they may prevent
its increase. Blood should then be drawn in such quantity only as will
relieve the action of the heart, restless under its efforts to propel
the blood through a hepatized lung. The quickness of pulse, the cough,
the difficulty of breathing, must now be aided and relieved by other
means; for although the pulse is not a certain indication, on which
dependence can be placed in the early stage of this complaint, the
breathing generally is; and as long as the respiration is oppressed,
blood should be carefully abstracted, until it becomes manifest
that the effect has been to quicken the pulse, while it materially
diminishes its power, when it is forbidden.

307. A cupped and buffy state of the blood, together with a firm
coagulum, is a satisfactory proof of the propriety of bleeding in
the first stage of the disease; but after the effect of mercury on
the system has been produced, it cannot be depended upon with the
same degree of certainty. When the propriety of further venesection
is doubtful, the greatest advantage may be obtained from the use of
leeches and from cupping, particularly in cases of injury to the
chest. Leeches may be applied by tens and twenties at a time; and when
they have ceased to bleed into a warm bread and water or evaporating
poultice, they may be replaced by as many more, until the pain and the
oppression are removed. Cupping is always to be had recourse to when
leeches cannot be obtained, and, when well done, it is frequently to be
preferred; cupping to sixteen ounces will usually be found equivalent
to forty or more leeches. Both these means often relieve to a greater
extent, with less general depression, than a smaller quantity of blood
taken from the arm, and are, therefore, at such times more advisable.
When blood cannot be obtained from the veins, the arteries must furnish
it; and both temporal arteries have been opened with the best effect in
injuries of the chest, when blood could not be obtained from the arm,
or from the external jugular vein.

308. The effects of bleeding were of old found to be different under
different circumstances and in different climates. Asclepiades
remarks that while phlebotomy was fatal at Rome and at Athens, it was
beneficial in the Hellespont. Nevertheless, at a much later period,
Baglivi says: “In Romano, phlebotomia est princeps remedium in
plenritide.”

In the Crimea blood-letting has not been so favorably viewed, nor found
so serviceable nor so necessary; although the abstraction of smaller
quantities than those indicated above, and less frequently repeated,
has been found eminently beneficial, the difference being dependent on
climate and the impaired vigor of the sufferers.

The remedy first to be administered, and most to be depended upon
in the first stage, is tartar emetic, which usually gives rise to
vomiting, purging, and possibly to sweating; it should not be omitted
because such effects are produced in the first instance. After a few,
perhaps three or four doses, the vomiting usually ceases, the stomach
tolerates its introduction, and its gradual increase from six to nine,
twelve, twenty, or more grains in the twenty-four hours, is often borne
not only with impunity, but with great advantage. Vomiting and purging
are not desirable, as the effects of tartar emetic are more rapid and
beneficial when they give rise to no particular evacuation beyond that
of general perspiration. The most valuable remark of Laennec on its
use is, “that by bleeding we almost always obtain a diminution of the
fever, of the oppression, and of the bloody expectoration, so as to
lead the patients and the attendants to believe that recovery is about
to take place; after a few hours, however, the unfavorable symptoms
return with fresh vigor; and the same scene is renewed often five or
six times after as many venesections. On the other hand, I can state
that I have never witnessed these renewed attacks under the use of
tartar emetic.” He further says that the same favorable results do not
occur from its use in pleurisy or in inflammation of serous membranes,
as in pneumonia.

309. Mercury is a remedy of the greatest importance in serous
inflammations, such as pleuritis, although of less value than tartar
emetic in the first stage of pneumonia, than which it would appear to
be more efficient in the later period of the stages of hepatization
and infiltration, though some physicians place entire confidence on
its efficacy in all. It is of most value when combined with opium.
Some suppose that the opium merely prevents the irregular action of
the mercury; others, in some papers printed in the journals for 1801,
state that opium has a distinct curative effect, being capable, when
given in large doses, of subduing inflammation, and more particularly
of allaying pain, relieving the cough and irritation, and of procuring
sleep; in which opinion I fully concur. Opium is highly advantageous in
irritable and nervous persons, and will frequently relieve the nervous
pain, the pleurodynia which remains after pleuritis, when nothing else
succeeds. Calomel in large doses is usually preferred to all other
forms, but a difference of opinion has occurred as to what is a large
dose; whether two, three, four, six, ten, or twelve grains are large
doses, and whether they shall be given every one, two, three, four, or
six hours. It has been attempted to solve this question by supposing
that in highly inflammatory cases in healthy persons, from three to
six, and even to twelve grains, may be given twice or three times a
day, with better effect than smaller ones more frequently repeated; but
this has not been made manifest.

In cases less inflammatory or complicated with gastric derangement,
the disease assuming more of a general than of a local character,
the excretions being vitiated, the skin dry and hot, and the tongue
loaded, from gr. iss to gr. iij of calomel, combined with three
grains of Dover’s powder, may be advantageously given every second or
third hour, the great object being to affect the gums as quickly as
possible. This is not effected in some cases by any of the quantities
given until after a considerable lapse of time, while in others it is
accomplished by less than half a dozen grains of the remedy. It has
not been ascertained that twenty-four or forty grains given in two or
four doses in twenty-four hours will affect the mouth more rapidly
than three grains every two hours for the same time, neither is it
less liable to cause irritation; while the third or half a grain of
opium given every two hours seems to keep up the effect of that remedy
with great advantage. It does not materially signify which method is
adopted in strong and healthy persons, although the smaller doses
are most satisfactory to all parties when the patient is weak and
irritable, while the large and less frequent doses often excite great
apprehension. It is argued that calomel in large doses never causes the
dysentery nor the severe ptyalism produced by smaller doses; that it
acts more quickly, and that after giving twenty grains, and repeating
it in six hours, any other medicines may be given without interfering
with it, although the strictest attention must be paid to diet,
generally confining it to very small sups of warm whey. Very serious
derangements do, however, follow the exhibition of the large as well
as of the small doses, inasmuch as it is impossible to know beforehand
what quantity will cause a severe salivation or diarrhœa, which it may
be difficult to arrest.

310. It may be concluded that, of the two heroic internal remedies,
tartar emetic and calomel, recommended for the cure of inflammation of
the chest, tartar emetic is the more appropriate for inflammation of
the lungs or pneumonia, provided it be not accompanied by symptoms of
gastric inflammation; in which case its use should be superseded by
leeches to the epigastrium, and saline aperients, lest the irritation,
vomiting, and purging should increase the evil. But care must be taken
that one inflammation shall not be allowed to increase, while attention
is principally paid to the other, and symptoms of irritation, the
_gastro-enterite_ of the French physicians, are not to be mistaken for
gastritis. Mercury, in the form of calomel, is more to be depended upon
in inflammation of the pleura, over which, as well as over inflammation
of serous membranes in other parts of the body, it exercises a
remarkable influence.

311. Blisters are never useful during the continuance of acute
inflammation of the chest, although their use is indicated when the
patient is much exhausted, the pulse weak, and the breathing continues
difficult; or in cases in which the disease proceeds slowly, or is
becoming chronic, when they often do much good. The same may be said
of dry cupping, mustard poultices, and other cutaneous rubefacients,
such as the ol. terebinth. used hot, which often do much good in
the commencement and termination of slight attacks, or of their
supervention on chronic disease, or after injuries.

In the acute stages simple drinks only should be allowed. As soon
as the inflammatory action has subsided, the lightest farinaceous
nourishment, gradually augmented by the addition of broths, jellies,
eggs, fish, and lastly of animal food, should be substituted. The
temperature of the room ought to be moderate and equal.

Inflammation of the lungs frequently terminates by the deposition of
a white or lateritious sediment in the urine, which is considered a
critical evacuation, not however to be relied upon, unless accompanied
by a remission of the important symptoms. A moderate diarrhœa and a
profuse perspiration are also signs of a favorable crisis.

312. Inflammation of the chest has been hitherto considered as
accompanied by inflammatory fever as an essential character, but
this is by no means always the case. In large cities, and among
troops after hard service, in which they have been subjected to much
privation, and in certain epidemics, the accompanying fever often
partakes of a low or typhoid character, and becomes infinitely more
dangerous. This modification of disease I have known from my earliest
years, in different climates, in all of which it proved most fatal.
It is a disease formed of a local inflammation accompanied by general
symptoms of a low asthenic type of fever, combined with those of marked
derangement of the stomach, intestines, or liver, as shown by a dry
black, or red black, or brown tongue, offensive breath, diarrhœa,
vomiting of a dark-colored or greenish fluid, watery or sanious
expectoration, great thirst, headache, a feeble and quick pulse, low
delirium, and great prostration of strength. It was marked, on the
banks of the Guadiana, by the discharge of lumbrici by the mouth and
by the anus. This disease has always appeared to arise from peculiar
circumstances, and to disappear when they ceased to exist; such as
great privations and exposure to cold and fatigue, the use of ardent
spirits without sufficient food, bad air, or other depressing causes.
It is sometimes epidemic. The fever is typhoid, the local inflammation
latent, and the symptoms of it masked. It may be complicated with
inflammation of the stomach and intestines; it may occur in cases of
erysipelas, or after wounds or injuries attended with large secretions
of purulent matter, or with other complaints. While the symptoms of low
fever are general and well marked, those of the latent affection of the
lung are not so prominent or even observable. The patient complains
but little, and sometimes not at all, of his chest, until attention is
drawn to it by a slight cough, and difficulty of respiration, attended
by a character of countenance which usually indicates embarrassment
in the functions of the lung. It may be brought on by a common
non-penetrating injury of the chest.

In typhoid pneumonia, general bleeding, if admissible, is to be had
recourse to with extreme caution, even in young and robust persons.
Local depletion is oftentimes useful, and perhaps ought to be alone
relied upon. The great dependence is on calomel and opium, and after
such local depletion as may be thought advisable, counter-irritation
by blistering, and the administration of stimulants, such as camphor,
ammonia, and wine, in small and repeated quantities. Mild aperients
only should be employed, and anodyne injections are frequently useful.
While auscultation has thrown a clear and steady light on the nature
of the mischief which is going on, it has added little or nothing
dissimilar to the practice pursued some forty years ago. The nature of
the hepatization or solidification which takes place in the lung in
typhoid pneumonia has given rise to some difference of opinion among
morbid anatomists, who incline to believe, from the rapidity with
which it takes place, and with which it is sometimes removed, that it
depends more on passive congestion, and on a typhoid alteration of the
state of the blood, than on an altered action in the vessels of the
part. This opinion does not seem to be fully supported by dissection,
unless it be generally admitted that gray hepatization, and the third
stage of disease of the lungs in pneumonia, mean simple congestion.

When the patient survives the imminence of danger in which he is placed
by the attack of the disease, and the expectoration becomes copious,
with great emaciation, quick pulse, and hectic fever, a slight infusion
of senega or of cinchona with ammonia, with a mild and well-regulated
diet, and change of air and climate, answer best in aiding recovery.

A typhoid pleuritis is presumed to exist, as a distinct disease from
typhoid pneumonia, although the analogy between them is admitted to be
close; like it the disease is latent and more frequently pointed out
by the sinking of the powers of life than by any new suffering. The
signs of effusion may be discovered on auscultation, and the treatment
is essentially similar; blistering and counter-irritants being perhaps
more useful, if time be granted for their application.

313. Empyema, _from_ εν, _in_, _and_ πυον, _pus_,--a name given to
all collections of fluids in, and to the operation for evacuating
them from, the cavity of the chest. Empyema is not a special disease,
but the result of another; commonly of acute or chronic pleurisy, or
of injuries of the chest, which give rise to inflammation, ending
in suppuration. When it occurs from the effusion of a serous fluid,
constituting a local dropsy, it is usually the result of disease of
the heart, or of the great vessels, and is accompanied or preceded by
symptoms indicating the existence of those complaints, in which case
it is not likely to be benefited by any operation. The disease is then
denominated hydrothorax. The serous fluid is generally transparent,
although more or less tinged with blood, when thrown out in persons who
die within a few days after receiving a wound of the chest. It may, and
does occasionally, contain in these cases a large quantity of blood;
but an early effusion of blood is not uncommon in very acute cases
of pleuritis. It is usually more or less turbid when the result of
ordinary inflammation, although the presence of albuminous or purulent
matter is not constant. Whether colorless, transparent, turbid, or
purulent, it remains free from fetor, unless gangrene has occurred
internally, or some communication with the atmosphere has taken place
by an external opening.

While the fluid remains transparent, the appearance of the pleura is
little changed, but when it has become turbid in any great degree, or
flocculent, or purulent, the pleura has lost its natural appearance.
In its simplest character, when the fluid is puriform, particularly
if the inflammation have not been very active, it is covered with a
layer of whitish inorganic sediment, which can be scraped off by the
scalpel. This is sometimes quite red, as if loaded with blood which had
been deposited upon it. Whenever pleuritic symptoms continue beyond the
ordinary period of about three weeks, or, after a temporary abatement,
are followed by those of effusion, which are not in turn removed, the
occurrence of empyema may be suspected.

Empyema may form from a pulmonic abscess bursting, or a gangrenous
spot being detached and falling into the cavity of the pleura. An
abscess in the liver or other parts may also communicate with the
pleura, and abscesses formed from injury or otherwise in the wall of
the chest may also give rise to it. It is usually, however, caused by
acute inflammation, by penetrating injuries, or by the introduction
of foreign substances. It should, however, be borne in mind that when
it occurs from wounds, the external opening must have healed, or the
complaint would be simply a wound in the chest, with a discharge from
the cavity of the side affected. A true surgical case of empyema,
following an injury of the chest, in which the wound has healed, is not
to be ascertained but by the same means as in a case arising entirely
from internal causes, unless the protrusion of the cicatrix should
indicate the presence of matter behind it.

314. The symptoms by which the termination of inflammation in effusion
may be known: are dyspnœa, or difficulty of breathing, which is greater
when the effusion has taken place rapidly, less when it has been
gradual; subsidence of pain; inability to lie on the unaffected or
sound side, which subsides, or is entirely removed, after the operation
has been performed and the fluid evacuated, although it should be
replaced by air in consequence of the lung being unable to resume its
natural position. When the effused fluid has filled one side of the
chest, that side is evidently enlarged, and this can be distinctly
seen when the dilatation does not exceed half an inch, measuring by
a tape from the spinous process of a vertebra behind to the center
of the sternum. The ribs are nearly, if not quite, immovable, and
partially raised, offering a strong contrast to the active motion of
the ribs on the other side. The intercostal spaces in these persons
may be more or less filled up, rendering the whole surface smooth and
soft. In some very severe cases the external parts become edematous,
so that the ribs cannot be felt, and this sign, although not always
present, is certainly pathognomonic when it takes place at a late
period of the disease. When the effusion is into the left side of the
chest, the heart is frequently pushed over with the mediastinum to
the right side, and its pulsation can be seen and felt to the right
side of the sternum; or it may descend with the diaphragm into the
epigastrium--changes which are not so extensive or remarkable when the
effusion is into the right side, as the liver materially impedes the
descent of the diaphragm, and the heart is already in the left side,
in which it is sometimes raised rather than depressed. It is said
that if the hand be placed over the affected side, while the patient
speaks with a tolerably loud voice, and a strong vibration is felt in
the part, the case is not one of empyema; but this is as uncertain a
sign and as little to be depended upon as the dullness on percussion
which sometimes takes place under the sternum in empyema. The cough
and expectoration offer nothing peculiar, unless a communication exist
between the lung and the cavity of the chest, when the expectoration
in general becomes very fetid and disagreeable. The febrile symptoms
depend on the activity of the previous disease, and the rapidity with
which the effusion has taken place.

Night-sweats, it has been supposed, never accompany the hectic fever
of empyema, unless there be tubercles in the lungs or pleura--a remark
which cannot be depended upon.

315. Two symptoms have been insisted upon by older authors as
distinctive of effusion in the chest, which more modern ones are
disposed to doubt, particularly in the early stages of the disease.
One is an edematous swelling of the back, the other a protrusion of
the intercostal spaces. A third may be added when the effused fluid
is blood, which is that the edematous swelling becomes ecchymosed, or
red, or bruised looking, from the effusion of blood into the cellular
membrane beneath the skin, over the whole space occupied by the blood
within. That the first two symptoms do assuredly indicate the presence
of pus, cannot be doubted; and that the third is a sign that the
effused fluid is blood, has not been disproved; but it must be borne in
mind that they are late, not early symptoms, and the operation should
not be delayed until they are present, if other signs should appear to
demand its performance. Valentin was the first to notice the ecchymosis
of the side and back when the chest was full of blood, a sign which
Larrey particularly insists upon, but which certainly does not appear
so early as to be distinctive, when other symptoms exist which almost
render it certain. The swelling does not arise from transudation of
matter through the pleura, but from irritation transmitted through it,
as in any other deep-seated abscess. Dilatation of the chest is usually
an early symptom, although a considerable effusion may exist without
it, or with but a slight elevation of the intercostal spaces. When the
complaint is distinct, these spaces are elevated to a level with the
ribs, so that the surface becomes perfectly smooth and equal; a farther
protrusion is a very rare occurrence. Effusion indeed of serous fluid
to a considerable extent, so as to displace the heart, may take place
without the intercostal spaces being elevated, which is only believed
to occur when the intercostal muscles have become paralyzed. When the
matter has been evacuated, the muscles recover their tone, and the
intercostal spaces reappear.

In all cases of empyema in which the lung is so bound down by adhesions
that it cannot be expanded by the continued process of respiration,
a cure can only be accomplished by an alteration of the form of the
affected side of the chest, by which its cavity is diminished, and
often nearly obliterated. This is an effort of nature. The pleura
changes its character, becomes so thick as materially to diminish the
cavity, the diaphragm ascends, the heart leans to that side in many
instances, the spine curves, the ribs thicken and become flatter, and
close in upon each other, abolishing the intercostal spaces.

_Treatment._--As long as the febrile symptoms consequent on the
inflammation continue to any extent, medicines will be of but little
avail, and counter-irritants should be avoided. When they have
subsided, purgatives and diaphoretics may be tried, in combination
with tonics and a light but good nourishing diet. Blisters applied
frequently upon a large surface often do good. When these means fail,
the operation must be resorted to.

316. It has not been satisfactorily decided whether the operation
for empyema was first performed on Phalereus, Jason, or Prometheus;
it is therefore said of all three that, being expected to die of an
abscess in the lungs declared to be incurable, they went into battle
for the purpose of getting killed; but being only run through the
body, they all recovered, in consequence of the escape of the purulent
matter through the holes thus made. The operation was performed by
Hippocrates and his successors, by the knife, by caustic, and by the
hot iron. Ambrose Paré was the first who recommended a trocar and
canula, and many instances of success in all ways are recorded. The
modern methods are by the trocar and canula, and by incision. Whenever
auscultation, percussion, or succussion give reason to believe that a
fluid is collected, which medicine has not been nor is able to remove,
the simple operation by the trocar and canula should be performed. If
fluid should pass through the small canula generally used by way of
exploration, a larger one may be introduced in its place if thought
advisable. In ordinary cases, the little wound should be closed
immediately after the evacuation of the fluid; it usually heals without
difficulty, and the operation may be repeated if necessary. Care should
be taken that the point of the instrument is perfectly sharp, or it
may separate the thickened false membrane from the inside wall of the
chest, and, by pushing it before it, prevent the fluid from passing
through the canula when the trocar is withdrawn.

317. The place of election, in England, for a _puncture_, in ordinary
cases, is usually between the fifth and sixth ribs, counting from
above, and between the sixth and seventh from below, and at one-third
the distance from the spinous processes of the vertebræ, or two-thirds
from the middle of the sternum. If there should be any protrusion of
the intercostal spaces, it may be a rib or two lower down. The point
of the instrument should be introduced a little nearer the lower than
the upper rib, and pressed on until all resistance has been overcome.
It is entered nearer the lower rib to avoid the intercostal artery,
and yet not touching the rib lest it should induce a too forcible
contraction of the intercostal muscles, by which the operator might be
inconvenienced.

If the person should be very fat, or the puffing of the integuments
considerable, it may not be easy to feel the ribs, in which case even
recourse should not be had to incision. When the arm is placed by the
side, and bent forward at a right angle so that the hand rests on the
ensiform cartilage, the inferior angle of the scapula will correspond
in general, but not always, with the interval between the seventh and
eighth ribs at the back part. The attachment, however, of the last
of the true ribs, the seventh, to the xyphoid cartilage, can always
be ascertained in front, and an error of importance cannot well take
place, as the object in making a puncture by measurement is to avoid
the diaphragm. Freteau, of Nantes, says that he performed the operation
on the left side between the tenth and eleventh ribs, and on the right
side between the ninth and tenth in more than thirty dead bodies, and
always opened into the cavity of the chest, commencing the incision
close to the edge of the latissimus dorsi muscle, or about three inches
and a half from the spine--an operation which in this place should
be done by incision, and not by the trocar. When there is reason to
believe that there is an extraneous body to be extracted, such as a
ball, the place of election is of importance, as it is desirable it
should be a little above the diaphragm in order to facilitate its
extraction; for although, by carefully shifting the position of the
patient, a ball or a piece of bone may be brought to rest against the
opening, it will not be easily taken hold of unless it lie upon the
diaphragm, a point which will be hereafter further elucidated. When an
external swelling indicates the presence of matter, and there is reason
to believe it communicates with the inside of the chest, the opening
should be made into the tumor, and is then called the “operation by
necessity,” which is not an uncommon occurrence after gunshot wounds.
It is not, however, always done in the most convenient place, and
should then be repeated lower down, which will also be sometimes
necessary in consequence of the matter collected in this way being cut
off by adhesions from the general cavity.

When the operation by incision alone was performed, the success was
certainly not great. In modern practice (after the operation by
puncture) it has been much greater, which may be attributed to the
operation having been had recourse to at an earlier period, or about
the end of the third week. After wounds penetrating the chest which do
not admit the effused fluid to flow out, it should be done much earlier.

It is possible that both sides of the chest may be affected; but both
sides may not be punctured in succession, for an error in puncturing
both, or even the sonorous or sound side instead of the dull or
affected side, has been almost immediately destructive of life.

318. The admission of atmospheric air into the cavity of the chest
during this operation has been much deprecated, and many inventions
have been recommended for its prevention, but it is scarcely possible
to prevent some air getting in. It is often seen to do so; it has been
proved by auscultation to have done so, and is usually absorbed in a
few hours. In one case which I saw it gave rise to distressing symptoms
from pressure on the lung, but was removed by a common syringe, to
the great relief of the patient. In all these cases two things must
be considered: Can the compressed lung expand so as to fill the chest
when the fluid is withdrawn? The answer must be, in many cases it is
so bound down by adhesions that it can dilate but slowly, if at all.
If it be asked whether a vacuum is formed in the chest, the answer
will be, no; and it will then be admitted, on consideration, that air
always finds its way into the chest, and never does harm to persons
in health. When mischief does ensue after an operation or an injury,
it usually occurs from the irritation caused in a particular state
of constitution, and not from the admission of air. A change in the
appearance of the discharge has been frequently found to follow, and
to depend upon, an accidental derangement of stomach, and to return
to its more normal state on the derangement being removed. If the
wound into a cavity can be closed and healed, the air will remain with
impunity until absorbed. If the wound cannot be healed, unhealthy
inflammation may be propagated from it to the whole cavity with which
it communicates, but this is not the effect of the admitted air.

Dr. H. M. Hughes has published several cases of pneumothorax in the
first part of the of the volume of “Guy’s Hospital Reports” for 1852.
In the sixth case, which he calls a genuine example of pneumothorax
from rupture of one or more of the vesicles of an emphysematous lung,
the patient died speedily; and, on examination, he says: “It is also an
interesting fact that no evidence of inflammatory action existed in
the pleura, as it indicates that air in a healthy serous membrane does
not excite inflammation;”--a Peninsular dogma I have been forty years
inculcating, and which I trust is at last admitted as an established
fact. How long it may be before it is generally taught, is another
matter; for surgeons, like other men, often adhere with tenacity to
preconceived opinions, however erroneous, particularly as they advance
in life and have ceased to desire to learn more than they already know.

319. In all cases of _serous_ effusion, there can be little doubt that
the fluid should be wholly evacuated and the wound closed. When the
fluid is _purulent_, a permanent drain should be early established. It
is not, however, common for the operation to be repeated several times
without the serous discharge becoming purulent; and, in such cases, it
usually becomes necessary at last to allow the wound to remain open
until the discharge shall cease of itself. Whenever more than one
opening is necessary, and the first is made between the fifth and sixth
ribs, the succeeding ones should be made lower down; so that when it is
thought right to leave the last puncture to become fistulous, it may be
made as near the diaphragm as may be thought consistent with the safety
of that part.

When a doubt exists as to the probability of more than one puncture
being sufficient, and it seems likely that a third, or even more, will
be required, the surgeon may anticipate this necessity by introducing a
piece of soft gum-elastic catheter through the canula into the chest to
the extent of about three inches, enough being left outside to admit of
its being secured by tapes and adhesive plaster; through this a certain
quantity of the fluid may be drawn off daily until it ceases to be
discharged. The elastic tube bends with the heat, and applies itself to
the inside of the ribs. If the lung should rub against it, which can be
ascertained by a blunt probe, the elastic tube should be removed, and
the external wound kept open by a softer plug. In all these operations,
care should be taken to prevent the occurrence of inflammation. The
accession of pain in the part, of difficulty of breathing, of fever,
should be met by the abstraction of a few ounces of blood by cupping,
by dry-cupping, by mercury in small doses, by rest, by diet, etc., and,
if a tube have been introduced, by its removal.

The propriety of injecting stimulating or even simple fluids into
the cavity of the chest has been often advocated, and as frequently
repudiated. Warm water or milk and water is certainly admissible, and
has been found very useful, particularly when there is an adventitious
cause keeping up the irritation, which may possibly be brought to the
opening by the sudden abstraction of the injection. Pieces of cloth
and bits of exfoliated bone have been floated out by throwing in an
injection of tepid milk and water. The opening, in a case of this kind,
should be made between the eleventh and twelfth ribs behind.

Dr. Wendelstadt, of Hersfield, in the year 1810, in the twenty-third
year of his age, suffered an attack of pleurisy, which became chronic,
and ended in effusion. After severe suffering for six months, he was
able to attend to his professional duties. The ribs of the right
side protruded, but the intercostal spaces did not; the whole side
was motionless on respiration taking place. The circumference of the
chest continued to increase, and fluctuation within became evident
on succussion. In June, 1819, having undergone another attack of
pleurisy, he submitted to the operation for empyema, as offering some
hope of preserving life. When a pint of fluid had been discharged,
the wound was closed, and he experienced great relief. The next day
a third of a quart was taken away twice in the day, and on the third
day as much more; but he thought this was too much, as he became
greatly exhausted, and feared that suffocation was impending. He was
recovered by stimulants. On the fourth day the fluid was thicker in
consistence, and fetid, and continued more or less so for a fortnight.
It was then allowed to flow as it would at each dressing. Astringent
injections were used for six weeks, but were then abandoned, and he
gradually recovered his strength. Thirteen years afterward, in 1830,
the wound was still open, discharging twice a day, sometimes only half
a drachm, sometimes three or four ounces daily. The right side had
altogether shrunk, and did not move on inspiration; he had no cough,
and was otherwise in good health; a piece of a rib became loose, and
was removed at the end of thirteen years, when the report of the case
terminated, the patient being in health.

It may be remarked on this case, that the admission of air did no harm;
that the lung remained compressed; that the whole side thickened and
flattened, as a consequence, so as to obliterate the cavity; but the
cure would not have been effected even then, if the piece of carious
rib had not been discovered and removed.

Mr. Winter, secretary to Admiral Sir C. Napier, was wounded by two
musket-balls, one in the arm, while the other entered between the
inferior edge of the left scapula and the thorax, which it penetrated,
fracturing a rib in its progress, and lodged. He fell, and spat up some
blood, and as symptoms of inflammation supervened in twenty-four hours,
he was bled largely; this was repeated frequently until these symptoms
were subdued. He was after a time sent to the Marine Hospital, Lisbon,
in a miserable plight, suffering from hectic fever, with a flushed
face, hot skin, glassy eye, great prostration of strength, cough,
restlessness, dyspnœa, and copious night-sweats. The wound discharged
a watery, sanious, fetid matter in quantity, and he was unable to do
anything but eat, and for food he had a great craving. From this state,
under good treatment, he gradually recovered his strength, and on the
18th of June, 1834, a piece of the rib was removed. The wound remained
open with a great purulent discharge, which kept him in a reduced
state; a little more than one year after the injury, he reached London,
and was taken into the Westminster Hospital. The left side of the chest
was flattened and contracted, and the lung was doing very little in
the respiratory way; the wound discharging a quantity of matter, which
he could readily evacuate by making the opening the dependent point,
but not otherwise. On enlarging the external wound, so as to make the
opening into the chest direct, I found a round-pointed gum-elastic
bougie could pass into it for four inches, and, on bending it down, for
six inches more, it having to pass over a thickened pleura, and false
membrane of an almost cartilaginous nature, for the extent of an inch,
before it could be felt to be in a large cavity. As it did not appear
that he had any chance of recovery, unless another opening were made
lower than the sixth rib, in a more dependent position, I proposed
the operation, but he would not submit; and after a time he left the
hospital and went into the country, where he died.

A non-commissioned officer, of the 2d Division of cavalry, was wounded
at the battle of Albuhera, on the 10th of July, 1811, in several
places, by the lances of the Polish cavalry; one of these penetrated
the left side of the chest behind, immediately below and in front of
the inferior angle of the scapula. He spat and coughed up blood, and
lost so much from the wound that he became insensible, the bleeding
having been stopped by a part of his shirt being bound upon it tightly
by means of his woolen sash. Brought to the village of Valverde, my
attention was drawn to him some days afterward, in consequence of the
difficulty of breathing having increased so that he was obliged to be
raised nearly to an upright position, as well as from his inability to
rest on the part wounded, round which a dark-blue inflammatory swelling
had taken place, the wound having closed. An incision being made into
it, a quantity of bloody purulent matter and clots of blood flowed from
it. The incision was then enlarged, so as to allow of a direct opening
into the cavity of the chest, which was kept open. The relief was
immediate. He was removed to Elvas, apparently doing well, some three
weeks afterward.

This case offered the nearest approach I have seen to the ecchymosed
edema described by Valentin as accompanying effusions of blood into the
cavity of the chest; and, as well as the following, is an instance of
operations, not by election, but by necessity.

A French soldier had been wounded at Almaraz by a musket-ball, which
went through the right side of the chest, in a line nearly horizontal
from a little below and to the outside of the nipple, backward. The
first symptoms having subsided, he gradually descended the Tagus to
Lisbon, where, after some months of continual discharge, the wounds
closed, first the back, and then the front. He did not recover his
strength, always looking sickly, and suffering from pain, difficulty
of breathing, and other inconveniences, which did not prevent his
walking about in the confined space to which he was doomed as a
prisoner of war. My attention was drawn to him in consequence of an
obvious fullness of the intercostal spaces, of the great difficulty
of breathing, and of a puffy inflammatory swelling which was forming
around and at the seat of the wound in front. Through this I made
an incision into the cavity of the chest, the walls of which, on
introducing the finger through the opening, appeared to be very much
thicker than usual. A large quantity of pus was discharged, and the man
was relieved, but this amelioration was not of long continuance, and he
gradually sank and died. On opening the body, the inside of the wall
of the chest was found to be half an inch in thickness, in consequence
of a firm deposition on the pleura, of a yellowish-ash color,
honey-combed or ulcerated, as it were, in plates, particularly where
the opening had been made. The lung was shrunk up from the anterior and
lower part of the chest, but adhered to the wounded part behind, and
was covered by a layer of false membrane of considerable thickness. The
wound through the lung could not be distinctly traced, from its being
diseased throughout.

At Santander, in October of the same year, 1813, I received some eight
hundred wounded in the affairs of Le Saca, Vera, etc. One of the
Light Division had been shot through the left side of the chest: the
posterior wound had closed, but a sufficiently large quantity of matter
was discharged through a small anterior one to show that there must
be some depot from which it proceeded. The wound was laid open into
the cavity of the chest, and free vent given to a quantity of matter.
Some small pieces of rib were discharged, and a bit of something like
the cloth of his coat also came away. He could lie on either side, and
hopes were entertained of his recovery, until after I left Santander
in December, to join the army in France, when he suffered a relapse of
inflammation, and died.

A soldier of the German Legion was wounded at Waterloo by a lance
between the sixth and seventh ribs of the left side. He spat up much
blood for several days, and was carried to Antwerp, where he remained
for several months, suffering from great difficulty of breathing and
other distress in his chest, which recurred from time to time, although
the wound had healed. He was admitted into the York Hospital, Chelsea,
in the spring of 1816, in consequence of an attack of inflammation,
of which he died. On examining the body, the lung of the right side
was found to be greatly inflamed, and full of purulent fluid, which
caused his death. The left or wounded side was found to contain a small
quantity of pus, the cavity being very much diminished by the great
thickening of the pleura and the falling in of the ribs, which were
thicker, greatly flattened, and changed in form; the lung, shrunk or
collapsed, was covered by a thick adventitious membrane, and bound down
against the spine, leaving a long, small space between the pleuræ,
which once had doubtlessly been full of matter. The mediastinum and
heart appeared to lean toward the left side, aiding in this manner in
the obliteration of the cavity, which must take place if a permanent
cure be effected in empyema. I have seen two cases in which this
obliteration appeared to be complete: one in a soldier, who had been
wounded in the chest; the other in a gentleman, the subject of empyema,
in private life. In both the spine was also distorted, the side wasted,
the nipple lower than the other. The breathing of the opposite side was
more marked and developed. It might have been called puerile.

320. _Pneumothorax_ means an effusion of air and of the matter of a
tubercular abscess from disease into the cavity of the chest, or from
an injury or a wound in the lung. When pneumothorax is the consequence
of disease of long standing, the patient may be sensible of a sudden
pain, which does not abate, and which is accompanied by an equally
sudden increase of the difficulty of breathing, for which he cannot
account. He feels relief by lying on his back or on the affected side,
rarely on the other, although the difficulty of breathing may increase,
so as to render the further continuance of life doubtful, while the
prostration of strength is considerable. The muscles of respiration are
all in rapid and powerful action; the heart is displaced to the right
side when the complaint attacks the left, and it will be displaced
somewhat to the left when the right is affected; in some cases it
even descends into the epigastrium, or is otherwise removed from its
natural situation, even toward the axilla, although the left side is
supposed to be more obnoxious to this complaint than the right. The
pulse becomes exceedingly quick and small, countenance pale, nights
sleepless. The affected side is oftentimes evidently dilated, and the
intercostal spaces may be less marked, or partly filled up, when the
respiratory motion given to the parts under ordinary circumstances is
seen to be deficient. But these differences, as well as that which can
be obtained by comparing both sides by measurement, are not so marked
as when the cavity is filled with fluid, of which in pneumothorax there
is always a small quantity effused.

_Percussion_, beginning from above, in the erect position, will give,
in cases in which it is ascertained that respiration is null, a clear
tympanitic sound, as low as the level of the fluid, when it changes
abruptly to a dull sound, or that indicating the presence thereof.
If the patient be then placed in the recumbent position, the clear
sound can be heard above, the dull one below, demonstrating the change
in the situation of the air and fluid. _Auscultation_, in addition
to the absence of respiration, when the chest is fully expanded,
discovers no respiratory murmur; but a peculiar sound called _tintement
métallique_, or metallic tinkling, is heard at intervals, particularly
on the patient’s coughing, speaking, or breathing. It may be imitated
by dropping a pin into a large wine-glass, but it more nearly resembles
the sound of a jew’s-harp in the hands of a child: once heard it cannot
be mistaken. It is a sound distinctive of pneumothorax.

“Mr. Cornish, a medical practitioner, having suffered an attack
of pleuritis, nearly expired from suffocation on Monday, the 29th
December, 1828. He was lying on his right side, breathing most
laboriously; countenance sunk; pulse between 130 and 140; had had no
sleep for many nights. The action of all the respiratory muscles was
painful to behold; no perceptible difference in the size or shape
of the two sides. The _right_ emitted an extremely dull sound; the
_left_ sounded hollow throughout. The apex of the heart was beating
rather to the right of the right nipple. The respiration was loud and
rattling in the _right_ side; metallic tinkling distinct in the _left_;
expectoration muco-purulent, with specks of blood, and many black
particles. Mr. Guthrie, who saw him for the first time, made a short
incision between the sixth and seventh ribs, and cautiously opened the
pleura, when a rush of air issued forth with a hissing noise, strong
enough to have extinguished several candles. The patient turned on his
back, breathed with comparative freedom, and expressed his gratitude
for the operation. No fluid issued from the wound when made a dependent
opening. On the 31st, the difficulty of breathing and the metallic
tinkling had returned, the wound having closed. The wound was reopened
and enlarged; the pulse fell to 120; the metallic tinkling ceased to be
heard; the patient took some nourishment and an opiate at night.

“Jan. 1st, 1829.--Has slept several hours; breathing easy; pulse
reduced in frequency; appetite good. A canula was placed in the wound,
when large quantities of air came through it on each expiration; the
heart beat two inches nearer the central line of the thorax than
before. During the night he became greatly oppressed, and died next
day. On raising the sternum, the heart was found rather to the right
of the median line of the chest. The left lung was collapsed to
one-fifth of its natural dimensions. The vacant space was filled with
air, and about fourteen ounces of turbid serous fluid. The pleuræ
costalis and pulmonalis presented marks of inflammation of a few
weeks’ standing--viz., some thin false membranes, which were easily
separated by scraping with the scalpel. There were no marks of more
recent pleurisy. A tube was inserted into the trachea, and air blown
into the lungs. The left lung expanded to a certain extent, and air was
heard to bubble out, when an aperture was immediately recognized at the
division between the two lobes, through which the air rushed forth and
extinguished a taper that was held near it. The aperture was circular,
fistulous, and capable of admitting a crow-quill, and was found to
communicate with a very small excavation, formed by the softening down
of some tuberculous matter; into this small excavation a bronchial tube
was seen to enter. Thus, the communication between the trachea and the
cavity of the chest was distinctly traced. The left lung presented some
trifling tuberculation, but was not materially diseased.”

William Griffin, aged eighteen, was admitted into the Westminster
Hospital on September 14th. Ten days before his admission into the
hospital he discharged a pistol against the left side of his chest,
causing a wound corresponding to the middle of the eighth rib, from
which a very small quantity of blood escaped. The medical practitioner
who was called to him at the time _passed a probe to the extent of
four inches_ into the wound. The wound had nearly cicatrized, but he
became the subject of acute pain, diffused over the whole of the left
side of the chest, accompanied by fever and frequent cough, dyspnœa,
and inability of lying on the right side. After the lapse of a week he
was transferred by his surgeon to the medical wards under Dr. Roe, at
which time he had begun to expectorate purulent matter of an extremely
fetid character, occasionally mixed with blood. His respiration was
hurried, the right side of the chest expanding much more freely than
the left; the lower three-fourths of the affected side were dull on
percussion; tubular respiration could be detected at the upper part,
but at the lower no air appeared to enter; well-marked modifications of
voice existed over the whole of that side of the chest. By measurement
no difference in the relative size of the chest was observed, but
the intercostal spaces of the left side remained motionless daring
expiration. The heart could be felt feebly pulsating at the epigastrium.

October 15th.--He suffered from a violent paroxysm of coughing,
during which great dyspnœa suddenly came on. He sat propped up in bed;
respiration was almost ineffectual, his face livid and covered by a
cold, clammy sweat, pulse scarcely perceptible at the wrist, and his
extremities were becoming cold. On examining the chest, the left side,
before quite dull, now afforded tympanitic resonance on percussion,
which, together with the total loss of respiration and the presence
of metallic tinkling, proved the existence of pneumothorax. A trocar
was introduced between the sixth and seventh ribs, and was followed by
an escape of gas with about five drachms of pus, both of a very fetid
character; the canula becoming obstructed, a larger one was then passed
through the opening, but not more than half an ounce of pus escaped;
it was then withdrawn, and found to be blocked up by what appeared to
be disintegrated lung. Being greatly relieved, no further attempts at
evacuating the fluid were then made.

At night, during a paroxysm of coughing, six ounces of fetid pus
escaped by the opening, after which he felt relieved. A second gush of
sanious fluid, to the amount of five ounces, containing small masses of
sloughing membrane, subsequently took place. Cavernous respiration at
the upper half of the lung, mixed with gurgling and metallic tinkling.
Expectoration muco-purulent and offensive.

21st.--Has somewhat improved, but suffers from accessions of fever
toward evening, and perspires very profusely during the night; the
cough is less frequent, and he expectorates freely, the sputa being of
a purulent, fetid character. Scarcely any discharge from the side.

Nov. 5th.--Has remained in nearly the same condition until yesterday,
when he ceased to expectorate, and has since become much worse; his
skin is now intensely hot; face flushed; tongue brown and coated; pulse
jerking, but feeble and frequent; the opening in the chest has quite
healed.

A second opening was now made about an inch external to the former one,
and a canula introduced, but not more than one ounce of pus escaped,
the instrument becoming blocked up by portions of sloughing tissue;
during a paroxysm of coughing, which occurred a few hours afterward,
several ounces of fetid sanguineous pus were forced through the wound.

16th.--Since the last report he has been slowly sinking--is emaciated
to an extreme degree. The wound originally produced by the pistol-ball,
as well as those made by the trocar, have become fistulous, so that
during respiration the air passes into the chest, and is expelled
with as much freedom as that passing by the trocar. Expectoration has
continued very copious, about a pint and a half having been passed in
every twelve hours; large sloughs have formed upon the nates and hips,
his intellect wanders, and he has frequent syncope. Died on the 5th of
December.

[Illustration:
 _A._ Section of the lung, made vertically.
 _B._ Section of the abscess communicating by the sinus,
 _C_, with the circumscribed cavity,
 _D_, in which the bullet had been lodged after its entrance by the
   sinus, _E_.
 _F._ The sinus by which the ball had passed into the pleural cavity,
 _G_. Opposite the 7th and 8th ribs the lung is quite adherent.
 _H._ The ball.]

_Sectio cadaveris._--The pleural cavity of the left side contained
about ten ounces of purulent matter mixed with blood, and floating in
it were numerous masses of white, curd-like matter, at the bottom of
which, in the angle formed by the diaphragm with the spine, was found
a pistol-ball partly covered by albuminous matter and discolored.
Fluid injected into the left bronchus was found to issue freely from
an opening at the most depending part of the lung, communicating with
a small cavity, the interior of which was lined by the same thick
membrane met with in cases of chronic phthisical disease; from the
upper part of this cavity two other sinuses were formed, the one
passing externally and terminating by an adhesion of the lung with the
ribs at the point where the ball had entered; the other was longer
and more tortuous, passing deeply in the substance of the lung, and
ending in a large abscess capable of containing five or six ounces of
pus. The lung was at its lower part firmly attached to the ribs by
intervening false membrane, while the upper part was free, and had
become compressed toward the spinal column. The substance of that part
of the lung not involved in the abscess was infiltrated with pus, and
the greater number of the bronchial tubes were filled up by masses of
curdy matter similar to those found floating in the effused fluid. The
natural division of the lung into lobes was quite destroyed by the
pleuritic adhesions of one to the other, while the pleura lining the
parietes was covered by rugged layers of false membrane of irregular
thickness, but readily detached. No trace of tubercular deposit
could be found, and the lung of the opposite side was quite healthy.
Since the first publication of these cases the operation has been so
frequently and, in many instances, so successfully performed, as to
leave no doubt of the advantages to be derived from it.

321. Lord Beaumont was wounded by a pistol-ball on the 13th of
February, 1832, when standing sideways. It entered the right side of
the chest a little below the nipple, appeared to pass under the lower
end of the sternum, just above or about the xyphoid cartilage, and
to have lodged in the cartilage of the last of the true ribs of the
left side near its junction with the bone, in consequence of a round
projection at that part resembling a pistol-ball, but which, on being
exposed, showed only a knob of cartilage which might have been a
natural formation; no further steps were therefore taken. The injury
had been received about four o’clock--it was now five; he could lay
flat on his back; had little or no pain or oppression.--Seven o’clock:
Breathing became oppressed, and accompanied by pain; vesicular murmur
distinct in both lungs; pulse 96; bleeding to thirty-two ounces.--Nine
o’clock: Difficulty of breathing; the pain greater; was again bled
until the pulse failed, although he did not faint; the relief
great.--Half-past ten: Oppressive breathing again returned; pulse very
low and quick; thirty-six leeches applied; relief obtained.--Half-past
twelve: Thirty-six more leeches.--Half-past two: Thirty leeches were
again applied. In all, four pints of blood were taken from the arm, and
one hundred and two leeches were applied to the chest, the bleeding
being encouraged afterward; during the first ten hours live grains of
calomel and four of the compound extract of colocynth had been given,
and now forty minims of Battley’s solution of opium were administered.

14th.--Eight o’clock: Slept after four o’clock; on waking took an
aperient draught, and is much easier; pulse 120, soft, small, and
weak.--Three P.M.: On the dyspnœa returning twenty-one leeches were
applied, and the oppression was relieved; an enema given, which acted
freely.--Half-past twelve: A returning oppression relieved by eleven
leeches; calomel repeated, and thirty minims of solution of opium.

15th.--Eight A.M.: Slept at intervals; little or no expectoration, no
blood; thinks he would faint if he sat up in bed; pulse 130, soft,
small, and weak; little pain; lies tolerably flat; respiratory murmur
distinct on both sides.--Nine P.M.: Oppression returned; twenty-four
leeches; repeat calomel and colocynth; an enema, after which the bowels
became free.--Evening: Six grains of calomel, and opium draught.

16th.--Eight A.M.: Had forty-eight leeches applied at intervals twice
during the night; slept at intervals, and is easier; no pain in the
chest; pulse 108.--Evening: An enema; six grains of calomel, and one
grain of opium.

17th.--Eight A.M.: Slept during the night, and is better; pulse 108,
soft; breathes freely; no pain.--Evening: Has had leeches applied
twice during the day, making in all 245, and each time with relief; an
enema,--calomel and opium as before.--Twelve at night: More oppression,
and, as the pulse was fuller and quicker, a vein in the arm was opened,
but only four ounces of blood could be obtained.

18th.--Eight A.M.: Slept at intervals, although very restless; pulse
120, fuller; oppression in breathing returning; bleeding to twenty
ounces, which caused him to faint; senna draught.--Evening: Has been
much relieved by the bleeding; blood cupped and buffy; twenty leeches;
enema; calomel and opium. In the night, at two o’clock, the dyspnœa
returning, twenty-two leeches were applied, and thirty minims of
solution of opium given.

19th.--Eight A.M.: Easier, quieter, better; pulse 110, soft; can
lie quite flat on his back. The wound discharged so little that the
external parts were dilated inward toward the sternum, until the
pulsation of an artery could be seen, perhaps the internal mammary,
which it was not thought advisable to disturb; respiratory murmur not
distinct at night; enema; calomel, opium, and twenty leeches.

20th.--At three in the morning, being greatly oppressed, thirty leeches
were applied, and at eight o’clock twenty more, which quite relieved
him, but left him in a state of great exhaustion, sick, and faint. A
little arrow-root relieved the faintness; discharge from the wound
free, and accompanied by _air_; bowels open.--Ten at night: Calomel,
and forty minims of the solution of opium.

21st.--Eight A.M.: Has now, for the first time, a hope of life: pulse
112, soft; no pain; can turn on his side, but fears to hurt himself;
wound discharges freely; has had a small piece of bread for the first
time.--Four P.M.: Restless, but better; senna and sulphate of magnesia
mixture.--Eight P.M.: Oppressed; pulse 120; twelve leeches; calomel,
and thirty minims of the solution of opium, at night.

23d.--Oppression at night relieved by six leeches; slept afterward;
breath slightly affected by the mercury, which was omitted in
consequence; ten grains of the compound extract of colocynth given at
night, with thirty minims of the solution of opium.

25th.--Free from pain; breathes easily and without difficulty; can
turn in bed with ease; slept well; the discharge from the wound is
free; takes farinaceous food, oranges, tea, etc. He gradually improved
until the 13th of March.--On the previous Friday, the 9th, he removed
from Bond Street to Mount Street; and on the 13th, amused himself by
washing all over in a small back room without a fire; caught cold, and
acquired a troublesome cough, which was quieted on the 14th, at night,
by opium.--On the 15th, A.M., it was evident that some mischief had
been done; pulse 120; breathing difficult; was bedewed with a cold
sweat; respiratory murmur indistinct on both sides; on the left, not
heard below the fourth rib; although the whole side sounded sonorously,
it evidently contained air, the _tintement métallique_ being very
remarkable. The wound having closed very much, and the distance to
the left cavity of the pleura under the sternum being considerable, a
piece of sponge tied around the eye of a small gum-elastic catheter was
introduced, so as to enlarge the track of the ball, and give passage to
the air from the left side of the chest. This was done at five o’clock
P.M., and at ten, on its being withdrawn, air rushed out in a very
manifest manner, to his great relief. The metallic tinkling, which was
distinct before the instrument was withdrawn, instantly ceased, but
could be reproduced by closing the opening. The small gum catheter was
therefore reintroduced with the eye projecting beyond the sponge, and
retained, air passing through it; cough very troublesome.

March 17th.--Better; pulse 100; bowels open; cough easier;
expectorates freely a _rouillée_, or reddish muco-purulent matter.

18th.--Easier and better; breathing on the left side not heard below
the fourth rib; discharge free; the permanent gum catheter taken out,
but passed in daily. After this he slowly recovered, and continued to
enjoy good health until the summer of 1854, when he died of what was
supposed to be ulceration of the stomach, being an admirable instance
of the treatment to be followed in such cases. When there is not an
opening to enlarge, one should be made with the trocar.

It has been stated by the latest writers on pneumothorax, that
tympanitic resonance on percussion, and the absence of respiration, are
not pathognomonic signs of pneumothorax, as these physical signs may
exist without it, and pneumothorax may exist without them. The metallic
tinkling, in addition to the absence of all appearance of disease in
the abdomen, will be conclusive of the presence of this disease.

322. Emphysema, from εν and φυσαω, to inflate; the diffusion of air
into a part of or throughout the cellular tissue of the body. It
has been said to take place after a wound of the chest, but without
an injury of the lung, from the air passing through the wound into
the cavity during inspiration; and by accumulation and subsequent
compression under the act of expiration, giving rise to all the
symptoms of the disease; a complaint more theoretical than real.

Emphysema, as a medical disease, is opposed to the surgical disease,
in not being an extravasation of air into the cavity of the chest,
but a dilatation of the air-cells formed for its reception. It is of
two kinds, _Vesicular_ and _Interlobular_--vesicular when dependent
on the enlargement of one or more air-cells; interlobular when, from
the sudden rupture of an air-cell, the air has found its way into the
interlobular structure of the lung. A third and very rare kind has been
added, in which air, being extravasated under the pleura, has raised it
in the form of a pouch. The morbid appearances these diseases afford,
and the symptoms they give rise to, do not fall within the range of
surgical skill; and are not frequently within the controlling power of
medical science and ability.

Emphysema is free from redness, and is distinguished from edema, or
the swelling containing a serous fluid which is also colorless, by its
not pitting on pressure, or retaining the mark of the finger. It is,
on the contrary, elastic; and the displacement of the air, on pressing
on the part, gives rise to a peculiar noise, resembling the crackling
of a dry bladder partly filled with air on its being compressed,
usually called crepitation. This swelling extends as the air introduced
increases in quantity until the whole of the areolar tissue of the body
may be fully distended.

Emphysema most commonly occurs from fractured ribs, a point from one
or more of which abrades the surface of the lung. Through the opening
thus made, the air escapes into the sac of the pleura, and thence by
the side of the broken part of the ribs into the cellular membrane.
The distress in breathing arises from the air being diffused over the
surface of the lung, which it gradually causes to collapse under the
pressure exercised by the act of expiration; while, at the same time,
the mediastinum yielding, the opposite lung suffers in a similar way,
although to a less extent, until the aerification of the blood is so
greatly obstructed as at last to interfere with life, unless relief be
obtained by the equalization of the pressure made on the lung by the
compressed air in the cavity of the pleura, with that exercised on the
inside of the lung through the glottis.

In ordinary but not severe cases of fractured ribs, a slight degree
of emphysema is frequently observed over the injured part, implying
that the lung has been wounded; such a case requires the application
of a compress, wetted with a little spirit and cold water, retained by
a bandage. The great art in the treatment of broken ribs by compress
and bandage consists in their proper application, which can only be
ascertained by the feelings of the patient. The application of a broad
flannel bandage, so as to restrain the motions of the chest, and to
cause the sufferer to breathe by the diaphragm, has been recommended
from the earliest periods of surgery; but many persons with injured or
broken ribs cannot bear the pressure of a bandage, while others derive
much ease from its use. A tight bandage generally disagrees when the
injury has been sustained at the lower part of the chest, and is more
frequently useful when the fracture is above the fifth or sixth rib.

When the emphysematous swelling extends so as to invade a considerable
portion of the body, the further diffusion of air should be prevented
by punctures made through the skin in such places as may be thought
necessary, and in extreme cases even by incisions; but these are
things more often spoken of and written about than practiced, or than
are even necessary.

323. Mr. J. Bell had so alarmed all military surgeons by stating, in
his able discourses on the Nature and Cure of Wounds, that emphysema
was “peculiarly frequent in gunshot wounds of the chest, both at the
orifice of entrance and of exit of the ball,” that they thought of
little else. They could not withstand the brilliant manner in which
this remarkable error--for error it is--was expressed. To such of us as
had served in the first part of the war in Portugal it was no longer
a bugbear; we slept in peace after the battles of Roliça and Vimiera,
of Corunna, of Oporto, and Talavera--laughing, perhaps, a little at
the credulity of the surgical portion of mankind; for the opening made
by a musket-ball rarely admits of emphysema. A slanting wound made by
a pistol-ball may sometimes give rise to it. After long and tortuous
wounds made by swords or lances it is seen more frequently, but then it
takes place shortly after the receipt of the injury.

A soldier, at the battle of Albuhera, was wounded in the right side
of the chest by a sword, which had passed slantingly under the
shoulder-blade, from which injury he did not suffer much, until the
whole side as well as the body and neck began to swell and impede
his breathing, which was effected with some difficulty and with any
ease only when sitting up. The external wound was enlarged until I
could distinctly hear the air rush out and see the part where the
weapon had penetrated between the ribs; upon which he declared himself
relieved, when the wound was closed by compress and bandage. It did
not unite, however; active inflammation of the cavity of the chest
ensued, requiring frequent and considerable losses of blood for its
suppression. At the end of three weeks the man was sent to Elvas, in a
favorable state for recovery.

324. When an opening is made into the cavity of the chest in the dead
body, the lung recedes from the pleura lining its wall, for some
distance; it is said to collapse; but this does not take place in
anything like the same extent in the living body; and if the continued
admission of air through the wound be prevented, it scarcely takes
place at all; or, should it have done so, the air is usually absorbed
and the lung quickly recovers its natural dimensions and functions.
Neither does a wound in the chest, when kept open, usually cause this
collapse to the extent which it is generally supposed to do in the
living body. The lung can be seen in motion and performing its office,
although imperfectly, as it does not fill the cavity of the pleura.
When the lung has been wounded by a ball actually going through its
substance, it does not necessarily collapse; and abrasions or deeper
injuries of its surface lead to no such result. To cause the complete
collapse of a living lung, its surface must be compressed by a fluid,
as in empyema, or by confined air, as in emphysema or in pneumothorax.

In extreme cases, when the patient can no longer lie down, but sits
up, supported, in the greatest agony of respiration, approaching to
suffocation, the face and lips swollen and blue, the pulse almost
imperceptible and countless, an opening should be made into the chest
by a small trocar and canula, for the purpose of evacuating the highly
compressed and compressing air, and to allow the expansion of the lung
after its evacuation. When this compressed air has been drawn off, as
in the case of Lord Beaumont, the compressing power being removed, the
lung expands in part, if not entirely, in spite of the breach in it,
and the mediastinum and heart return to their natural situation, the
distress in breathing is removed, the failing circulation is restored,
and the opposite lung resumes its functions.

The course then to pursue in such extreme cases is merely to puncture
the chest, evacuate the air, withdraw the canula, and close the
opening. The life of the patient having been thus saved, time is
given for the wound in the lung to heal under the usual inflammatory
processes, provided it will do so without a recurrence of the mischief.
This, if it should take place, must be met by another puncture, or the
opening in the chest should be made permanent in order to equalize the
pressure of the air in the cavity.

The incisions (the “_taillades_” of the French) into the cavity of the
chest formerly recommended, should only be resorted to when the means
indicated have failed, which they will rarely do when combined in the
first instance with an antiphlogistic treatment, aided by sedatives,
and if necessary by cordials.

The advantages to be derived from auscultation in these cases are
evident. Its value has been sufficiently shown, and the ear or the
stethoscope should be resorted to at least three times in every
twenty-four hours, in every case, however trifling it may appear to be,
until the absence of danger has been ascertained.



LECTURE XXII.

SIMPLE INJURIES OF THE CHEST, ETC.


325. The most _simple injury_, perforating the wall of the chest, is
a stab by a triangular sword, a small knife, or other weapon, which
may or may not abrade the surface of the lung, and which is usually
attended by little pain, although it often gives rise to considerable
alarm. It might be supposed that a very slight wound of the lung would
be followed by some expectoration of blood, but this does not always
take place; and although its presence may be considered demonstrative
of the injury, its absence is no proof of the contrary; for a
considerable injury from a stab or from a musket-ball may be inflicted,
with scarcely any sign of blood in the matter expectorated. If the
pleuræ are in their natural state, a small quantity of air may enter
the chest, but the opening will require to be direct and tolerably
large before the lung will separate or shrink from the wall on that
account; if adhesions should have been previously formed between the
pleuræ preventing it, they will be for the advantage of the sufferer.

In a simple incised wound, injuring the lung perhaps extensively, as
supposed from the bleeding from the mouth, no examination by probes or
other instruments need or ought to be made as a general rule; but the
wound should be immediately closed by sutures after the external parts
have been sufficiently examined to satisfy the surgeon that no portion
of the offending instrument has been broken off, or other extraneous
matters are sticking in the part.

The advantages derived from the closure of punctured wounds of the
chest in former times led to the practice of sucking them by the mouths
of irregular practitioners, generally the drum-major of the regiment,
when the patient was a soldier; and the consequences, although in some
instances apparently miraculous, were in others quite as unfortunate.

That bleeding may take place from the lung into the cavity of the
chest is indisputable, but little or no blood will escape through a
small wound; and its continuing to flow from such a wound will be a
presumptive if not a conclusive proof that some artery external to
the pleura has been wounded. Sucking, under ordinary circumstances,
of a small wound, unattended by bleeding, does good by attracting the
natural fluids to the parts, and thus causing them to swell so as to be
placed in apposition in the most advantageous manner for their reunion.
Punctured wounds of small size, therefore, may be sucked chirurgically
if any one be willing to do it, after which a bit of gold-beater’s
skin, or dry lint, should be placed upon the wound, supported by a
compress covered by adhesive plaster; these dressings should not be
removed for several days.

326. The patient should lie on the wounded part, as a general rule,
if he can conveniently bear it, not for the purpose of allowing any
effused blood or fluid to flow out, unless some particular reason
require the precaution of keeping the wound open, but to allow the
pleura covering the lung to be as closely applied as may be to the
pleura lining the wall of the chest, with the hope that the adhesive
process may take place between these parts, and by this means cut off
the wound from the general cavity of the pleura, a proceeding due to
the practice of the Peninsular war, yet so little attended to at the
present time by some teachers of surgery, who seem to confound the
practice thus recommended in incised wounds penetrating the cavity of
the chest with that which should be adopted in gunshot wounds, that few
students obtain even a reasonable degree of knowledge on this subject.
Teachers are entitled to prefer any mode of treatment they please, but
they should be careful not to neglect the opinions of others, whose
authority, derived from experience, they are bound at least to notice,
even if it should be to disapprove.

327. _Incised_ wounds of even greater extent ought not to be examined
by the probe or finger; no disturbance of any kind should be permitted
unless the cartilage or bone be injured. The external parts should be
brought together as closely as possible, so as to facilitate in every
way their union, and the processes which it is desirable should go on
within. The external parts or skin and cellular membrane cannot be kept
in perfect and continued apposition without sutures, and the proper
method of proceeding is to sew up the wound in the skin with a needle
and fine silken thread in a continuous manner, including absolutely
nothing but so much of the cut edges as will retain the thread; a
small piece of gold-beater’s skin or lint should then be laid over the
stitches and retained by a compress and adhesive plaster.

In a _simple_ case of this kind little or nothing is effused into
the cavity or secreted from the membranes of the chest, which will
interfere with the processes which may have happily begun, and which
it is desirable should be aided by the absolute quiescence of the
patient, to whom no medicine should be given which may render any
movement of the body necessary. It was formerly supposed that the
greatest object to be attained was the prevention of inflammation, and
a man was no sooner stabbed by his opponent than he was blooded and
purged by his surgeon, regardless of the necessity which existed for
perfect rest and the presence of a certain amount of inflammation, in
order to enable nature to carry on those processes which are essential
for the restoration of the injured parts. This inflammation should be
allowed to commence without interference and to continue in a moderate
degree until the object shall have been effected. It should only be
interrupted or subdued when it is supposed to be about to exceed that
degree which experience has pointed out as likely to be useful.

328. When the most courageous persons are wounded in parts essential
to life, there is more or less alarm or shock created by the injury;
although it has been gravely argued that a man does not always know
when he is actually shot or run through the body. A continued state of
anxiety and depression after an accident of this kind is a disagreeable
accompaniment of the injury, during which little should be done
beyond the giving a little cordial, and quieting the apprehensions of
the patient, leaving him to rest, if possible, after the necessary
applications have been made. If a gradual improvement take place, if
the pulse rise, if the patient resume more of his natural appearance,
and that state of commencing excitement which is denominated reaction
follow, hope may then be entertained. The general symptoms, as long as
they continue within ordinary bounds, are of little importance; the
local ones, significative of action commencing in the injured part,
are, however, to be carefully watched. They are those of inflammation
of the pleura, and it may be of the lung. This inflammation begins
slowly, and a day may elapse before it is well marked; for, when
persons have died within the first few hours after such injuries,
the pleura has often shown but little sign of inflammatory action.
Auscultation should always be resorted to from the moment of injury,
and constantly used throughout the treatment. Whenever it is concluded
that adhesion between the two pleuræ has failed to take place, the
direction to lie on the wounded side ceases to be of importance. Until
this period no food whatever should be allowed, and thirst should be
allayed by small quantities of water.

329. A punctured, incised, or gunshot wound, going fairly through
both cavities of the chest, is usually believed to be quickly if not
immediately mortal--an opinion generally correct with respect to wounds
made by musket-balls, although it is certainly not the case with regard
to punctured wounds, and does not always occur in those made by pistol
or musket-balls.

Sergeant-Major Richards, of the 29th Regiment, received thirteen sword
or bayonet wounds, and other injuries, on the heights of Roliça, on the
17th August, 1808--one particularly through each side of the chest,
between the ribs, as if the small-sword had made a wound of larger
size than usual. He had distinguished himself greatly in covering the
body of his commanding officer, and was beaten down before the British
column, which had been repulsed, could rally and recover its ground.
He was an object of particular attention to me, for the few minutes
he lived after I saw him; he had coughed up a little blood, and died
gasping, as if suffocated, the chest laboring on each side to do its
work in vain. His commanding officer, Colonel the Hon. George Lake, lay
dead by his side, killed instantaneously by a musket-ball, which passed
from the upper part of the left through the right side of the chest.

A French gentleman, fencing with his pupil in July, 1834, received a
blow under the right axilla in a very violent lunge, whereby the button
of the foil was broken off, and the foil itself passed into and through
the back part of the thorax, the point coming out between the sixth and
seventh ribs on the left side near the angles. There was but little
bleeding. The chief symptoms were those of great inflammation of the
contents of the cavity, which gave way to full and repeated bleeding
from the arm, with perfect rest and almost starvation. He recovered
very favorably, and was quite well in about eight weeks. He remains
well, and is following his profession as a teacher of fencing.

330. When an incised wound into the chest is large and direct, injuring
the lung, two very important points usually demand immediate attention.
The first is to relieve the oppressed state of the breathing; the
second, to suppress the bleeding.

In large penetrating wounds of the chest, with injury of the lung, it
has been observed that the patient has breathed most easily when the
external wound has been covered; and has been hardly able to breathe
when it was opened, which is attributed to the air getting into that
side of the thorax in inspiration, instead of entering the lung by the
trachea. If the wound admit of being well closed, the difficulty of
breathing diminishes; adhesion may take place, and the inflammatory
action within the chest may terminate; but if the inflammatory symptoms
continue, adhesion does not take place, and the secretion and effusion
of a quantity of serous fluid are the consequence. This secretion of
fluid is the natural consequence of inflammation which has passed the
stage of adhesion, whether the injury of the chest have occurred from
a stab or from a gunshot. It is the leading fact in the treatment of
these injuries, hitherto disregarded by writers on this subject, but
on the proper management of which, in both instances, a successful
result principally depends. If the closure of the wound lead, in the
course of a few days, to the re-establishment of the breathing, and
the antiphlogistic means employed to the cessation of all urgent
inflammatory symptoms, adhesion has most likely taken place, or is
about to take place, in the neighborhood of the wound, and the patient
will in all probability recover without much further suffering. If
this should not occur, and effusion take place, the wound should be
reopened, or the fluid otherwise evacuated.

A soldier of the 9th Regiment was wounded at Roliça, in 1808, by the
point of a sword in the left side; it penetrated the chest, making
a wound somewhat more than an inch long, through which air passed
readily, accompanied by a very little frothy blood, which was also spit
up on any effort being made to cough, leaving no doubt of the lung
having been injured, that viscus appearing to be retained against the
wall of the chest. As the edges of the wound could not be accurately
kept in apposition by adhesive plaster, two sutures were applied
through the skin, and the man was desired to lie on the injured side,
with the hope that adhesion might take place, as there appeared to be
no effusion of blood into the cavity. He was freely bled on each of the
two days following the receipt of the wound, and gradually recovered.

A French soldier was brought into the village after the battle of
Vimiera, wounded by a sword in the right side of the chest. He said he
had lost a good deal of blood; was very pale; pulse small; extremities
cold; breathing hurried and oppressed; had spit up some blood. On
removing the handkerchief, a gaping wound presented itself, an inch
and a half long, through which the cavity of the chest could be
seen, the lung having receded. The wound did not bleed. As adhesive
plasters would not keep the edges of the skin in perfect contact if he
attempted to move, they were sewn together, and after the application
of a compress he was much relieved. The next day all the symptoms were
alleviated, and after the supervention of some serious inflammatory
symptoms, he was forwarded to Lisbon, for embarkation for France, in a
fair state of recovery.

It was the successful results of these cases which led to the closure
of all such wounds in the first instance, with the hope of preventing
thereby the extension of the inflammation to the whole sac of the
pleura, which in many instances it succeeds in doing; and thus that
which was done in the first instance from apparent necessity, rather
than scientifically adopted, became a rule of practice, which may be
laid down as a principle to be followed in similar cases. When persons
thus wounded are neglected, the wound remains open, and the cavity of
the pleura passes into a state of suppuration, after all the symptoms
of acute pleuritis or of pleuro-pneumonia have taken place.

331. If the union of a large incised or other wound by the adhesive
process does not take place, a bloody, serous fluid oozes out from
under the dressings, if the oppression of breathing should not have
led to their removal; the patient is relieved by the discharge, which,
after a time, as the case proceeds toward recovery, will become less in
quantity and more purulent in quality.

If the union of the divided parts should take place externally, and
the general as well as local symptoms become more urgent, there can
be little doubt of a collection of some kind having taken place, and
then auscultation and percussion, if the latter can be borne, become of
the greatest importance. From the moment the wound is closed the ear
becomes the most important guide; the only one in fact to be depended
upon as to what is going on within the chest. The case is one of
pleuritis, perhaps of pleuro-pneumonia, and hence the reason that the
symptoms and treatment of these complaints have been more fully noticed
than might be considered to appertain to the province of surgery.
The effusion of a bloody, serous fluid comes on, after a penetrating
injury, from the third until the seventh or ninth day, by which time
the cavity of the pleura may be filled; puncturing the chest between
the sixth and seventh ribs at the point of election, or reopening the
wound, should be early resorted to for its evacuation.

A picket of Portuguese infantry being surprised by a sudden rush of
French cavalry from the town, during the first unsuccessful siege of
Badajos, were nearly all sabred. The survivors were brought to me. Two
had been run through one side of the chest, and one through both sides;
the last died a few minutes after I saw him. The other two seemed to
be nearly in a similar situation from loss of blood by the mouth and
from the wounds. These were immediately closed by stitches, compresses,
and adhesive plasters. A little hot brandy and water was given to
each, and they were laid aside without hope of recovery. They did not
die, however; the breathing became more easy, the distress less, and
the pulse more distinct; reaction after a time took place. The next
morning, the siege being abandoned, they were removed to Elvas, where I
afterward heard they were doing well.

A soldier of the Third Division of Infantry, under the command of Sir
James Kempt, was wounded at Waterloo, by a straight sword or sabre,
which penetrated the left side of the chest. He fell, and lost a
considerable quantity of blood from the mouth as well as from the
wound, and was supposed to be dying. On showing some signs of life, the
wound was covered by a part of his shirt; and on his arrival at the
Elizabeth Hospital in Brussels, four days afterward, it was closed.
On the ninth day, when my attention was drawn to him, he was sitting
up in great distress, from difficulty of breathing, his hand pressed
upon the wounded part, the cicatrix of which was red, swollen, and
projecting. I recommended the assistant-surgeon in charge to open this
with an abscess lancet, which he did, giving vent to a very large
quantity of bloody and purulent matter, to the great relief of the
patient for several days, although he did not ultimately recover.

The advantage derived from the closure of the wounds in these cases
was manifest. It relieved the breathing, and caused the hemorrhage
to cease, aided, in all probability, by the exhausted state of the
patients. The relief to the breathing was at the moment the most
essential point, the wounds of entrance being nearly two inches long,
and the free admission of air quite unopposed; the lung had receded
from the opening.

332. _The important question of hemorrhage_, in cases of incised wounds
admitting of being accurately closed, remains for consideration. In
many instances, the quantity of blood effused is trifling, and in
others, although greater, it is absorbed without being productive of
evil. In a third class, the quantity extravasated is larger than can
be absorbed, although it does not flow in an inconvenient or dangerous
manner through the wound, and may ultimately become coagulated and
adherent to the diaphragm and spine in the angle between them, when the
patient lies long on his back. In the worst or most alarming cases, the
loss of blood is and has been so great that its suppression offers the
only chance for the continuance of life. It is between these two last
cases only that a difference of opinion exists as to the treatment to
be pursued: one party desiring that the effused blood, if moderate in
quantity, should be allowed to discharge itself, the wound being kept
open; the other, that under all circumstances, whether the quantity
of blood poured out be small or great, the wound should be closed,
and the result awaited. The right course is, I apprehend, to remove
all the blood which can be evacuated by position, provided it can be
done without danger to the patient, rather than to allow it to fill
the chest; but as the bleeding vessel in the lung cannot readily be
got at, if seen, nor be secured by ligature with advantage, it is
advisable, if the bleeding continue, to close the wound, and allow the
cavity of the pleura to be filled, until the lung shall be sufficiently
compressed to cause the hemorrhage to cease, if the person survive
so long. The first object is to save life; after that, if time be
given, the next will be to relieve the loaded cavity. After the wound
has been closed, and the patient has so far recovered that reaction
has begun to take place, it may be concluded that the bleeding has
ceased. The chest should then be most carefully auscultated from day
to day, so that its respiratory state may be known, particularly with
regard to the increase of effusion, which will then be serous. This
will not take place until after the third, and not perhaps before the
fifth or sixth day, in any considerable quantity; when, if it should
have occurred, the wound should be reopened, or another opening made
at the most convenient place for the evacuation of the effused blood
and serum. It is probable that the wound of the vessel in the lung
which furnished the blood will be closed in five or six days: while
it is of great importance that the lung should be early relieved from
pressure, that it should be allowed to expand, and not be bound down
by false membranes; which will be the case if the compressing fluid be
not removed, and the inflammatory symptoms subdued. There is no object
to be gained but the suppression of the hemorrhage by retaining the
blood and serum within the chest; while the probability of a return of
the bleeding is not great after an opening has been made, and the blood
and serum have been evacuated, although much mischief will inevitably
follow the effused fluids remaining too long.

Repeated observation has shown that in sabre-wounds penetrating the
chest and lung, which have not united, and from which no excessive
hemorrhage has occurred, a great discharge of serous fluid usually
takes place from the cavity, which, gradually diminishing, becomes
purulent, and at last ceases, without the function of the lung being
destroyed; while, if the wound had been early closed, and the fluid
collected too long retained, the functions of the lung would be
impaired, and a counter-opening, for the relief of the resulting
empyema, may be unavailing. Whenever, therefore, the adhesive process
between the pleuræ has failed, and great effusion has taken place, the
sooner it is discharged the better.

In addition to the closure of the wound, it is desirable to arrest
the hemorrhage by other means, if possible, such as the abstraction
of blood from the arm to such an extent as it may be considered the
patient can bear, the administration of the acetate of lead with opium,
turpentine, matico, or the mineral acids; and the external and internal
use of cold or iced water, if it can be borne. If there be reason to
believe that a rib or ribs have been injured--that any extraneous
body is inclosed in the wound--or, from its appearance, that it will
certainly reopen, an incision should be made in the part injured, for
the purpose of giving the necessary assistance. The cure, however, will
not only be assisted, but mainly effected, by procuring a depending
opening by means of the small trocar and canula introduced as low down
as auscultation will authorize; the introduction of this instrument
will give the desired information on the one hand, and do little or no
harm on the other.

A soldier of the 3d Regiment of Infantry was wounded by a lance at the
battle of Albuhera, in the left side, between the fifth and sixth ribs;
and was thrown down, bleeding from the mouth and from the wound, which
was afterward closed by his comrades, by confining upon it a piece of
his shirt folded up for the purpose. Brought to the hospital, at the
village of Valverde, he appeared ten days afterward to be dying from
difficulty of breathing. On enlarging the opening in the integuments,
a quantity of blood, partly fluid, partly coagulated, issued from the
cavity of the chest. The wound was kept open to allow the discharge of
this, and of a reddish, watery fluid, which, after a few days, became
purulent. At the end of three weeks I sent him to Elvas, doing well,
and with but little discharge from the wound.

A heavy dragoon, of the German Legion, was wounded at the battle of
Salamanca by a sword, which penetrated the cavity of the right side
of the chest, between the sixth and seventh ribs. He fell from his
horse, and lost a considerable quantity of blood from the mouth and
from the wound. On examining the wound next day, a black coagulum
was seen filling up the orifice, the cellular membrane around being
considerably ecchymosed, and little doubt existed that the oppression
in breathing under which he labored was caused by blood effused into
the cavity. On separating the edges of the wound with a director,
several ounces of blood, half fluid, half coagulated, were evacuated
by making the external opening, which was enlarged, quite dependent.
The lung was then seen in contact with the external opening of the
wound, having expanded as the pressure of the blood was removed
from it. The wound was closed simply by lint, compress, and adhesive
plaster, without bandage; the man was largely bled, and placed upon his
wounded side on the ground, being the most comfortable position, in
some degree relieved from the oppression in breathing. Two days after,
the wound discharged freely a reddish-colored watery fluid, evidently
from the cavity of the chest, the exit of which was aided by keeping
the wound generally dependent. This continued for several days, the
fluid gradually becoming less in quantity, and purulent; under careful
management he was able to go to the rear, nearly well, by the end of
October.

333. On the subject of the ecchymosis, which Valentin considers to be
a pathognomonic sign of effusion of blood within the chest, he says:
“It is very dissimilar to that which occurs after a blow or wound,
and which takes place shortly after the accident, beginning around
the wound, if there be one, and extending from it. The patient also
complains of pain when the bruised part is pressed by the fingers.
These characters are not observed in the ecchymosis, the sign of
effusion, which always takes place near the angles of the lower or
false ribs descending toward the loins. Its color is identical with
that which appears on the abdomen of persons some time after death,
a bright violet, (_violet très éclairci_.) It appears about ten days
after the receipt of the injury, sometimes later.” The same sort of
thing, he thinks, takes place when the cavity of the chest is filled
with pus, but that edematous swelling is without discoloration.

334. In order to be explicit on points so important as those of which
I have treated, I have thought it right to lay down certain general
conclusions, subject to occasional deviations:--

_a._ All _incised_ or _punctured wounds_ of the chest should be closed
as quickly as possible by a continuous suture through the skin only and
a compress supported by adhesive plasters, the patient being afterward
placed on the wounded side--a precept which is absolute only with
respect to _incised_ wounds capable of being united by suture in the
manner directed.

_b._ As soon as the presence of even a serous fluid in the chest
is ascertained to be in sufficient quantity to compress the lung,
a counter-opening should be made in the place of election for its
evacuation by the trocar and canula, which may be afterward enlarged;
unless the reopening of the wound should be thought preferable, which
will not be the case unless it should be low in the chest.

_c._ If blood flow freely from a small opening, the wound should be
enlarged so as to show whether it does or does not flow from within the
cavity. If it evidently proceed from a vessel external to the cavity,
that vessel must be secured by torsion or by a ligature applied on it,
all the other methods recommended being simply surgical absurdities.

_d._ If blood flow from within the chest in a manner likely to endanger
life, the wound should be instantly closed; but as the loss of a
reasonable quantity of blood in such cases, say from two to three
pounds, will be beneficial rather than otherwise, this closure may be
delayed until syncope takes place or until a further loss of blood
appears unadvisable.

_e._ If the wound in the chest have ceased to bleed, although a
quantity of blood is manifestly effused into the cavity of the pleura,
the wound may be left open, although lightly covered, for a few hours,
if the effused or extravasated blood should seem likely to be evacuated
from it when aided by position; but as soon as this evacuation appears
to have been effected, or cannot be accomplished, the wound should be
closed. It must be borne in mind that the extravasation which does
take place is usually less than is generally supposed--a point which
auscultation will in all probability disclose.

_f._ If the cavity of the pleura be full of blood, and the oppression
of breathing and the distress so great as to place the life of the
patient in immediate danger from suffocation, the wound should be
reopened, if it have been closed, or freely enlarged, if small, to such
an extent as will allow a clear evacuation of the effused blood. It
has been supposed that in such a case the lung does not sufficiently
collapse, and the bleeding is therefore continued because the vessel
cannot contract; but the lung will usually collapse under pressure of
the air, unless prevented by previously-formed adhesions, when the
hemorrhage may possibly cease--instances of which are said to have
taken place, and the practice should therefore be borne in mind.



LECTURE XXIII.

WOUNDS OF THE CHEST, ETC.


335. Gunshot wounds of the chest, penetrating the cavity, are always
exceedingly dangerous. After the battle of Toulouse, on the 10th of
April, 1814, one hundred and six cases of wounds in the chest in
officers and soldiers, in all of whom the cavities were not penetrated,
were received into hospital. Between the 12th of April and the 28th
of June thirty-five died, fourteen were discharged to duty, and
fifty-seven were transferred to Bordeaux to proceed to England, some to
die, some to be pensioned, but few in all probability to return to the
service--being an ultimate loss of nearly one-half, if the fifty-seven
cases sent to England could be traced. M. Menière, in giving an account
of the wounded carried to the Hôtel-Dieu of Paris, in the three
remarkable days of July, 1830, where every case was immediately taken
care of, says forty cases were received into the hospital; of these
twenty died; he states the case of ten more, seriously wounded, who
recovered; and he gives the names of seven more, in six of whom the
cavity of the chest was not perforated, and alludes to three wounded
by small-swords, who recovered--the loss being thus one-half, even if
the rest happily and perfectly recovered, which may be doubted, thus
showing that with the ablest assistance the Hôtel-Dieu of Paris could
afford the loss was one-half. After the battle of Waterloo the loss was
much greater; with the army on the Sutlej the loss was deplorable, in
consequence of the want of a sufficient number of medical officers and
of means--a state of destitution to which I have drawn the attention
of the directors of the East India Company in the strongest possible
terms, but which they will not rectify, but which will some day, I
hope, become the subject of Parliamentary discussion, and, I doubt not,
of public reprobation. That the wounds of the chest with the army in
the Crimea will afford a more satisfactory result, cannot, I fear, be
expected, and for similar reasons.

336. When a musket-ball fairly passes through the cavity of the chest,
the orifice of entrance is round, depressed, dark colored, and more or
less bloody in the first instance; the orifice of exit is generally
more of a rugged slit or tear than a hole. The alarm is great, and the
powers of life are much depressed. The wounds may or may not bleed; the
sufferer may spit up more or less blood; respiration may be difficult,
countenance pale, extremities cold, pulse variable--symptoms dependent
on particular constitutions and circumstances connected with the extent
of the injury.

It has been said that balls are apt to run round the body, coming out
at a point opposite to that at which they entered, without penetrating
the cavity of the chest; this, whenever it does take place, is a rare
exception to a general rule, dependent on the ball being reflected from
something solid which it cannot penetrate, such as a button, a piece of
money, a rib, etc. If the ball run under the integuments exterior to
the fascia covering the intercostal muscles, it is usually marked by a
tenderness in its course on touching the part and a discoloration of
the skin. A ball may, however, run between two ribs for some distance,
injuring the muscular structures between them without penetrating the
cavity, in which case, after the first moments of alarm have passed
away, the symptoms indicative of a penetrating wound either cease or do
not occur, although those of inflammation of the pleura or lung may and
often do follow to a considerable extent.

When the ball cannot be traced, the absence of symptoms, after the
first period of alarm has subsided, will enable the surgeon to form
the surest prognosis; their absence, however, cannot too certainly be
relied on.

A ball will occasionally rebound from the sternum, leaving merely
a black mark; from the spongy nature of that bone in which they
frequently lodge, they require the application of the trephine. If a
ball should be felt through a wound in the sternum, the broken portions
of bone should be removed by the small saw or by the trephine, and the
ball extracted.

337. An enlargement of the wound, the “_debridement_” of the French,
does no harm beyond the pain it occasions, unless there be something to
be removed, when an incision becomes necessary, in many instances, for
the removal of extraneous bodies or for the evacuation of blood, etc.
When a wound from a musket-ball appears likely to have penetrated the
cavity of the chest, and is too small to admit the end of the finger,
the opening ought to be enlarged so as to allow its introduction as far
as the ribs, in order to ascertain whether those bones have sustained
any injury, or whether anything is lodged exterior to or within them.
It is not necessary that a man should be cut simply because he has been
shot; and an enlargement of the wound should be of no greater extent
than is absolutely necessary for the purpose intended. When pieces of
shell, or of a sword or lance, are broken off and partly lodged in
the cavity of the thorax, which is more likely to happen when they
enter through the large muscles of the back, they will require larger
incisions to give room for their removal. Great praise was given of
old to Gerard, surgeon-in-chief of La Charité in Paris, who, having
perceived that a small sword, after going through a rib, was broken
off close to it, thought it advisable to make an incision through
the intercostal muscles into the chest, and then to introduce his
forefinger, armed at the end with a thimble, with which he pressed back
the point of the broken blade. In a case of this kind, the surface and
outer edge of the bone should be removed, until the piece of steel can
be firmly seized and withdrawn by a fine pair of pincers or pliers.

When a ball sticks firmly between two ribs, it requires some care
to remove it, as the rib both above and below may be more or less
interested, although not actually fractured. The attempt should be
made during inspiration, when the lower rib should be depressed, and
some thin but not sharp-pointed instrument like an elevator should be
gently pressed around and under the looser edge of the ball, in order
to extricate it.

When a musket-ball fractures a rib, there ought to be no hesitation
about the propriety of enlarging the wound, to allow the splintered
portions of bone to be removed. It is possible that in doing this some
pieces of cloth or other matters may be extracted, which might else
glide into the cavity of the thorax, or stick in the lung itself.

A soldier of one of the regiments on the left of the position of
Talavera was brought to me, wounded by a ball in the left side of the
breast; it had struck the sixth rib, and passed out about four inches
nearer the back. As the point of the finger indicated the presence of
broken bone, I enlarged the anterior wound, and then found that the
ball had driven some spiculæ of bone into the surface of the lung,
which appeared to have been previously attached to the pleura costalis
at that part. These having been removed, together with a piece of coat
which had been carried in with the ball, a small, clean wound was left,
which gradually healed up, the man accompanying me on the retreat over
the bridge of Arzobispo.

338. When a ball impinges with force on the center of one of the ribs,
and passes into or through the chest, the bone is usually broken into
several splinters of different lengths, some of which frequently
accompany the ball in the commencement of its course, or are even
carried into the substance of the lung, together with a part of the
wadding of the gun, or of the clothes of the patient. These should if
possible be extracted if they can be seen, and the sharp ends of the
rib rounded off. When the ball fractures a rib on passing out of the
chest, the splinters are driven outwardly, and should be removed by
incision.

339. When a ball strikes a cartilage of one of the ribs, it does not
punch out a piece as it were, but merely divides and passes through
it, bending it inward, rarely tearing away a portion. The parts of
the cartilage thus bent and turned inward are to be drawn outward,
and replaced by the end of the finger, a bent probe, or other curved
instrument.

A ball, when striking obliquely but with force on the chest, will
frequently penetrate, and then run round, between the lung and the
pleura lining the wall of the chest, for a considerable distance,
before it makes its exit. In this case the lung may be only slightly
bruised, without the pleura pulmonalis or costalis being more than
ruffled. In others the lung shows a distinct track or hollow made by
the ball. A shade deeper, and the ball penetrates, and forms not a
hollow, but a canal. The patient in all these cases spits blood, and
the first symptoms are severe; they frequently, however, subside, and
are not always followed, under proper treatment, by effusion, although
it may always be expected.

340. When a ball fairly passes through the lung, it leaves a track
more or less bruised, which continues for a time to bleed according to
the size of the vessels which are injured, thus making a wound more
dangerous as it approaches the root of the lung where the vessels
are largest. More or less blood is spit up, or, if effused, it
gravitates in the chest, until it rests on the diaphragm or other most
depending part, according to the position of the patient. If it should
be in quantity, the filling up of the chest may be ascertained by
auscultation, if the wound be closed. As the quantity of effused blood
increases, the lung becomes more and more compressed, until at last
the hemorrhage ceases under pressure, if the wound be covered; and the
patient is saved for the moment, unless he should die of asphyxia, from
the lung on the other side being also compressed through the bulging of
the mediastinum on it; to prevent which, if possible, the wound should
be reopened or enlarged, so as to take off the pressure of the effused
and perhaps coagulated blood. If the person wounded shall have suffered
formerly from inflammation, and the lung has adhered in consequence to
the wall of the thorax, at the parts where the ball enters and goes
out, the cavity of the chest will not be opened, and the track only
of the ball will communicate with the external parts, unless the ball
shall have perforated some of the large vessels, when he will continue
to bleed by the mouth. The pressure of the blood effused into the track
of the ball, which may become coagulated, will sometimes suffice, under
even these circumstances, to effect the suppression of the hemorrhage
which the loss of blood, the faintness of the patient, and the weakness
of the circulation, under proper treatment, will materially assist in
rendering permanent.

General Sir G. Lowry Cole, G.C.B., was struck at the battle of
Salamanca, on the 22d of July, 1812, by a musket-ball, which entered
immediately below the clavicle, fractured the first rib, and, inclining
inward, came out through the scapula behind; as he spat blood for
three days, the upper part of the lung was shown to have been injured.
The ball appeared to have passed so close to the under part of the
subclavian artery that the greatest fears were entertained for his
safety; more particularly as a marked difference in the size of the
pulse was perceived in the left arm, which did not exist before. He
remained three days on the field of battle, in a Portuguese officer’s
tent I always carried with me. Under repeated bleedings, and the
strictest antiphlogistic treatment, several splinters having come away,
and a large piece of the rib and of the scapula having exfoliated, he
gradually recovered, so as to be able to resume the command of the
Fourth Division in October at Madrid. The subclavian artery never
resumed its power, and the radial always beat less forcibly on the left
side. He perfectly recovered his health, the respiratory murmur of the
lung being natural. He died suddenly in 1844, from rupture, I believe,
of an aneurism of the abdominal aorta.

A dragoon of the King’s German Legion, shot in a nearly similar manner
on the same occasion, suffered more severely: the clavicle and first
rib were splintered to a greater extent, and he lost a large quantity
of blood by the mouth. The splinters having been removed, after
enlarging both wounds for that purpose, and the inflammatory symptoms
subdued, he appeared to be going on favorably for three weeks; when,
having eaten some meat obtained irregularly, he suffered what seemed
to be a bilious attack of vomiting and purging, attended by fever and
oppression in the chest; an ipecacuanha emetic having been given with
full effect, relieved him much. During the efforts to vomit, the wounds
discharged a quantity of sero-purulent fluid, a piece of the cloth
of his coat, and another of bone, which had gone in with the ball,
and in all likelihood had been lying with the matter at the bottom of
the chest. After this he slowly recovered. This case is peculiarly
instructive.

General Sir Andrew Barnard, G.C.B., was wounded when in command of the
Rifle Brigade, at the passage of the Nivelle, on the 10th November,
1813, by a musket-ball, which entered between the second and third
ribs, in front of the right side of the chest, passed directly through
the cavity and through the shoulder-blade, from under the integuments
covering which it was removed. He not only felt but heard the sound of
the ball as it struck him, and he fell from his horse. Blood gushed
from his mouth, and continued to do so until after he was completely
exhausted by bleeding from the arm to the amount of two quarts. He was
again bled at night, and the subsequent morning, which relieved all
the material symptoms. During six weeks he suffered from difficulty of
breathing and cough, and from night-sweats. Some pieces of bone and
cloth came away from the wounds, with a free discharge in the first
instance, which gradually diminished until the wound closed. In eight
weeks he was able to resume his command.

More than forty years afterward I found the lung pervious; the
vesicular murmur could be freely heard even up to the situation of
the wounds, to the internal parts of which it may be concluded the
lung adhered, from the sound conveyed to the ear on auscultation. He
suffered little or no subsequent inconvenience from the injury, and
died in January, 1855, aged 82.

_Case of Major-General Broke, by himself._--Toward the close of
the battle of Orthez, on the 27th of February, 1814, a musket-shot
struck me between the second and third ribs on the right side, near
the breast-bone. I was then on horseback, being aid-de-camp to
Lieutenant-General Sir Henry Clinton, commanding the Sixth Division.
The sensation was precisely as if I had been struck a violent blow with
the point of a cane, but it did not unhorse me. I was attended in a
very short time by the surgeon of the 61st Regiment, when, on removing
my clothes, the air and blood bubbled out from the wound as I drew my
breath. The surgeon, turning me on my face, discovered the ball to
be lodged under the thin part of the blade-bone. This he cut through
and extracted the ball, and with it pieces of my coat, waistcoat, and
shirt, which were lodged between the ribs and the blade-bone. This
occurred about four P.M. I was then removed to the town of Orthez, a
distance of about three miles, and in the course of the afternoon the
veins of both arms were opened in at least seven different places, but
scarcely any blood came away; breathing became exceedingly painful in
a day or two, and I felt nearly suffocated, when, in the evening, my
brother, Sir Charles Broke Vere, arrived with my friend, Mr. Guthrie,
who examined me carefully. The agony of drawing breath was such that
I could scarcely endure it. He opened one of the temporal arteries,
and desired that it might be allowed to bleed without interruption.
He afterward left me to visit some other wounded men, and returned in
about three hours, when I told him that I felt relieved, and had much
less of the suffocating pain in breathing. He then opened the other
temporal artery, directing as before that its bleeding should not be
checked. I shortly after that dropped asleep, and on waking could
breathe freely; my recovery was progressive from that time, the wound
in front, where the ball entered, being the first closed; but both were
healed at the end of about eight weeks, and in about ten I was able to
rejoin the army at Bordeaux.

  H. G. Broke, _Major-General_.

He is now, in 1855, in perfect health, the respiratory murmur being
free all over the chest.

The Duke of Richmond, then Earl of March, was wounded by a musket-ball
at the battle of Orthez, while at the head of his company in the 52d
Light Infantry. He was standing at the moment with his right face
toward the enemy. The ball entered that side of the chest, between the
fourth and fifth ribs, nearly in a line with the lower edge of the
scapula. He fell to the ground with great violence, and was speechless
for some time. He stated to me at a subsequent period that the
sensation he felt at the moment was as if he had been “_cut in two_.”

On immediate examination there was no other opening to be found but the
_one_ where the ball had entered; nor were the medical officers able to
feel the ball anywhere under the skin or under the muscles.

The wound having been dressed he was laid on a door and removed to
Orthez, about three miles from the scene of action, during which he
complained of excruciating pain, extending from the wound to the top
of the os ilii on the same side, the pain being much aggravated by
frequent and severe cough, with copious expectoration of frothy mucus,
and much florid blood; respiration hurried; countenance pale.

The moving him to Orthez occupied nearly three hours; a great part of
the ground being very rough and broken, the men could not well step
together, and the consequent unavoidable shaking and jolting caused him
much pain. On his arrival at Orthez, he was extremely languid, with a
tendency to syncope. Pulse feeble; extremities rather cold.

Seven in the evening: After having been faint for an hour, he
became hot and restless; pulse 108, and full; skin more hot, and
the respiration short and more hurried. After he was placed in bed
hemorrhage from the wound took place to a very considerable extent.
Eight ounces of blood were taken from the arm. (Could bear no more.)

15th inst., nine A.M.: After the bleeding he became more quiet, and
had less pain; but he has since become very restless, and the pain
returned, with a full, hard, and frequent pulse. The wound has again
discharged a very considerable quantity of blood. Bleeding repeated as
before.

Nine P.M.: Deputy-Inspector Thomson and Staff-Surgeon Maling examined
the wound. Mr. Maling introduced his finger (the whole length) between
the ribs into the wound without any interruption to its progress, and
without being able to reach the termination of the passage of the ball;
and Dr. Thomson then passed a probe (its whole length) straight into
the chest, with a similar result; thus leaving no doubt on the minds of
all present that the ball had passed directly into the posterior part
of the chest.

Midnight: The blood last taken is very buffy; and there has again been
an _immense discharge_ of blood, etc. from the wound; the sheets,
mattresses, etc. are saturated with it; and on the floor, under the
bed, there is a large pool of blood which had soaked through the
bedding. Pulse 114, low and frequent; cough and expectoration as
before; pain violent, and great restlessness. Repeat the bleeding.

_Mem._--Perhaps enough has now been stated to show the nature of the
wound; and any further detailed statement of his lordship’s sufferings,
or the treatment of his case, would be unnecessary. On the latter
point, however, it may be mentioned that, exclusive of the _general
treatment_, he was bled _seven times_ between the evening of the
27th of February and the morning of the 2d of March, the _cough_,
_expectoration_, _breathing_, _pain_, _etc._ being much relieved by
each bleeding.

  A. Hair, M.D.

Mr. Guthrie saw the Earl of March on the same day as Colonel Broke,
and suggested that no further efforts should be made to find the ball,
while the treatment adopted should be steadily pursued; and in 1846,
he pointed it out lying under the edge of the base of the scapula. His
grace is now, 1855, in good health, and the chest, well formed, sounds
clearly and healthily in every part, even at the point injured.

341. The ball in passing through the lung, in these cases, destroyed
the life of that part only which it touched; and although air would
pass out at the time, this would not be of long continuance. The wounds
being kept covered, the lung did not and does not usually, in similar
instances, collapse or recede from the wall of the chest, but quickly
recovers its state of expansion, however impaired it may be at the
moment by the injury. The track made by the ball gradually suppurates
and heals, leaving merely a depression or cicatrix on the surface
attached around or in part to the wall of the chest by adhesion. The
track through the lung may be readily seen in such cases after death;
although during life it interferes so little with the respiratory
murmur as not to be observable, unless by its greater distinctness,
from the thinness of the intervening parts.

Mrs. M. was wounded by a small pistol-ball, which entered on the right
side from behind, between the seventh and eighth ribs, just under the
arm when hanging down, and passed out in front over the cartilage of
the sixth rib, more than an inch from the pit of the stomach. She had
not spit blood, and the ear declared the lung to be pervious to air
at the wounded part, which raised a hope that the ball might not have
penetrated the cavity, although it might have injured the pleura.
As she suffered great pain twenty-four hours after the injury, the
breathing being oppressed, Mr. Adams bled her into a hand-basin,
until about to faint. She lost nearly thirty ounces of blood, but her
symptoms were quite relieved, so as to render any other bleeding during
her treatment unnecessary. At the end of the third day she spat a very
little blood after removal in a carriage to another lodging, and then
gradually recovered. After four different stethoscopic investigations,
I came to the conclusion that the ball had not struck the lung in the
first instance, although the lung adhered to the pleura costalis, and
suffered from some abrasion or ulceration at that point, which gave
rise to the expectorated blood.

These cases are instances of wounds of the upper part of the lung,
which are in general more dangerous than those of the lower, from the
vessels being larger, and from the greater difficulty with which any
extravasated blood or fluids can escape. They also prove that when
blood is poured out in small quantity, it may be absorbed, but what
that quantity may amount to is doubtful.

342. In cases in which the external opening or wound does not
communicate freely with the cavity of the chest, the principal danger
arises from the inflammation of the pleura ending in effusion, which,
if not evacuated, leads to the loss of the individual. _It is the great
fact to be attended to in the treatment of pistol wounds of the chest,
or those made by small balls which do not pass out._ All the persons I
have seen die from small balls have died with the affected cavity more
or less full of fluid. The post-mortem reports of all persons killed
in England in duels by wounds through the chest, unwittingly attest
this fact, as well as the insufficiency of the surgical treatment they
received; and the necessity, for the future, for its amendment. It is
in these cases that the stethoscope is most valuable--its frequent use
indispensable. When the respiratory murmur ceases to be heard except
at what is the upper part of the chest, whatever the position of the
patient may be, it is full time to enlarge the original opening, or to
draw off the fluid by the trocar and canula.

Laennec thought that when a considerable effusion took place in
pleuro-pneumonia, filling the posterior part of the chest when the
patient lay on his back, it nevertheless diffused itself over the
whole surface of the lung; but dissection has shown, in cases of
wounds, that the fore part of the lung may be applied to the anterior
part and sides of the ribs, while a serous effusion fills the hollow
behind, the respiratory murmur being distinctly heard above it. It
is the most important fact to ascertain, particularly in pistol or
small penetrating wounds of the chest, in which the opening is not
sufficiently large to allow any fluid effused to run out.

Sir C. B. was wounded by a pistol-ball in the back, which passed into
the chest through the lower part of the lung of the right side, and
lodged on the inside of the wall of the chest in front of the same
side, sticking in and against a rib, but giving rise to no external
marks or signs of mischief at that part, so as to admit of an operation
for its removal. The inflammatory symptoms having been restrained,
it was nevertheless obvious that the cavity of the chest was full of
fluid, and that the oppression in breathing arose from it, and not
from the injury done to the lung. The stethoscope was then unknown,
the ear was not in use; my older colleagues were obstinate; they would
not hear of an operation for enlarging the wound into the chest; and
as our patient was, unfortunately for him, shot in London, instead of
at the pass of Roncesvalles, or on the bridge over the Bidassoa at
Irun, we let him die on the eighth or ninth day, without all the aid
which surgery might have given him. It is possible he would not have
recovered under any circumstances, from the ball having lodged, and
from his advanced age.

A soldier of the Fifth Division of Infantry was wounded at Toulouse by
a musket-ball, which entered between the fourth and fifth ribs of the
right side, near the sternum, and came out behind nearly opposite,
fracturing the ribs, the splinters of which were removed. The first
symptoms of inflammation, having been in some degree subdued by the
sixth day, were followed by those more immediately indicating effusion;
such, particularly, as great oppression, difficulty of breathing,
and inability to lie in the recumbent position, which induced me to
introduce, after a little pressure, a gum-elastic catheter into the
posterior wound, through which a quantity of red, serous fluid was
withdrawn, exceeding, perhaps, three pints by measure. On the removal
of the catheter the discharge of fluid ceased, and, under a strict
antiphlogistic treatment, the man gradually recovered, so as to be
sent to England in the following June. If the symptoms of oppression
had returned, I should have repeated the operation perhaps lower down.
Auscultation, if it had been then known, would have smoothed away many
doubts and difficulties.

A soldier of the 40th Regiment was wounded at Toulouse on the 10th
of April by a musket-ball, which entered about two inches below the
nipple of the right breast, passed through the cavity and the lung, and
came out behind at a nearly opposite point, injuring the ribs above
and below, without entirely destroying their continuity. He was bled
largely on the morning of the 11th, and again at night. On the 12th
the bleeding was repeated; some small pieces of ribs were extracted
from both orifices, and some part of his dress from the anterior
one. He spat blood when he coughed, and respiration was difficult.
Calomel, opium, and antimony were given in pills every six hours,
and the bleedings were repeated daily, and sometimes oftener, for
the first eight days, during which time a free discharge, at first
serous, afterward purulent, took place from the wound, after which
the inflammatory symptoms subsided; the cough became easier, the
expectoration less, and free from blood; breathing easy. The calomel
was omitted; a mild farinaceous diet was allowed instead of a little
gruel, and a very little bread and milk. In a fortnight the wounds
began to heal. On the 1st of May, some small pieces of rib were removed
from the anterior wound, after which both gradually closed, and he was
forwarded to Bordeaux on his way to England in the beginning of June,
cured.

Corporal Dunleary, of the 69th Regiment, was wounded on the 16th of
June, 1815, at Quatre Bras, by a musket-ball, which entered the
thorax, fracturing the seventh rib on the fore part of the right side,
and lodged. He said he had lost a large quantity of blood from the
mouth, and some from the wound, between that and the 19th, when he was
brought to the hospital in Brussels. The pulse was then quick and hard,
respiration difficult and anxious, and a bloody discharge issued from
the wound on every respiration; bowels confined since the accident; was
bled to forty-four ounces; saline purgatives, with calomel, antimony,
and opium, were given until the 29th of June, when the wound discharged
good pus. From this time, at different periods for six weeks, he lost
ninety-two ounces more blood, being strictly placed on milk diet.
Several pieces of rib exfoliated. He was sent home on the 31st of
August, declaring himself quite as well as ever he had been in his
life; the ball remaining undiscovered.

A soldier of the Fusilier Brigade was struck by a musket-ball on the
right side of the front of the chest, at the battle of Albuhera; it
entered between the fifth and sixth ribs, passed through the lungs,
and lodged. Three days afterward, when the first symptoms were in part
subdued, he complained of pain in a particular spot, nearly opposite
to where the ball had entered, at which part something could be felt
deeply seated. An incision being made, the ball was found lodged in the
intercostal muscles between the ribs, whence it was easily removed. A
considerable discharge of reddish-colored serum followed, with great
mitigation of the symptoms, after which, under strict treatment, the
man recovered, and was sent to Elvas with every prospect of a cure.

Lieutenant-Colonel Harcourt and Major Gillies, of the 40th Regiment,
were both shot through the chest, at the head of the regiment, at
the successful assault of Badajos; the wounds were as nearly similar
as possible, from before directly backward. They were taken to the
same tent, and treated alike with the same care by the late Mr.
Boutflower, the surgeon of the regiment, with whom I saw them daily.
The inflammatory symptoms ran high in both. In Major Gillies, a tough
old Scotchman, they could not be subdued, and he died, at the end of
a few days, of pleuro-pneumonia. Colonel Harcourt slowly recovered,
and died Marquis d’Harcourt, near Windsor, more than twenty-five years
afterward, suffering little or no inconvenience from his chest, when I
last saw him.

Captain Cane, 23d Fusiliers, was wounded at the affair of Saca Parte,
in front of Alfaiates, in 1812, by a musket-ball, which struck him
below and a little to the outside of the left nipple, fractured the
rib, and entered the chest, giving rise to the sensation as if the ball
had passed diagonally downward and backward to the loins of the same
side. He spat blood, and was very faint. The next day he could scarcely
breathe, was in great pain, continued flushed and anxious; pulse 100.
He was bled into a washhand-basin until he fainted, and every day
afterward, some days twice, to a less extent, for ten days, and once
again until syncope was induced, on an accession of symptoms after an
imprudence in taking a little wine, which nearly smothered him, he
said. Some pieces of flannel shirt, of braces, coat, etc. were removed
from the wound, and several portions of bone gradually followed,
together with a quantity of matter, which continued to flow from May
until the end of the following September, when the wound healed.

On the 23d Jan., 1821, I had an opportunity of examining this
gentleman. My report says, he is never free from a little pain in
the loins, where the ball is supposed to be, and cannot take a full
inspiration without pain in the chest; expectorates more or less
constantly, and occasionally a little blood about once in three or
four months in half congealed lumps. Cannot ride or take any exercise
because it brings on the pain. The cicatrix shows a large, deep hole,
and the deficiency of the rib is well marked. The side of the chest is
altogether contracted and flatter; the heart has been moved behind the
sternum; the beat of the apex being on the other side of the xiphoid
cartilage, and that of the heart, as a whole, is more indistinct than
usual. In other ways in good health. It is possible that the ball may
be lodged in or be retained by layers of coagulable lymph in the angle
formed between the diaphragm, the ribs, and the spine.

William Downes, of the 11th Regiment of infantry, aged thirty-three,
was wounded by a musket-ball, on the 31st of August, 1813, in the
Pyrenees; it fractured the fourth rib of the left side, passed through
the chest, and came out behind through the scapula. He spat a good
deal of blood, although little flowed from the wound. The next day
he was bled largely twice, to relieve the bleeding from the lung,
and was sent to Passages, where he was bled daily; and thence, a ship
being ready, to Santander, where he arrived on the 14th of September.
A free, bloody, purulent discharge took place from the anterior wound,
but little from the posterior, and he expectorated a bloody, purulent
matter, and occasionally a little blood. Toward the end of September
the sanguineous expectoration ceased; but the soft parts of the chest
had sloughed and separated under an attack of hospital gangrene, from
which he had a narrow escape during the month of October. The wound in
the chest gradually closed during the month of November; and on the
14th of December he was discharged convalescent, his health tolerably
good, but his breathing by no means free; no expectoration. The left
arm was impaired in power, in consequence of the mischief done to the
muscles of the fore part of the chest and shoulder by the hospital
gangrene. The chest was altogether somewhat flattened and shrunk, but
there did not seem to be any diseased action going on within.

_Case of Lieutenant-Colonel Dumaresq, aid-de-camp to Lord Strafford,
by himself._--While turning round, after a successful charge of
infantry, at Hougomont, on the 18th of June, 1815, I was wounded by a
musket-ball, which passed through the right scapula, penetrated the
chest, and lodged in the middle of the rib in the axilla, which was
supposed to be broken. When desired to cough by the medical officer who
first saw me, almost immediately after receiving the wound, some blood
was intermixed with the saliva. I became extremely faint, and remained
so about an hour and a half, after which I rode four or five miles to
the village of Waterloo, where I was bled, which relieved me from the
great difficulty I had in breathing; this difficulty was accompanied
by a severe pain down my neck, chest, and right side. I was much
easier until the evening of the 19th; but in the course of the night,
the difficulty of breathing becoming much greater, and the spasmodic
affection having very much increased, I was bled seven times, until the
middle of the next day.--20th. I continued better, but was then seized
with the most violent spasms imaginable in my neck, chest, and stomach.
I could scarcely breathe at all, and was in the greatest possible
pain; I was again bled twice very largely, and my stomach and chest
fomented for a length of time with warm water and flannels. I passed a
very tolerable night, and continued pretty well until two o’clock the
following day, when I was again very largely bled, by which I was very
much relieved. I continued pretty well, and free from much pain; but my
pulse having very much increased, and having a good deal of fever, on
the 23d I was bled again; after this I continued free from much pain or
difficulty of respiration, and on the 26th was removed into Bruxelles,
when I came under your care. I forgot to mention that when I was so
violently attacked I had two lavements most vigorously applied; salts,
etc. proving of no avail, took digitalis, commencing with ten drops
every four hours, increasing to fifteen from the second day.

N.B.--Up to this period, the 2d of July, the devil a bit have I eaten.

    While with fat mutton-chops, and nice loins of veal,
    You stuff your d--d guts, your hearts are all steel.
    Oh! ye doctors and potecaries, you’ll all go to hell,
    For cheating our poor tripes of their daily meal.
          H. Dumaresq.

The ball in this case was lodged in the rib, which ultimately became
thickened around it. He recovered with good health, but with occasional
spasms in the chest; and died of apoplexy, in Australia, twenty-five
years afterward. His doggerel lines show the buoyant and unconquerable
spirit of a soldier, who knew that his chance of recovery was small. It
was a most gallant, a most friendly spirit. Peace to his manes.

If the ball had caused a greater degree of irritation, I was prepared
to cut down upon the rib, and remove a part of it, if necessary; for
I have seen balls so situated slip from their lodgment, roll on the
diaphragm, and cause general inflammation, suppuration of the cavity,
and death, which must almost always ensue in such cases, unless the
ball can be removed, and the matter evacuated by an operation to be
hereafter described.

General Macdonald, of the Royal Artillery, was present at Buenos Ayres,
when a bombarder of that corps received a wound from a two-pound shot,
which went completely through the right side, so that when led up
to the general, who was lying on the ground, he saw the light quite
through him, and supposed he was of course lost. This, however, did not
follow, and some months afterward the man walked into General (then
Captain) Macdonald’s room, so far recovered from the injury as to be
able to undertake several parts of his duty before he was invalided;
thus proving the advantage of a shot, however large, going through
rather than remaining in the chest.



LECTURE XXIV.

Appearances After Death, Etc.


343. The appearances after death differ materially even in apparently
similar wounds.

A French soldier, shot through the right side of the chest at the
siege of Badajos, died in December, 1812, in Lisbon, apparently of
consecutive phthisis. The ball had gone through the chest from before
directly backward; the posterior wound was closed; the anterior one
was fistulous, and discharged a small quantity of matter, of which he
spat up daily a large quantity until he died. The lung was diseased
throughout, and contained several vomicæ or small abscesses, from which
the matter expectorated was secreted. The track of the ball was nearly
filled up, although the part immediately around was harder than usual.
The lung adhered in many places to the wall of the chest, which was
much flattened.

In other cases, portions of wadding, of leather belts, of splinters of
different lengths, pieces of buttons, and even balls, have been found
loose in the chest, showing the necessity for an especial and decided
treatment.

A French soldier was wounded by a musket-ball at the battle of
Waterloo; it penetrated the chest, fracturing the second rib, then
passed through the lung, and went out behind in nearly a straight line,
close to the spine. Left on the field of battle for five days before
he was brought to Brussels, he was nearly dead with difficulty of
breathing and other symptoms of inflammation, from which he recovered
in the course of the next ten days, under repeated bleedings and
the strictest antiphlogistic regimen. At the end of this time, when
apparently doing well, an accession of inflammation and of all his
bad symptoms took place, destroying him at the end of four weeks
from the receipt of the injury. On dissection, the lung was found
adherent to the chest by false membranes of some thickness, with a
quantity of purulent fluid in the cavity. The track of the ball was in
a suppurating state, and two pieces of rib were found in the center
of its course. The whole of the lung appeared to be filled with a
sero-purulent fluid, which could be readily squeezed out.

John Roth, of the 5th battalion of the 60th Regiment, aged twenty-nine,
had been wounded by two balls, one on the 10th of April, 1814, at the
battle of Toulouse, which grazed the left temporal bone; the other had
gone through the upper part of the right chest, in the Pyrenees, the
autumn before. Both wounds had healed. He was seized on the 8th of May,
after a little intemperance, with pains in his body and joints, pain in
the chest, and cough, with bloody expectoration; skin hot, tongue foul,
and bowels confined. On the 9th he was bled, and purged by calomel,
antimony, and salts. On the 10th symptoms augmented, pulse 120, small,
and wandering, but no pain in the head. Repeat the medicines. Head
shaved and cold applied; bleeding to ten ounces. 11th. Every symptom
increased; great pain on touching the chest; pulse 126; skin hot. On
the 12th passed his urine and feces involuntarily; and on the 13th he
died, his body being covered by petechiæ.

The head, on examination, showed pus under the dura mater, at and
behind the situation of the wound he had received. The right lung
adhered to the walls of the chest where the ball had entered and passed
out, the track made by it being very visible, indurated, and inflamed,
from the last attack: the parts otherwise sound; no fluid in the cavity.

Mr. Drummond was wounded by a pistol-ball in the back, low down, about
two inches from the spine, and three inches from the inferior angle
of the scapula; it was afterward found to have entered between the
eleventh and twelfth ribs, and to have _passed between the base of
the lung and the diaphragm_, abrading the former, and passing through
the latter into the abdomen, ultimately lodging in the fat under the
skin, over the cartilage of the eighth rib of the left side, nearly
at an opposite point in front. From the absence of all symptoms of
shock and alarm, it was hoped by some that the ball might have run
round, but on the removal of the little ball its course could not be
traced. This occurred on Friday. On Saturday morning at five o’clock
he suffered great uneasiness and difficulty of breathing, accompanied
by a particular catch or jerk in respiration, indicating a wound of
the diaphragm. The stethoscope and the ear attested the clearness of
the respiratory murmur in every part of the chest, which sounded well,
and I was satisfied the lung was not materially injured; twelve ounces
of blood were drawn with difficulty from both arms. At ten o’clock,
the jerk and difficulty of breathing being greater, the left temporal
artery was opened, as no blood could be drawn from the veins; five
ounces only could be obtained; a dose of calomel and a senna draught
had been followed by the discharge of a teaspoonful or two of blood,
leaving no doubt on my mind that the ball had penetrated the cavity
of the abdomen, as well as of the chest, and that a bowel had been
injured. With a constitution apparently unequal to bear an inflammation
of the most dangerous character, or the remedies necessary to subdue
it, the prospect was but melancholy. Thirty-six leeches were applied
around the wound in front, but they drew little blood. Pulse from
108 to 112. Dr. Hume, Mr. B. Cooper, and Mr. Jackson were added in
consultation on Monday at twelve, when the jerk became worse, the
oppression in breathing greater. Muriate of morphia, half a grain; at
two, bled to twelve ounces; blood very buffy; calomel, two grains,
opium, half a grain, every two hours. In the evening, bleeding,
repeated to fourteen ounces; no more would flow. Tuesday morning, at
five, bled again to twelve ounces. The ear now indicated effusion for
the first time. It was not, however, in sufficient quantity to render
the evacuation of the fluid necessary. After this he gradually sank,
and died on Wednesday morning. He lost on the whole fifty-six ounces of
blood. On examination after death, it was found that the ball, after
entering the cavity of the chest, had slightly abraded the left lung
at its lower and inferior edge, which was covered by recent lymph,
the lung being internally sound. The left side of the chest contained
nearly a pint of red-colored serum. The ball had perforated the
diaphragm, grazed the fat of the left kidney, passed through the great
omentum below the stomach, to the part where it was extracted, injuring
apparently no important organ in the abdomen in its transit, but giving
rise to an effusion of blood from some small vessel which had sloughed,
the blood being partly coagulated and partly diffused to the amount
of many ounces; its loss appeared to have been the immediate cause of
death.

A gamekeeper’s gun burst at the Red House, Battersea, and a small
part of the lock entered the middle of the left arm, and passed
upward into the axilla, where it could not be traced by Mr. Keate,
who saw him within an hour after the accident. The symptoms which
followed were those of inflammation of the chest, and were subdued by
active treatment; the wound healed, and he returned to his occupation
in Wiltshire. Having exposed himself to the night air some weeks
afterward, the inflammation of the chest returned, and he died. On
opening the thorax, one edge of the bit of iron was found impacted
in the surface of the lung, the other edge was rubbing against the
inside of the sixth rib, which was nearly worn through by the constant
friction it underwent during respiration; there was also a mark on the
pericardium as of a cicatrix, and of a graze on the surface of the
heart.

Among the French prisoners in Lisbon, in the spring of 1813, I saw a
man in whose chest a ball had entered midway between the fifth and
sixth ribs, and lodged; from this a constant and considerable discharge
of purulent matter took place. The ball was found after death lying
between the diaphragm and the spine, surrounded by coagulable lymph,
and adhering by its envelope to the spine and diaphragm at the angle
formed between them; there was a very thickened pleura costalis; the
lung was shrunk and attached by membrane almost equally thickened
across the chest, the lower part of which was filled in the upright
position by the discharge, which was only evacuated in quantity when
the opening of the wound was made dependent.

A case was met with after the battle of Waterloo, among the French
wounded, which was somewhat similar. A portion of rib had been
driven in, and the assistant-surgeon was aware that the ball could
occasionally be felt. The man died at the end of a fortnight, the
cavity containing a quantity of sero-purulent bloody matter. The lung
had been injured by the ball, which had fallen loose into the cavity of
the chest.

344. The removal of splinters of bone, or of other foreign bodies from
the lung, has occupied the attention of surgeons from the earliest
periods, and some of them proposed to draw a piece of cambric or other
things through the chest, for the purpose of removing them. These
extreme measures have been abandoned; but there can be no doubt of the
propriety of removing as many of these causes of irritation as can be
either seen or felt. If the ball have broken a rib, the orifice of
entrance especially should be enlarged as early and as carefully as
possible, so as to give an opportunity for the removal of the splinters
and of all angular points of bone which may be turned inward. A little
addition to the original opening can do no harm, and if the lung should
not collapse, or should it be adherent, it will enable the surgeon to
see whether any splinters are impacted in it, and to remove them. It
is possible that the end of the finger even may be introduced, and the
lung felt, if it should not have receded too far; as it is insensible
to such an operation, no evil will ensue; but all probings with small,
sharp-pointed instruments should be avoided. That wadding, buttons,
pieces of cloth, and of bone have been frequently coughed up, I have
had experience; but although it is said that even balls have been thus
brought up, I have not had an opportunity of seeing them.

An officer was wounded by a musket-ball on the 9th of July, 1745; it
passed through the chest, entering in front, fracturing the seventh
rib near its junction with the cartilage attaching it to the sternum,
and passing out behind near the angle of the same rib, which it
again broke, together with the one immediately below it. M. Guerin
enlarged the openings of entrance and of exit to the extent of nearly
two inches, by dividing the pleura, the intercostal muscles, and the
integuments from within outward. Several splinters of the rib injuring
the lung were removed, the smallest of which might be half an inch
or six lines long, by two wide. A tent was then passed through the
wound. The patient suffered much, and spat a great deal of blood; pulse
feeble, extremities cold. He was bled three times the first night,
and twenty-six times during the first fifteen days, the seton being
retained in the chest the whole time. On the twenty-second day, a
piece of cloth was felt by the finger, after removing the seton, and
was extracted; a splinter was also felt, but so deeply that it could
not be removed without enlarging the incision. As the inflammatory
symptoms were re-excited, he was bled for the twenty-ninth time. On
the thirtieth day these symptoms had so much increased that the seton
was withdrawn, under the impression that it was doing more harm than
good, and the thirty-first bleeding was effected. The next morning the
patient complained of something pricking him within, and the parts left
between the two original wounds, after the incisions which had already
been made, were divided. The chest was now open from the articulation
of the head of the rib with the sixth and seventh vertebræ behind,
nearly to the cartilage in front; and the whole course of the ball was
seen; it had made a groove in the surface of the lung, in the substance
of which a splinter was sticking. This was extracted, and the wound
dressed simply, after which the patient gradually improved, and was
quite cured in four months.

The two first incisions for the removal of the splinters were
necessary. The tent or seton drawn through the chest was an error;
and although the fortunate result of the case depended probably on
the removal of the splinters of bone sticking in the lung, few would
survive the formidable operation performed for their removal. The case
is suggestive and instructive.

345. When the lung can be seen through the opening made by the ball,
or after some moderate enlargement for the purpose of removing any
splintered pieces of rib or any spiculæ which can be felt or seen, the
object is attained. I have not had experience of the utility of large
incisions for the purpose of making the lung more visible, although the
importance of extracting foreign substances in the first instance is
inculcated, provided their situation can be ascertained.

A Spanish soldier, wounded at the battle of Toulouse, was brought to
me the same evening, shot through the right side of the chest, between
the fifth and sixth ribs, one of which was fractured, the ball passing
out nearly opposite behind. On removing the splinters by the aid of
an incision, I found that the lung was adherent to the inside of the
chest, and was enabled to withdraw from within the lung some splinters
of bone and a part of his coat. He left Toulouse apparently doing well;
but natives of warm climates rarely suffer from such severe attacks of
inflammation as those of northern habits and constitutions.

A soldier of the German Legion was wounded at the battle of Waterloo,
the 13th of June, 1815, by a musket-ball, which entered between the
seventh and eighth ribs in front, about two inches from the sternum on
the right side, passing out behind. He died in York Hospital, Chelsea,
in the month of January following, where he was taken after some
drunken fits, which induced an attack of pneumonia. A fistulous opening
existed, and had discharged a little matter, which was gradually
diminishing; the sinus was from six to seven inches long, extending
into and nearly through the base of the lung, and was lined by a
mucous membrane, the lung around being thickened to the extent of from
a quarter to half an inch. There was but little fluid in the cavity,
although the lung on both sides showed signs of recent inflammation,
without which he would in all probability have recovered. The orifices
of entrance and of exit through the lung adhered to the walls of the
chest, thus separating the track of the ball from the general cavity
of the pleura, which would in all probability have led to his ultimate
recovery, if it had not been for his intemperance.

346. When a ball, or portion of bone, leather, cloth, wadding, or
other foreign substance is driven into the cavity of the pleura, it
usually gives rise to fatal results, constituting, therefore, cases of
the greatest importance, to which attention has not been sufficiently
given, but on which too much cannot be bestowed, if life is to be
preserved by the art of surgery. The neglect of these cases has
probably arisen from the insufficiency of the means of ascertaining
their nature--an insufficiency which auscultation has in some measure
removed, and which the science of surgery may still further diminish.
The presence of a ball, a piece of bone, or of any other substance,
lying upon or rolling about on the pleura covering the diaphragm, must
give rise to more or less irritation and inflammation, and consequently
to suppuration, or the formation of matter upon the surface of that
membrane in its thickened state, until, in all probability, the foreign
substance has been removed or the person has wasted away and perished.

A dragoon of the King’s German Legion was wounded between the eighth
and ninth ribs at the battle of Salamanca. The ball had entered
and lodged; the symptoms were severe; the breathing laborious. As
the discharge from the wound was not free, I enlarged the opening,
removed some scales of bone, a bit of cloth which stuck between the
ribs, the lower of which was broken, and evacuated a great quantity
of bloody-colored fluid, not purulent. After a few days the discharge
became purulent, and, as he felt something, as he thought, roll
within him, which he supposed might be the ball, I contemplated
again enlarging the wound, so as to be able to see whether anything
were loose in the cavity; but a sudden relapse of inflammation, from
drinking some brandy, carried him off. On examination, the ball was
found lying loose on the diaphragm in the chest, and might, with some
enlargement of the wound, have been extracted.

A French prisoner of war, who had been wounded near Almaraz by a
musket-ball, which had lodged in the left side of the chest, was sent
to Lisbon in 1812, with a considerable discharge through the wound,
and died there. The ball was found in the angle formed between the
diaphragm and the spine, enveloped in coagulable lymph, by which it was
attached to the spine; there were some splinters of bone inclosed with
it.

A soldier of the 29th Regiment was wounded at Talavera by a
musket-ball, which penetrated the right side of the chest, between
the fourth and fifth ribs, and lodged. He died the day after, and on
opening the body, I found that the ball had passed through the lung,
and was lying loose on the ribs behind, near the union of the diaphragm
with the spine.

Major-General Sir Robert Crawford was wounded at the foot of the
smaller breach at the storming of Ciudad Rodrigo, by a musket-ball,
which passed through the posterior fold of the armpit and entered the
side of the chest in the axilla by a small opening or slit, apparently
too small to allow a ball to pass through. I saw him a few minutes
afterward with Dr. Robb, under whose care he remained, when, from the
general anxiety manifested, I was satisfied as to the severity of the
injury. The symptoms were not at first urgent, but their continuance
and augmentation, in spite of the most rigorous antiphlogistic
treatment, led, in a few days, to his death. On examination of the
body, the ball was found lying on the diaphragm; the cavity of the
chest contained a large quantity of very turbid serum; false membranes
had formed on the lung, which was compressed toward the spine, and at
the upper part retained the mark of an injury as from a ball which had
not had force enough to penetrate and lodge.

Baron Larrey has had the good fortune to meet with some remarkable
cases of this kind. In the first he did not see the man for some weeks
after the wound had been inflicted, the ball entering at the upper
edge of the fourth rib, about an inch from its junction with the
cartilage. By means of a bent and flexible sound introduced through the
wound, he distinguished a hard, metallic substance at the bottom of
the cavity of the chest, which he supposed to be the ball, nearly in
the situation of the place where the operation for empyema is usually
performed. This operation having been done, about twelve ounces of pus
escaped, and the ball was discovered rather flattened. It was easily
removed with the aid of a pair of polypus forceps. After this there was
every prospect of recovery, until the patient, having unfortunately one
day drank too much brandy, was attacked by enteritis, and died.

William Barrett, of the Life Guards, a middle aged, muscular man, of
full habit, was wounded by a musket-ball at the battle of Waterloo;
it fractured the third and fourth ribs behind on the left side, and
broke the left arm. He was brought to Brussels, where the inflammatory
symptoms were subdued by repeated general and local bleedings, and the
other ordinary but strictly antiphlogistic means, during the first six
weeks, by which time the external wound had nearly closed, and no trace
of the ball could be perceived. At the end of this time, Staff-Surgeon
Collier, now Inspector-General of Hospitals, under whose care he was,
and who furnished me with these particulars of the case, which I saw in
Brussels, finding that his symptoms became worse, that he had rigors
and evening exacerbations, and that the difficulty of breathing had
increased almost to suffocation, decided on opening into the cavity of
the chest and following the course of the ball. This he did by a deep
incision, which enabled him to remove some pieces of the ribs, which
were denuded but not detached. A bag-like protrusion was then felt
between the ribs near their angles, which was opened, and nearly two
pints of thick, fetid pus escaped, the relief which followed being as
complete as sudden. The wound was dressed from the bottom, and every
means adopted, except introducing a tent, to prevent its closing, but
in vain; the opening closed, and matter again collected, requiring a
second incision for its removal. Between these two operations small
bleedings were resorted to most beneficially. A short gum-elastic
catheter was introduced into the cavity of the chest after the second
incision; very little matter, however, was secreted. From this time he
gradually recovered, and was sent to England, cured, in November.

347. The presence of a ball, rolling about on the diaphragm, can now be
ascertained by means of the stethoscope at an early period, so as to
admit of an operation being undertaken with confidence for its removal;
while the knowledge acquired by auscultation or percussion, of the
filling of the chest by fluid, whether serous, bloody, or purulent, is
at the same time incontestibly demonstrated. The presence of a ball,
or of any other foreign body, decides the question as to the place
where the opening into the chest should be made. On this point the
information derived from the practice of the French surgeons in Algeria
is valuable.

M. Baudens, whose labors I again refer to with great pleasure, says
that he has also seen splinters of bone and even a ball, surrounded by
a cyst formed by the pseudo-membranes of inflammation, cut off from
the general cavity, and confined in the angular space formed behind
between the rib, the diaphragm, and the spine. In one case, M. Baudens
introduced a _sonde à dard_, such as is used in the high operation
for the stone, between the second and third ribs, and made it project
behind between the eleventh and twelfth. He then cut down upon it, and
extracted a ball and some splinters of the rib. The wound thus made
was then closed, the upper one being sucked dry daily by a pump. The
patient recovered in forty days.

A., 54th Regiment, was brought to the hospital at Algiers, on the 22d
of October, 1833, wounded eleven days before by a ball, which, having
broken the right clavicles was lost in the chest, without any sign of
effusion having taken place; he appeared to be going on well, until
suddenly he complained of pain about the middle of the sixth rib,
which could not be removed by the means employed, and was accompanied
by a great discharge from the wound. On the 10th of November he died.
The clavicle and the first rib had been fractured, and an abscess
had formed behind them, the size of a hen’s egg, containing several
splinters of bone, which had stuck in and afterward separated from the
lung. The ball had passed from above downward and outward, forming a
sinus, which terminated at the middle of the sixth rib, to which this
part of the lung was attached; the posterior three-fourths of this
canal were closed; the anterior fourth contained two splinters of
bone, one of which was about to fall into the abscess in front. The
sixth rib was broken, although it had not been perceived during life;
and a small digital cavity was formed at this part in it by the ball,
surrounded by portions of lymph, floating loosely from its edges; from
this the ball had been detached, and had given rise to the inflammation
which destroyed him. The ball had fallen on the diaphragm, where it was
lying loose, surrounded by a quantity of purulent matter.

M. Baudens says himself, and rightly, that the operation of opening
into the chest should have been performed in the eleventh intercostal
space, and that the wound in front should have been enlarged.

M. Baudens relates another case, in which the posterior wound,
situated near the angle of the tenth rib, had healed, the anterior
one, half an inch below the clavicle, giving issue to an abundant and
weakening suppuration. The lung above this was permeable to air, but
the respiratory murmur could not be heard below it. To draw off this
offensive fluid, he adapted an empty caoutchouc bag to a gum-elastic
canula, which he affixed against the orifice of the wound, and thus
sucked out six pints in five days. Some days later the wound behind
reopened, and a piece of bone was discharged from it, which saved the
man’s life. Two years afterward he was seen in good health.

The desire to have as dependent an opening in the chest as possible in
these injuries has been manifested by all surgeons of experience; and
the interspaces between the ninth and tenth, and between the tenth and
eleventh ribs, have been often selected for this purpose; but as the
operation was formerly done with the trocar, the abdomen was as often
opened as the thorax, and death was frequently thus caused, even if it
would not have been occasioned by the disease. To prevent, or to avoid
this evil, M. Baudens advises its being performed at three fingers’
distance from the spine, by incision, and he says he has frequently
done it with success, although he does not give any circumstantial
directions as to the operative method to be pursued. I therefore caused
several experiments and dissections to be made in the workroom of the
College of Surgeons by Mr. Quekett, with the following results:--

348.--1. That a trocar and canula pushed in between the eleventh and
twelfth ribs, in a diagonal direction upward, on a line with the angle
of the ribs generally, will in the _dead body_ invariably enter the
cavity of the chest without injuring the diaphragm.

2. That the same operation performed on the _living body_ would, in
all probability, if done at the moment of expiration, first enter the
thorax, then pierce the diaphragm, and thus open into the cavity of
the abdomen,--a difference in result to be explained by reference to
the anatomy and physiology of the parts concerned; showing that this
operation, when required on man, should always be done cautiously by
incision, and not by puncture with the trocar and canula.

On examining the lower part of the chest from within, after removing
the pleura, the diaphragm is seen forming the boundary between the
thorax and the abdomen, commencing from the transverse process of the
first lumbar vertebra, and forming an arch under which the upper part
of the psoas muscle passes, (the ligamentum arcuatum proprium.) From
this part extends another aponeurotic arch along the lower border,
to the end of the last rib, called the _false ligamentum arcuatum_,
(ligament cintré du diaphragme of Cruveilhier,) which is nothing
more than the upper edge of the anterior layer of the aponeurosis of
the transversalis muscle, folded upon itself in all its extent. The
diaphragm is afterward attached to the lower border of the twelfth,
and in succession to the eleventh, tenth, ninth, eighth, seventh, and
sometimes to the sixth, ribs, counting from below upward. The external
intercostal muscles are distinctly seen between the ribs, extending
from the spine until they meet and are concealed by the fibers of
the internal intercostal muscles, near the angles of the ribs. The
vessels and nerves, after passing on the external intercostal muscles,
subsequently run between them and the internal ones.

The lower intercostal arteries arise from the aorta on each side, and
before they enter the space between the ribs give off a branch passing
backward to the vertebral canal and the posterior muscles of the spine.
The eleventh and twelfth intercostal arteries, covered at first by the
pillar of the diaphragm, ascend on leaving the vertebræ to reach the
under edges of the ribs, and are accompanied by a vein and nerve. The
tenth intercostal artery, and those immediately above it, run almost
horizontally, and nearly in the mid-spaces of the ribs, as far as
their angles, at which part a small artery is commonly given off, which
descends from the main trunk at an acute angle to the rib below, and
may be injured in opening into the chest, and be perhaps mistaken, in
operating, for the intercostal artery itself. From the angles each
artery runs in a groove in the under edge of the rib as far as the
anterior third, when they all become very much diminished in size,
and, leaving the grooves, run in the middle of the intercostal spaces,
until lost in their different anastomoses with the branches of the
epigastric, phrenic, lumbar, and circumflexa ilii arteries.

In making an opening into the chest between the tenth and eleventh, or
between the eleventh and twelfth ribs, the artery will not be injured,
provided the opening be made below the middle of the intercostal space,
which is wider between the eleventh and twelve ribs than between those
above it. The vein is situated above the artery, and proceeds to the
vena azygos major on the right, and to the smaller azygos vein on the
left side.

The intercostal nerves are the anterior branches of the dorsal
nerves, and lie below the arteries under the pleura upon the external
intercostal muscles, until they approach the angles of the ribs, where
they enter between the layers of the intercostal muscles.

It is worthy of observation that the pleura is necessarily continued
over the inside of the twelfth rib to line the different attachments of
the diaphragm, and that an incision may always be made into the chest
above this point, if done carefully.

On removing the integuments of the back, covering the muscles and
the lower ribs, the broad expanse of the _latissimus dorsi_ muscle
is brought into view, extending from the ilium and spine upward
and outward, and covering all the parts of importance beneath in
the operation to be described. On the removal of the lower part of
this muscle the _serratus posticus inferior_ is seen, of a somewhat
quadrilateral form, arising by a thin aponeurosis common to it and to
the latissimus dorsi, from the spinous processes of the three superior
lumbar vertebræ and the two inferior dorsal, and proceeding upward and
outward to be inserted by four flat, tendinous digitations into the
four lower ribs.

If this muscle be separated from its origins and turned outward, or
divided in the middle, and its two portions reflected, the posterior
spinal or long muscles running in and filling up the groove or hollow
of the side of the spine will now be distinctly seen, composed chiefly
of the sacro-lumbalis and the longissimus dorsi muscles, sometimes
called as a whole the _erector spinæ_ or the _sacro-spinal_ muscle.
This, which forms a thick mass over the beginning of the tenth,
eleventh, and twelfth ribs, is not to be divided or interfered with
beyond a very few at most of its external fibers; the opening into the
chest about to be made should begin at its external edge and go through
the external intercostal muscle, which is now exposed on a plane below
it.

The eleventh and twelfth ribs, unlike all those which precede them,
except the first, have only one surface of articulation with the
corresponding vertebræ, to which they are attached, instead of two
facettes articulating--one with the body of the vertebra above, the
other with that below. They form, particularly the twelfth, a more
acute angle with the spine than the other, which gives to them their
greater degree of obliquity, while the freedom of their cartilaginous
extremities enables the twelfth, particularly, to be depressed or
separated by a moderate force from the rib above to a greater extent
than at any other part, by which means a foreign body of larger size
may be removed from between them more readily than elsewhere.

349. _Operation._--The eleventh and twelfth ribs having been distinctly
traced, and the obliquity of their descent from the spine having been
clearly made out, the patient ought, if possible, to be placed on a
stool, with the upper part of the chest supported by a pillow on a
table before him. An incision should then be made over the intercostal
space between these ribs, three inches long and slightly curved,
through the integuments down to the latissimus dorsi muscle, and as the
mass of long spinal muscles is usually three inches in width, and can
in general be seen, the incision should commence two inches from but
between the spinous processes of the eleventh and twelfth vertebræ,
and be continued obliquely or diagonally downward in the course of the
interspace between these ribs. The latissimus dorsi and the serratus
posticus inferior muscles having been divided at the upper part where
they cover the longissimus dorsi or the long spinal muscular mass
alluded to, its edge becomes apparent; from this point the latissimus
and the serratus are to be further divided downward. The external
intercostal muscle being thus exposed, its fibers should be scratched
through or separated in the middle of the interspace between the ribs,
which can now be seen as well as felt. A director should be introduced
below the muscle, on which it may be carefully cut through, as well as
any fibers of the internal intercostal muscle which may extend as far
as the wound thus made. The pleura will then be exposed, and if the
cavity of the chest contain fluid in any quantity, it can scarcely fail
to project in such a manner as to convey to the finger the assurance
of its being beneath. An opening may then be carefully made into it at
the upper part of the incision close to the external vertical fibers
of the spinal mass of muscles, _at the moment of inspiration_, and
on the existence of fluid being ascertained by its discharge, the
opening should be enlarged by a director previously introduced under
the pleura, the patient being desired to draw a full breath at the
time, in order that the diaphragm may descend as low as possible. If
there should not be any fluid in the chest, the diaphragm, in ascending
during expiration, may be applied to the inside of the pleura lining
the chest as high even as the fifth rib, counting from above, and might
easily be divided with the pleura, if great care were not taken to make
the opening during the process of inspiration.

In all cases of wounds of the chest, in which auscultation points out
the presence of a ball rolling loose on the diaphragm, this operation
should be performed for its removal, and may save the life of the
sufferer. It would, perhaps, have done so in the case of Sir Robert
Crawford. At a later period the presence of a foreign body, perhaps,
can only be known by the sounds or defect of sounds which may be
observed at the back part of the chest, in which the ball or other
foreign bodies lodge or become enveloped by matters confining them in
that situation.



LECTURE XXV.

HERNIA OF THE LUNG, ETC.


350. _Hernia of the lung_, as a consequence of a wound in the chest
which has healed, is a complaint of rare occurrence. It appears to take
place when the intercostal muscles have been much injured and are
deficient, the opening through them being merely covered by the common
integuments which have yielded to the pressure exerted from within. It
has been supposed that it might be mistaken for the thinning of parts
from the formation of matter within, or empyema. The early occurrence
of the abscess after the receipt of the injury forbids the supposition,
while the ear, applied to the protruded part which is most prominent
during EXPIRATION or coughing, perceives not only a crepitation, felt
equally by the touch, but the natural respiratory murmur stronger,
softer, but less vailed and more like the sound given out by a
pulmonary lobule inflated close to the ear, but without enlargement of
the part.

A portion of lung will sometimes protrude during the efforts made by
the sufferer to breathe, particularly in expiration, when the wound
is left open and the lung is sufficiently free to admit of it. When
protruded, it sometimes happens that the efforts of nature are not
sufficient for its retraction, and it remains filling up the opening
into the thorax. A large portion of lung is rarely protruded, except
through an opening which readily admits of its return; but when the
wound is small, the return of a portion of protruded lung, when it
is not positively strangulated, should not be interfered with. The
surface of the lung is but little sensible; touching it causes no
apparent pain, and its adhesion to the edges of the cut pleura is
more advantageous than its separation from it. It should, therefore,
be allowed to remain or be only so far returned, if it can be so
managed, as to rest within the edges of the divided pleura and fill
up the gap made by the incision, over which the integuments should be
accurately drawn and retained. The adhesion of the lung to the pleura
costalis arrests the inflammation, and may prevent its progress to
other parts of the cavity. That the inflammation may extend farther
into the substance of the lung, is possible, but when the sufferers
are otherwise healthy, the chance of evil from pneumonia is less than
from inflammation of the general cavity. Whenever the protruded lung
has been completely returned, more inflammation has followed than where
it has been allowed to remain under the precautions recommended. Three
cases were brought under my notice at Brussels, after the battle of
Waterloo, which were not interfered with, greatly to the advantage of
the patients. It is rare, however, to see a protrusion of the lung
after a gunshot wound.

The protruded lung, when left uncovered and unprotected, soon loses its
natural brilliancy, dies quickly, shrinks, and becomes livid, without
being gangrenous. In such cases the protruded part may be removed, but
it should never be separated at its base from its attachment to the
pleura costalis by which it is surrounded.

351. _Wounds of the diaphragm_ were known to the older surgeons
from the time of Paré; they were aware that these wounds were not
immediately, although generally, mortal. They knew that the viscera
of the abdomen did sometimes pass through such wounds into the cavity
of the chest, but they did not know that a wound of the diaphragm
never closes, except under rare and particular circumstances; that it
remains an opening during the rest of the life of the sufferer, ready
at all times to give rise to a hernia which may become strangulated
and destroy the patient, unless relieved by an operation as yet
unperformed, but to which attention is especially directed--a fact
first pointed out by me early in the war in the Peninsula.

A soldier of the 29th Regiment was wounded at the battle of Talavera,
and died in four days after the receipt of the ball, which went through
the chest into the liver. I found, on examining the body, an opening in
the central part of the diaphragm of an oval shape, the edges smoothing
off as if they were inclined to become round; this opening was nearly
two inches long, evidently ready to allow either the stomach or the
intestines to pass through it on any exertion.

Captain Prevost, aid-de-camp to Sir E. Packenham, was wounded by a
musket-ball, on the 27th September, 1811, on the heights of Saca Parte.
It penetrated the chest from behind, splintering the ninth and tenth
ribs of the left side, and made its exit a little below and to the
right of the xiphoid cartilage. A good deal of blood was lost from
the posterior wound, but he did not spit up any. He was carried to
Alfaiates, and there he threw up a small quantity of bloody matter by
vomiting. The posterior wound was enlarged and continued to discharge
some blood, the intercostal artery being in all probability wounded.
Sixteen ounces of blood were taken from the arm, giving great relief,
and the bowels were opened by the sulphate of magnesia.

Sept. 29th.--Bleeding to eighteen ounces; on the 30th he was bled again
to thirty-two ounces, from which great relief was obtained; he fainted,
however, on making a trifling exertion to relieve his bowels.

Oct. 1st.--Accession of symptoms as yesterday, relieved by bleeding in
a similar manner; bowels open.

3d.--The inflammatory symptoms recurred this morning, and were again
removed by the abstraction of sixteen ounces of blood. Beef-tea.

5th.--Passed a sleepless night, and was evidently suffering from
considerable internal mischief; wandered occasionally; pulse quick,
120, and small; felt very weak and desponding. A little light, red wine
given, with beef-tea and bread; opium night and morning.

6th and 7th.--Much the same; pulse always quick, with much general
irritability.

15th.--The wounds discharged considerably, particularly the posterior
one; has a little cough; pulse continues very quick; spasms of the
diaphragm troubled him for the first time, and caused great pain and
uneasiness; they were relieved by opium in large and repeated doses.

On the 18th the spasmodic affection of the diaphragm and the pain
returned with great violence, so as to threaten his dissolution, which
took place on the 20th.

On examination, I found that the ball had passed through the under part
of the inferior lobe of the left lung, and through the pericardium
under the heart, through the tendinous part of the diaphragm, and
into the liver, before it made its exit. The wound in the lung was
suppurating; the matter and fluid from the cavity of the chest had
a free discharge by the shot-hole; the edges of the wound in the
diaphragm were smooth as if cicatrized, leaving between them an
elliptical opening an inch long. The injury to the liver was through
the substance of the anterior part of its right lobe; the matter having
a free discharge, and generally slightly yellow, as if tinged with bile
in small quantity. The skin did not show a yellowish tinge, neither
were the conjunctivæ discolored.

A soldier of the 23d Regiment was wounded at the same affair, by a
musket-ball, on the right side; it fractured the sixth rib, from three
to four inches from the sternum, and passed out behind, between the
ninth and tenth ribs, near the spine. The rib being fractured, the
splinters were removed after an enlargement of the wound by incision,
when the opening into the cavity of the chest was manifest, air being
discharged freely from it. The shock in the first instance was great;
but after a time reaction took place, and he lost a considerable
quantity of blood in six bleedings during the first sixty hours. The
discharge, at first serous and bloody, gradually became purulent, and
the occurrence of jaundice showed that the diaphragm and liver had in
all probability been injured. Under the administration of calomel,
antimony, and opium, this symptom was gradually disappearing, when I
left him to rejoin the army. He was sent to the rear at the end of ten
weeks nearly well.

On the day preceding the battle of Fuentes d’Onor, in 1811, Sergeant
Barry was wounded in the chest. The ball entered close to the nipple
of the left breast, and passed out at the back, between the eighth and
ninth ribs. The anterior opening of the wound soon healed, but the
posterior one did not do so for a considerable period, when he became
affected by such severe cough, with expectoration, that his medical
attendant deemed it proper to reopen it. The symptoms were relieved,
and portions of his shirt and jacket were discharged. After this
his health improved so rapidly as to enable him soon to rejoin his
corps. The wound in the back repeatedly opened and healed--generally
at intervals of twelve or fourteen months; but for five or six years
it ceased to do so. His appetite was small and delicate; flatulence
was much complained of; and if the stomach at any time happened to be
overloaded, vomiting occurred. He died of mortification of the left
leg, January 4th, 1833.

On examination, the whole of the stomach and the greater part of the
transverse arch of the colon were found in the left cavity of the
chest, having passed through an opening in the diaphragm extending
about three inches in a transverse direction, near the center of the
dorsal attachments of that muscle. The peritoneum lining the diaphragm
was firmly attached to the parts passing through it.

The wound in this instance was through _muscular_, not tendinous parts.
The preparation is in the museum at Chatham, No. 63, Class 6.

A French soldier was admitted into the Gensd’armerie Hospital at
Brussels, in consequence of a wound from a musket-ball, at the battle
of Waterloo, which entered behind between the eighth and ninth ribs,
near the spine, and lodged internally. After many severe symptoms
and much suffering, he died on the 1st of December, worn out by the
discharge, which often amounted to a pint daily, for the free exit of
which the external wound had been early enlarged. On examination, the
lung was slightly ulcerated on its surface, opposite to where the ball
had entered, and a little matter contained in a sac had formed between
it and the wall of the chest. That the ball had gone on was proved
by the fact of there being an opening in the tendinous part of the
diaphragm, through which a portion of the stomach had passed into the
chest, from which it was easily withdrawn. The ball could not be found
in the abdomen; in all probability, it had passed into the intestine
and had been discharged per anum, as has happened in other instances.

James Wilkie, 12th Light Dragoons, aged thirty-four, was suddenly
attacked, at four P.M. of the 6th September, 1815, with violent pain
in the umbilical and epigastric regions, accompanied with nausea
and great irritability of stomach; pulse small, rapid, and regular.
Assistant-Surgeon Egan visited him half an hour after the attack, bled
him freely, and caused the abdomen to be fomented with hot water; a
large blister was applied to the seat of pain, an ounce of castor-oil
was given, and emollient and laxative clysters were occasionally
administered. At night the symptoms abated, and he slept about three
hours. The next morning his countenance exhibited that appearance of
haggardness and anxiety which have always been alarming indications;
pulse feeble and rapid; the pain severe; at noon he vomited from two
to three ounces of black, fetid blood in a fluid state; the pulse
became very feeble. At four P.M. the pain increased, he ejected from
his stomach from four to six ounces of dark, fluid blood that had less
fetor; and at six the same evening he expired in pain.

This man, on the 18th of June, at Waterloo, received a punctured wound
from a sword, which entered about an inch below the inferior angle of
the scapula on the left side, penetrated the thorax, appeared to have
passed through the diaphragm, the point of the weapon coming out on the
opposite side of the chest between the first and second false ribs. The
wounds were quite healed, and he apparently enjoyed good health, when
he arrived from Brussels in August.

_Appearances on dissection._--On opening the abdomen, the whole of the
intestines, with the exception of the duodenum, were in a high state of
inflammation. On tracing the duodenum upward a very small portion of
the stomach was found in its natural situation; while, on opening the
thorax, a large spherical tumor was seen in its left cavity, containing
two quarts or upwards of black, fluid, fetid blood. This sac was soon
seen to be the stomach, which had protruded through the aperture in
the diaphragm, by which it was so firmly embraced as to render the
communication between the portion of the stomach in the thorax and
that in the abdomen impervious to each other. The hernial sac and its
contents were supported by the diaphragm. The left lung exhibited a
shriveled, contracted appearance, as if its function had been impeded
by the pressure of the sac and its contained fluid. The cicatrix and
the course of the sword were well marked. The cardiac and pyloric
orifices of the stomach were in the natural cavity.

S. Fletcher, 31st Regiment, wounded at Sobraon on the 10th of February,
1846; died at Chatham, February, 1847. On opening the thorax, the
greater part of the stomach, and a foot and a half of the transverse
arch of the colon, with the omentum attached, were found in the left
pleural cavity. There was an opening in the diaphragm with a rounded
margin two inches and a half in diameter, two inches to the left of the
œsophagus. The stomach, colon, and omentum adhered firmly, at one part,
to the pleura covering the diaphragm and lining the ribs to the extent
of a few inches, although otherwise loose and free in the cavity. The
parts in the aperture of the diaphragm were free from adhesions, and
the finger passed easily through the opening from below upward. Two
cicatrixes were to be seen on the left side of the chest--one between
the eleventh and twelfth ribs, close to the transverse processes of the
vertebræ; the other between the eighth and ninth ribs, three inches and
a half from the cartilages. The preparation is in the museum at Chatham.

352. These cases confirm the fact that wounds of the diaphragm, whether
in the muscular or the tendinous part, never unite, but remain with
their edges separated, ready for the transmission between them of any
of the loose viscera of the abdomen which may receive an impulse in
that direction. That parts of these viscera do pass upward and back
again, cannot be doubted; and it is probable that incarceration may
take place for a length of time before strangulation occurs from some
sudden and distending impulse giving rise to it.

When the solid viscera of the abdomen are injured, as well as the
diaphragm against which they are applied in their natural situation,
the wound may sometimes be considered a fortunate one; for the liver or
spleen may adhere to the opening in the diaphragm and fill up the space
between its edges.

A wound of the diaphragm may be suspected from the course of the
ball, particularly when it passes across the chest below the true
ribs. It is necessarily accompanied by an opening into the cavity
of the abdomen, and is by so much the more dangerous. The symptoms
will partake of an injury to both, although they are principally
referable to that of the chest, and are those of intense inflammation,
accompanied by a difficulty of breathing, which in the case of Mr.
Drummond was a peculiar sort of jerk; in that of Captain Prevost it
was more spasmodic. The risus sardonicus, hiccough, pain on the top
of the shoulder, and loss of power of the arm, which were all more or
less present, in all probability depended on some larger fibrils of the
phrenic nerve being wounded. The treatment should be antiphlogistic,
with a free external opening for the discharge of matter. The accession
of jaundice shows an injury to the liver; vomiting of blood or its
passage per anum indicates a wound of the stomach or intestines.

353. When the patient recovers, the probability of a hernia taking
place into the chest through the diaphragm should be explained to him.
If any reason should exist for the belief that it had occurred, he
should be doubly cautious as to eating and drinking in small quantities
only, and remaining in the erect position for some time after each
meal; he should carefully avoid a stooping posture and all muscular
exertion or straining. If symptoms of strangulation should come on, an
opening made into the abdomen would appear to offer the only chance
for life. The hernia may perhaps be drawn back into its place in the
abdomen; but if firm adhesions have formed between the protruded parts
and the edges of the opening in the diaphragm, the case must be treated
as one of adherent strangulated rupture in any other part, by a simple
division of the stricture in the most convenient situation. The opening
should be a straight incision through the wall of the abdomen, large
enough to admit the hand, immediately over the part where the diaphragm
is supposed to be injured. It should be closed by a continuous suture
through the skin. This operation, now for the first time recommended,
although apparently formidable, cannot be compared as to danger with
the incisions of twelve and fourteen inches long through the wall of
the abdomen, which have been in some instances successfully made for
the removal of diseased ovaria.

354. _Wounds of the heart_ are for the most part immediately fatal.
Many persons have, however, been known to live for hours, nay days,
and even weeks, with wounds which could scarcely be otherwise than
destructive; and several cases are recorded in which the cicatrixes
discovered after death, in persons known to have been wounded in the
vicinity of the heart, have shown that even severe wounds of that most
important organ are not necessarily fatal. As our knowledge of the
nature of the injury inflicted can never be distinct, it follows that
every wound should be considered as curable until it is unfortunately
proved to be the contrary.

355. _Auscultation_ and _percussion_, and principally auscultation
of the whole precordial region, have afforded means of judging of
injuries of the heart which were not formerly known. A vertical line,
coinciding with the left margin of the sternum, has about one-third of
the heart, consisting of the upper portion of the right ventricle, and
the whole of the left, on the left. The apex of the heart beats between
the cartilages of the fifth and sixth left ribs, at a point about two
inches below the nipple and an inch on its external side; or, if one
leg of a compass be fixed at a point midway between the junction of the
cartilage of the fifth rib on the left side with the rib and sternum,
and a circle of two inches in diameter be drawn around, it will define
as nearly as possible the space of the precordial region occupied by
the heart while uncovered, except by the pericardium and some loose
cellular texture. In the rest of the precordial region it is covered,
and separated from the walls of the chest by the intervening lung.

If the chest of the dead subject be transfixed with long needles,
it will be found that the center of the first bone of the sternum
corresponds with the lower edge of the left subclavian vein and to
the arch of the aorta crossing the trachea, the center of the second
bone to the upper edge of the appendix of the right ventricle, and
the center of the third bone to the right side of the right auricle,
the right ventricle being lower down. A needle penetrating the chest
at the costal extremity of the fifth rib, close to the upper edge of
its cartilage, will touch the septum of the ventricle. The apex of the
heart is an inch and a half below this, and inclined to the left side.

The semilunar valves of the pulmonary artery correspond to a spot a
little below the center of the third bone of the sternum. The aortic
valves are a few lines below and behind the pulmonary. The mitral
valves are a little lower, and still more deeply seated. The pulmonary
artery, after touching the sternum, inclines to the left, and is found
close to the sternum between the second and third ribs. The aorta
ascends to the first bone, and crosses it to form the arch.

One-third of the heart, consisting of the upper part of the right
ventricle and of the whole of the right auricle, is beneath the
sternum; the remainder of the right, with the left ventricle and
auricle, are to the left side of that bone.

356. On applying the ear to the precordial region, the patient being
in the erect position, two sounds are distinguishable in a healthy
heart--one duller and more prolonged, the other clearer and shorter;
between these there is scarcely an appreciable interval. The period of
repose is sufficiently marked before the first or duller sound returns.
Of the time thus occupied, one-half is filled up by the first or dull
sound, one-quarter by the second or sharp sound, one-quarter by the
pause or period of repose.

Twenty-nine theories have been proposed, each accounting for the sounds
of the heart. The theory of Dr. Billing appears to prevail at present,
which supposes that the sounds thus heard “are caused by the valves,
which, being membranous, each time they resist the reflux of the blood
are thrown into a state of sudden tension, which produces sound.”

The impulse of the heart, as far as it can be felt by the touch,
depends much on the position in which the body is placed. In the
erect position, it is heard between the fifth and sixth ribs. In
the recumbent posture, the impulse is almost imperceptible. It is
perhaps more observable when the body is turned on the right side,
but decidedly more so when it is turned on the left. A clearer sound
proceeds from a thin, and a duller sound from a thick heart; a sound of
greater extent from a large heart, and a sound of less extent from a
small one. A more forcible impulse is given by a thick heart, and one
more feeble by a thin one; the impulse is conveyed to a longer distance
from a small heart.

From a clearer sound we believe in the probability of an attenuated
heart, but we argue its certainty from a clearer sound joined with
a weaker impulse. A stronger impulse denotes the probability of a
hypertrophied heart, but we argue its certainty from a stronger impulse
with a diminished sound.

The terms endocardial and exocardial are used to designate the
alterations which take place in the sounds of the heart under
disease--endocardial when they occur within the heart, and exocardial
when they take place upon its surface. The endocardial murmur of
disease, or bellows-sound, takes the place of and is substituted in
certain cases for the first or second, or even for both the healthy
or normal sounds. The exocardial murmur of disease is heard with the
normal sounds, but confusing and overpowering, sometimes overwhelming,
them by its rubbing or crumpling noise. The natural sounds exist,
although rendered imperceptible by the greater distinctness and nearer
approach of the unnatural or unhealthy ones.

The heart apart from the pericardium never moves without a sound; the
pericardium apart from the heart never gives out one. Under disease
the heart gives out the natural sound, diminished, exaggerated, or
modified, or it may be totally altered. The sounds given out by a
diseased pericardium must always be new, (there being no old ones,)
and are described as rubbing, or to-and-fro sounds. The pleura, when
diseased, being a serous structure, like the inner membrane of the
pericardium, gives out less marked but somewhat similar sounds (the
“_frottement_” of the French) in particular stages of disease.

The alterations in the ordinary sounds constituting the endocardial
murmurs of the heart under disease depend principally on the altered
state of the endocardium, or membrane lining its cavities; the sounds
given off, and called exocardial, on an altered state of the serous
membrane of the pericardium, reflected over the outer surface of the
heart. The endocardial or bellows-sound, when it accompanies the
normal sounds of the heart, may result from any kind of derangement
affecting the internal membrane of that organ, particularly rheumatic
inflammation, or from any force which may compress its cavities; or
it may depend on the altered quality of the blood, from anemia. It
should be present after excessive hemorrhages have greatly reduced
the powers of the sufferer. When this murmur or sound occurs after
injury in the vicinity of the heart, and is accompanied by fever, it
indicates inflammation of the lining membrane, although no local pain,
no palpitations, no irregular movements of the heart be present.

When a murmur or sound is heard of a different kind, possessing the
character of friction, of surfaces moving backward and forward on each
other, or to and fro, it is the sign of inflammation of the membrane
covering the heart, as well as of that lining the fibrous external
tissue of the pericardium. The signs of both external and internal
inflammation may be present at the same time, and they frequently are
in cases of acute rheumatism.

357. When the heart is supposed to be wounded, even without much loss
of blood, there is fainting; palpitation; irregular movement or total
cessation of its action; coldness of the extremities; ghastliness
of countenance, succeeded by great anxiety; a sense of anguish; an
intermission or cessation of pulse, followed, if the patient should
survive, by reaction, which renders it very frequent and sometimes
increases its impulse; while the anxiety is increased by pain,
sometimes intolerable, referred to the part. These symptoms imply a
serious injury, although they may not all be present, and many of them
differ in intensity. If the patient should survive, the ordinary sounds
of the heart will return, with more or less irregularity, accompanied
after a few hours by the endocardial murmur, although something like
it may perhaps be observed from the first period of injury. The
friction or attrition sound, indicating the presence of inflammation
of the pericardium, may be absent; it will not be discernible, if a
layer of blood be effused into the cavity of that membrane; while
the natural sounds of the heart are rendered more indistinct as the
heart is separated from the walls of the chest by the effusion which
distends the pericardium, and impedes the regular action of the heart,
but cannot compress it, as an empyema does the lung. If inflammation
take place without an effusion of blood, the friction sound will be
heard, and will usually continue even after some effusion of serum and
of lymph has occurred, as the quantity of serum secreted is rarely
sufficient to prevent the effused and attached portions of lymph from
rolling against each other.

The presence of a larger quantity of fluid may be more distinctly
known by percussion, if it can be borne in cases of injury, the
degree and extent of the dullness being the measure of its existence
and accumulation. It may extend over a part or over the whole of the
precordial region, reaching as high as the second, or even the first
rib, beneath the sternum, and even under the cartilages of the ribs of
the right side.

358. That the heart when wounded is capable of recovery by the
permanent closure of the wound, in a few rare instances, is
indisputable; and it would seem, from a consideration of the different
cases which have been recorded, that such recovery takes place in
consequence of there being but little blood discharged through
the wound, or into the cavity of the pericardium, or into that of
the pleura. The absence or the cessation of the hemorrhage by the
contraction of the wound, or the formation of a coagulum, is the first
step toward a cure, and it was to one or other of these circumstances
that most of those who survived the injury for several days or weeks
owed their existence for the time, although they usually died from the
effects of inflammation, more of the inner lining and outer covering
than of the substance of the heart itself.

If the wound be inflicted by a musket or pistol-ball, it cannot be
closed, although pressure may be made upon it for a time, so as to
suppress the external flow of blood. If this should succeed, it is more
than probable that the hemorrhage will continue internally, and that
the patient may die after much suffering, principally from oppression,
caused by the escape of blood into the cavity of the chest.

If the wound be a stab, the external opening may be accurately closed,
and the escape of blood prevented; but as the pressure of the blood
in the pericardium is unequal to restrain the action of the heart,
blood forced out through the opening fills the cavity of the pleura,
and causes suffocation, unless from some accidental circumstance the
opening in the heart becomes obstructed, and the bleeding ceases.

If all the circumstances be considered, there can be no doubt of the
propriety of closing the wound in the first instance, if the flow of
blood be excessive and appear likely to endanger life. It seems to be
as little doubtful that the wound should be reopened after a time,
if the danger from suffocation be imminent. The relief obtained by
the escape of a little blood may be efficacious, while it does not
necessarily follow, although it is more than probable it will be so,
that its place will be occupied by a further extravasation of blood,
which will prove fatal. It is a choice of difficulties, and death from
hemorrhage is easier than death from suffocation.

In the case of the Duc de Berri, whose right ventricle was wounded,
and who died from loss of blood, Steifensand reprehends Dupuytren
for having opened the external wound every two hours, to prevent
suffocation; but if death were actually impending from the filling of
the cavity of the chest being about to cause suffocation, there was
nothing to be done but to give relief at all hazards.

359. When the sufferer has recovered from the imminent danger attendant
on the infliction of the injury, and the pericardium is believed to
be so full of blood or of serum as to prevent in a great measure the
movements of the heart, it has been proposed by Baron Larrey to open
the pericardium by the following operation--equally, as he thinks,
applicable in an ordinary case of hydrops pericardii:--

“An oblique incision is to be made from over the edge of the ensiform
cartilage, to the united extremities of the cartilages of the seventh
and eighth ribs. The cellular tissue being divided with some fibers of
the rectus and external oblique muscles, there remains only a portion
of the peritoneum called its false layer, above the pericardium, which
can be seen after the division of all the intervening cellular tissue,
projecting between the first and second digitations of the diaphragm.
Into this the bistoury is to be entered, with the precaution of doing
it with the edge turned upward, and directed a little from right to
left, to avoid the peritoneum. The smallest portion possible of the
anterior border of the diaphragm is next to be divided, where it is
attached to the inner part of the cartilage of the seventh rib. The
internal mammary artery is to the outside. The patient should be placed
perpendicularly, and supported on his bed, which inclines the anterior
part and base of the pericardium to the fore part of the chest.”

Skielderup recommends this operation to be done by first trepanning the
sternum a little below the spot where the cartilage of the fifth rib
is united to that bone, at which part the periosteum lining it offers
considerable resistance, and should not be divided by the trephine.
Below this there is a triangular space formed by the separation of the
layers of the mediastinum, free from cellular tissue, and tending a
little more to the left than to the right. The apex of this triangle is
opposite the fifth rib; its base touches the diaphragm. The bone having
been removed, the patient is made to lean forward, when the projection
of the pericardium will enable the operator to feel that a quantity of
fluid is within, and to open it with safety.

360. J. Dierking, a stout, muscular man of the 3d Regiment of German
Hussars, was wounded at the battle of Waterloo by a lance, which
penetrated the chest between the fifth and sixth ribs, and was then
withdrawn. He fell from his horse, lost a good deal of blood by the
mouth, and some by the wound, and was carried to Brussels without any
particular attention being drawn to the injury. His strength not being
restored, while he suffered from palpitations of the heart, and other
uneasy sensations in the chest, he was sent to England to be invalided;
and in November, 1815, was admitted into the York Hospital, Chelsea, in
consequence of an attack of pneumonia, of which he died in two days,
without attention being particularly drawn to the cicatrix of the wound.

On examining the body, I found that the lance, having injured the edge
of the cartilage of the rib, passed through the inferior lobe of the
left lung, the track being marked by a depressed, narrow cicatrix. It
then perforated the pericardium under the heart, and sliced a piece of
the outer edge of the right ventricle, which, being attached below,
turned over and hung down from the heart to the extent of two inches,
when in the fresh state, the part of the ventricle from which it had
been sliced being puckered and covered by a serous membrane like the
heart itself. The lance then penetrated the central tendon of the
diaphragm, making an oval opening, easily admitting the finger, the
edges being smooth and well defined. It then entered the liver, on the
surface of which there was a small, irregular mark or cicatrix. The
heart in front was attached to the pericardium by some strong bands,
the result of adhesive inflammation, but the general appearance of
the serous membrane showed that this had not been either great or
extensive. The pericardium was not thickened.

If this man had lived long enough, he might have furnished an instance
of hernia of the stomach or of intestine into the pericardium. The
preparation is in the military museum at Chatham, Class 1, Div. 1,
Sect. 7, No. 156.

[Illustration:

  _a_, right ventricle;
  _b_, left ditto;
  _c_, right auricle;
  _d_, left ditto;
  _e_, aorta;
  _f_, pulmonary artery;
  _g_, coronary ditto;
  _h_, a portion of the cartilages of the ribs seen on the inside;
  _i_, a portion of the diaphragm;
  _k_, the pericardium.

  1, a portion of the pericardium reflected to show abnormal adhesions
     to the surface of the heart;
  2, aperture of wound through the diaphragm and the pericardium;
  3, pendulous slice off the substance of the right ventricle;
  4, puckered cicatrix of the wound of the ventricle.]

That the heart, when exposed, is insensible, or nearly so, to the
touch, was known to Galen and to Harvey. Galen is said to have removed
a part of the sternum and pericardium, and to have laid his finger
on the heart. Harvey did the same to the son of Lord Montgomery, who
was wounded in the chest. Professor J. K. Jung not only introduced
needles into the hearts of animals, but also galvanized them without
disadvantage, although Admiral Villeneuve is supposed to have died
suddenly from running a long pin into his heart, which scarcely left
the mark of its entrance.

That persons may die from the shock of a blow on the heart, need
not be doubted, and that they do die when little blood is lost, is
admitted. History preserves the fact that Latour d’Auvergne, Captain of
the 46th demi-brigade, who had obtained the honorable title of “Premier
Grenadier de France,” fell and died immediately after receiving a wound
from a lance at Neustadt, in the month of July of the sixth year of the
Republic; it struck the left ventricle of the heart near its apex, but
did not penetrate its cavity. He was, however, sixty-eight years of age.

361. In wounds of the heart, all extraneous matters should be removed,
if possible, and all inflammatory symptoms should be subdued by general
bleeding, by leeches, by calomel, antimony, opium, etc. The chest
should be examined daily by auscultation. If the cavity of the pleura
should fill with blood, it ought to be evacuated to give a chance for
life, and if the pericardium should become permanently distended by
fluid, it should be evacuated.

_Lacerations and ruptures of the heart_ have frequently taken place
from blows or other serious contusions.

Ollivier, who devoted much time to reading and collecting the
observations made by different writers on the injuries of the heart,
says: “That of forty-nine cases of spontaneous rupture of the heart,
thirty-four were of the left ventricle, eight only of the right,
two of the left auricle, three of the right, and that in two cases
both ventricles were torn in several places; and that these results
were in an inverse proportion to those which occurred after blows or
contusions; the right ventricle being ruptured in eight out of eleven
cases, the left ventricle three times; the auricles being also torn in
six of these eleven cases; the ruptures not being confined to one spot,
but taking place occasionally in several different parts, or even in
the same ventricle.” In eight of these cases he had noticed, the heart
was ruptured in several places. That a spontaneous rupture may be cured
as well as a wound, seems likely, from a case reported by Rostan, of
a woman who died after fourteen years’ suffering with pain about the
heart, and was found to have the ventricle ruptured. A cicatrix was
observed to the left side of the recent rupture, half an inch in extent
in every direction, in which the new matter was evidently different
from the natural structure of the heart.



LECTURE XXVI.

WOUNDS OF THE INTERNAL MAMMARY ARTERY, ETC.


362. _Wounds of the internal mammary and intercostal arteries_ have
so much occupied the attention of theoretical surgeons, and so many
inventions have been broached for the suppression of hemorrhage,
particularly from the latter, that it becomes consolatory to know that
bleeding from these vessels rarely takes place; that the inventions
are more numerous than the case requiring them, and that no notice
need be taken of them, they being as unnecessary as they are useless.
I have never had occasion to see a distinct case of hemorrhage from an
internal mammary artery, but if bleeding should take place from a wound
in its neighborhood, of a nature to lead to the belief that it came
from this vessel, the wound should be enlarged until the part whence
the blood flows can be ascertained, when, if it be from that artery,
the vessel should be twisted or secured by ligatures, and if these
methods should be impracticable, the wound should be closed and the
result awaited.

The following method of operating for the application of a ligature on
this vessel has been proposed by M. Goyraud. It may be done with ease
in the three first intercostal spaces, it offers some difficulties
in the fourth, is very difficult in the fifth, and is scarcely to be
done lower down. An incision two inches in length is to be made near
the side of the sternum from without inward, at an angle of forty-five
degrees with the axis of the body. The middle of this incision should
be three or four lines distant (a quarter of an inch) from the bone,
and in the center of the intercostal space, within which the vessel
is to be found. The skin, cellular substance, and the great pectoral
muscle having been divided, the aponeurosis of the external intercostal
muscle with the muscular fibers of the inner intercostal muscle are to
be separated and torn through with a director, until the artery and its
two venæ comites are laid bare at the distance of three lines from the
edge of the sternum, lying before the fibers of the triangularis sterni
muscle, which separates these vessels from the pleura. A bent probe, or
other proper instrument, can then be readily passed under the artery.
The vessel can only be secured in this way when injured at the upper
part of the chest; below this it must bleed into the cavity, unless
there be an open wound.

363. The _intercostal artery_, although often injured, rarely gives
rise to hemorrhage so as to require a special operation for its
suppression; but whenever it does so happen, the wound should be
enlarged so as to show the bleeding orifice, which should be secured by
one ligature if distinctly open, and by two if the vessel should only
be partially divided. The vessel is sometimes so small as to be easily
twisted, or its end sufficiently bruised as well as twisted, to arrest
the hemorrhage. It lies between the two layers of intercostal muscles,
and in the middle of the ribs it runs in a groove in the under part of
each.

I have had occasion to twist and bruise the end of an artery bleeding
in an intercostal space, and I have tied the vessel under the edge of
the rib; but I have not met with any of the great difficulties usually
said to be experienced in suppressing a hemorrhage from this artery,
when the wound was recent, and the parts were sound; no reliance should
be placed on the hypotheses often entertained on this subject.

When the parts are unsound, and the hemorrhage is secondary, greater
difficulty is sometimes experienced in arresting it, because the
ligature easily cuts its way through the softened parts, and styptics
are liable to fall into the cavity of the chest.

The late General Sir G. Walker, G.C.B., after scaling the wall of
Badajos, with the fifth division, was wounded by a musket-ball, which
struck the cartilages of the lower ribs of the right side, broke the
bones, penetrated the chest, and then passed outward. He remained in
Badajos under my care during the first three weeks, with many of the
other principal officers who were wounded; and overcame the first
inflammatory symptoms in a satisfactory manner. After I left him the
wound sloughed, some part of the cartilages separated, and one of the
intercostal arteries bled, although the bleeding was arrested once by
ligature, and afterward, on its return, by different contrivances; each
time it reappeared his life was placed in considerable jeopardy from
it and the discharge from the cavity of the chest, which was profuse.
The bleeding was ultimately arrested by the oil of turpentine, applied
on a dossil of lint, and pressed on the bleeding spot by the fingers
of assistants until the hemorrhage ceased. He recovered after a very
tedious treatment, with a considerable flattening of the chest, and a
deep hollow at the lower part of the side, whence portions of the rib,
and of the cartilages had been removed.

A young man, aged fifteen, was wounded by small shot in the chest,
between the first and second ribs, and near the sternum, at the
distance of about forty-eight paces. He ran about six hundred paces,
fell, and died thirty-eight hours afterward. On opening the injured
cavity of the thorax, it was found to contain twenty-eight ounces
of blood, the lung having collapsed to one-fourth its natural size.
An opening on its upper part corresponded to the external one in
the paries; but the track of the shot could not be traced into its
substance for more than two inches and three-quarters; a lacerated spot
was, however, perceived at the lower edge of the sixth rib, about two
inches from its head, at which part the intercostal artery was found to
be torn through; the shot could not be found, and there was no opening
in the skin behind.

The discussions which took place on this case led to the statement of
an anatomical fact--that when a man is standing erect, a line drawn
horizontally from the upper border of the second rib in front would
touch the upper edge of the fifth rib behind, and that very little
inclination, viz., an inch and a half, was necessary to make the shot
wound the intercostal artery of the sixth. Auscultation would have
made known the extravasation, and relief might have been given by an
incision over the spot where uneasiness was felt; for the loss of blood
was not sufficient of itself to destroy life, unless some other injury
had been sustained, which was not perceived.

364. _Wounds of the neck_ which are made with swords, or by knives
or razors, by persons attempting to destroy themselves, are to be
treated on two great principles. The _first_ is, not to place the
parts in contact until all hemorrhage has ceased, lest the patient
be suffocated. In the mean time, while any oozing continues, a soft
sponge should be placed between the edges of the cut. When the larynx
or trachea is obstructed by a quantity of blood, it may be sucked out,
or drawn up by an exhausting pump, and it may be advisable in some
cases to introduce a tube. If the trachea be cut across, a stitch
will be necessary to keep the ends in contact. The _second_ is, to
keep the divided parts in contact afterward, by position and bandage,
but not _by suture_. If the œsophagus be wounded, nourishment should
be administered by a gum-elastic tube introduced through the nares
into the stomach. It is almost unnecessary to add that the artery, if
wounded, should be secured by ligature. A hole in the internal jugular
vein may be closed by a thread passed around it when raised by a
tenaculum.

Captain Hall, of the 43d Regiment, was wounded by a ball which passed
between the upper part of the back of the larynx and the termination of
the pharynx, without causing much further inconvenience than the loss
of voice. In this instance it must have been the superior laryngeal
nerve that was injured, and not the recurrent, yet the voice could only
be heard in a whisper, and was not completely recovered for years. If a
ball should lodge in the trachea, it must be removed by the operation
of laryngotomy or tracheotomy, if the original wound cannot be
enlarged; although Birch, says Christopher Wren, hung up a man wounded
in this way by the heels, when the ball dropped out through the glottis
and mouth. General Sir E. Packenham, who was killed at New Orleans by
a ball which went through the common iliac artery, had been twice shot
through the neck in earlier life. The first shot, which went through
high up from right to left, turned his head a little to the right.
The second shot, from left to right, brought it straight. My kind and
excellent friend had ever afterward a great respect and regard for the
doctors and a strong feeling for the wounded. The recollection of that
regard, and the advantages derived from it, have made me sometimes
think it might be advantageous for the unfortunate as well as for the
doctors if every general could be at least shot once through the neck
or the body, before he was raised to the command of an army in the
field; for there is nothing like actual experience of suffering to make
men feel for their fellow-creatures in distress. A Minister at War
would not perhaps be the worse for a little personal experience in this
matter.

365. _Wounds of the face_ made by swords or sharp-cutting instruments
should be always retained in contact by sutures. When the cut is of
small extent, and not deep, the skin only should be included by the
thread, and that in the slightest possible manner, and the part
supported by adhesive plaster and bandage. When the cheek is divided
into the mouth, one, two, or more sutures may require to be inserted
more deeply, but the deformity of a broad cicatrix will in general be
avoided, by carefully sewing up the whole line, taking the very edge
of skin only; and a cut in the bone or bones of the cheek should not
prevent the attempt being made to unite the external wound over it.

Incised or even lacerated wounds of the eyelids and brows should be
united by suture, as far as can possibly be done in the first instance,
by which a subsequent painful operation may be avoided; great care
should be taken in doing this; the suture must be inserted through
the eyelid, and a leaden thread is often the best, the first being
introduced at the very edge of the lid, and two, or as many more
afterward as may be necessary. They may remain for three or more days,
as circumstances seem to require. If the eye be wounded, any part
protruding beyond the sclerotic coat should be cut off with scissors;
but the eye, however injured, should not be removed unless the ball
be detached in every direction, or destroyed. The treatment should
be strictly antiphlogistic, in order to prevent suppuration of the
eyeball, which may in general be effected, if too much injury have
not been done to it, and if the treatment be sufficiently decided and
well continued. These observations apply to the nose and ears, and
all parts not actually separated--or, if separated, for a short time
only--should be replaced in the manner directed, and every attempt
made to procure reunion. If this should fail, surgery may yet be able
to yield assistance by replacing the loss by a piece of integument
dislodged from the neighboring parts--a proceeding requiring a separate
consideration. Injuries from musket-balls are often attended by
considerable laceration, particularly when near the eyelids. Whenever
this occurs, the parts likely to adhere should be brought together by
suture, after any splinters of bone which may present themselves, or
can be seen or felt, have been removed from the holes made by the ball.
If the bones should be broken, and not splintered, they will frequently
reunite under proper management.

366. _Wounds of the eye_ from small shot are remediable when these
small bodies lodge in the cornea or sclerotica, whence they may be
removed by any sharp-pointed instrument. When a shot or piece of a
copper cap is driven through the cornea, into the iris, or lies in the
anterior chamber, it should be removed by an incision to the extent of
about one-fourth or one-fifth of the cornea, near its junction with the
sclerotica, but in these cases a cataract, if not amaurosis, frequently
results. When the shot passes through all the coats of the eye, it
can neither be seen nor removed with safety; vision will be lost,
much pain may be endured, and the eye will frequently be destroyed by
suppuration, or by a gradual softening, and ultimate diminution in
size. A contused wound from a large shot which only injures the coats
of the eye, but does not perforate them, will oftentimes be cured by
a proper antiphlogistic treatment, which in all cases should be most
strictly enforced, although loss of sight is a frequent consequence
after such injuries.

When a ball lodges behind the eye, it usually causes protrusion,
inflammation, and suppuration of that organ. If it be not discovered
by the usual means, its lodgment may be suspected from the gradual
protrusion and inflammation of the eye itself. If it be discovered,
it should be removed together with the eye, if such proceeding be
necessary for its exposure. If suppuration have commenced in the
eye, a deep incision into the organ will arrest, if not prevent, the
horrible sufferings about to take place, and allow of the removal of
the offending cause. If the eye remain in a state of chronic disease
and suffering, a similar incision will give the desired relief. If the
chronic state of irritation affect the other eye, the incision and
sinking of the ball of the one first affected or injured is urgently
demanded, and should not be delayed. If the back part of the eye be
left with the muscles attached to it, a stump remains, against which an
artificial eye may be fitted, so as sometimes to render the loss of the
natural one almost unobservable.

367. I have several times seen both eyes destroyed and sunk by one
ball, with little other inconvenience to the patient; one eye sunk,
the other amaurotic, and both even amaurotic, almost without a sign
of injury, by balls which had passed from side to side through both
orbits, but behind the eyes. When the eye becomes amaurotic from a
lesion of the first branch of the fifth pair of nerves, the pupil does
not become dilated; the iris retains its usual action, although the
retina may be insensible and vision destroyed. This was well shown in
the case of the late Major-General Sir A. Leith, who was wounded by
a sword in the forehead, this nerve being divided. It has so often
occurred as to leave no doubt of the fact, and of the error formerly
existing on this point.

368. Penetrating wounds implicating the bones of the face are always
distressing. When the bones of the nose are carried away, there must
always be some deformity remaining, although there is oftentimes but
little suffering. When these bones are merely splintered and depressed,
great pains should be taken to keep them properly elevated. If the
duct of the parotid gland be implicated by an incised wound, care
should be taken to divide the cheek into the mouth, if it should not
have been already done, and to keep the incised wound open until the
external one is closed. If a salivary fistula have formed externally,
from inattention or otherwise, it must be treated according to the
ordinary methods adopted in such cases. When a wound of the gland
itself becomes fistulous, and weeps, which is a rare occurrence, it
will be best treated by actual or potential cauterization, if moderate
pressure should fail. When these wounds are of some extent, they are
often followed by partial paralysis, in consequence of the seventh
pair of nerves being injured, when the mouth is drawn somewhat to the
other side. When the lachrymal bones or sac are injured by balls or
swords, the tears usually continue through life to run over, and give
inconvenience, although much good may be done by early attention to the
injuries of this part. Wounds injuring the upper jaw are oftentimes
followed by much suffering, and by permanent inconvenience.

General Sir Colin Halkett, G.C.B., was wounded on the 18th of June, at
Waterloo, when in front of his brigade, which was formed in squares
for the reception of the French cavalry, by a pistol-ball, fired by
the officer commanding them, which struck him in the neck, and gave
him great pain, but without doing much mischief. A second shot shortly
afterward wounded him in the thigh, and he was obliged to leave the
field toward the close of the day, by a third musket-ball, which struck
him on the face, when standing sideways toward the enemy. It entered
a little below the outer part of the cheek-bone on the left side,
and, taking an oblique direction downward and forward, shattered and
destroyed in its course several of the double teeth in the upper jaw,
fracturing the palate from its posterior part, forward to the front
teeth. The ball then took a direction obliquely upward, destroying
the teeth of the opposite side of the upper jaw, which bone it also
broke, and lodged under the fleshy part of the cheek. These wounds gave
great pain, and until the ball was removed, the left ear was totally
insensible to sound and all external impressions, although the general
suffered much from distressing noises in his ear. These subsided on the
removal of the ball some days afterward.

The treatment of this wound, however, was most painful; the extraction
of several pieces of bone was necessary at different times, during
the three following years, before the wounds were finally closed.
Considerable derangement of health followed, the deafness remains; and
the general has ever since been subjected to attacks in the head of an
increasing and most distressing nature.

369. Wounds of the lower jaw are perhaps more common, and are certainly
more troublesome than those of the upper; they are more difficult of
management, and, for the most part, end in greater deformity, unless
particular care be taken to prevent it, and then only in very severe
cases, by operations which were formerly not in use, but which the
intrepidity of the surgeons of the present day have deprived of all
their terrors. I mean the methodical division of the soft parts,
the sawing off and removal of the broken pieces of bone, and the
rounding off of those parts of the jaw which may remain irregular and
pointed. M. Baudens has given two good examples of the success of
this proceeding during his campaigns in Algeria. In the first case,
the ball entered at the middle of the left cheek, and came out by the
side of the spinous process of the seventh cervical vertebra. The
ascending ramus of the lower jaw was broken into numerous splinters.
M. Baudens divided the soft parts down to the bone, entering the
straight bistoury four lines, or the third of an inch, below the
articulation of the jaw with the temporal bone. He then carried it
downward, and a little obliquely forward, so as to terminate it in the
fibers of the masseter muscle, about half an inch below the base of
the bone. This incision was begun below the seventh pair of nerves,
and exposed the parotid gland divided vertically at its middle part.
The splinters were removed, a part of the pterygoideus internus muscle
was divided, and a projecting point of bone attached to it sawn off.
He then separated the attachments of the buccinator, temporal, and
pterygoideus externus muscles, divided the ligaments, and removed the
coronoid and articulating processes, taking care to avoid the fifth and
seventh pairs of nerves. The bleeding from two arteries was suppressed
by twisting their ends; and the parts were afterward brought together
by sutures, which remained for eight days. A month after the operation
the patient ate solid food, and in six weeks was cured. In the second
case, the ball entered near the left commissure of the lip, and came
out behind on the side of the middle of the neck; three inches of the
jaw were splintered, the ends of the bone being sharp and angular. In
order to remove the splinters, and to prevent the evils anticipated,
M. Baudens divided the lip from the angle downward and outward, below
the base of the bone, as far back as the edge of the masseter muscle.
He then separated the flaps, and sawed the jaw across, first near the
symphysis, and then behind, outside the attachment of the masseter. The
facial artery was twisted, four sutures were inserted, and the jaw duly
supported. The patient was bled twice, and in six weeks was cured; at
the end of that time he could eat solid food. After the healing of such
wounds, mechanical means are often necessary to enable the sufferer
to eat and to live without causing disgust to his neighbors and his
friends.

It is said there are fifteen men in the Hôtel des Invalides, in Paris,
wearing silver masks on the lower part of their faces, in consequence
of injuries of this kind.

Colonel Carleton was an instance of a ball fracturing the jaw directly
through its body, near where the masseter muscle is attached on both
sides; the jaw was broken into three pieces, besides splinters; several
teeth were knocked out, and the tongue very much hurt. By sawing off
the splinters both from within and without, and by cleansing and
supporting the parts with great care, he recovered after a length of
time, the deformity after such a wound being much less than might be
expected.

370. Incised wounds of the tongue do sometimes give rise to hemorrhage
somewhat difficult to restrain, particularly if it occur a few days
after the receipt of the injury, when the tongue is swollen and
painful. It does not so frequently occur after gunshot wounds. As
the vessels of one side do not communicate with those of the other,
any bleeding which continues after the artery of one side has been
properly secured, can only take place from a wound of the artery
of the other, which must then also be tied. This should be done by
drawing the tongue as far as possible out of the mouth by a flat pair
of forceps, which may be easily effected at an early period, when
it is not tender and painful. At a later date, and under difficult
circumstances, various styptics, such as the mineral acids, nitrate of
silver, etc., will be useful. The actual cautery has been recommended,
but I have never seen it used in such cases.

371. One of the most curious instances of the lodgment of a foreign
body in the face occurred in the person of Captain Fritz, at Ceylon;
his gun burst in his hand, and drove the iron breech into the forehead,
whence it descended into the nares, and, at the end of a year, part of
it made its appearance in the mouth, through the palate. He died eight
years afterward, having suffered much inconvenience from the offensive
discharge it occasioned. When the iron was removed, it had obviously
injured no part of any material importance to life. I have seen balls
descend in this way into the throat and soft palate, and have removed
them from both places with success, and from the hard palate with equal
surprise and advantage to the patient. I have known a ball lodge in the
superior maxillary sinus for months, and even for years, before it was
removed, or the death of the patient proved the fact.



LECTURE XXVII.

STRUCTURE OF AN INTESTINE, ETC.


372. If an intestine be divided circularly in any part, its walls will
be found to be composed of three principal coats or tunics, which
are--commencing from the inside--the mucous, the muscular, and the
serous or peritoneal, each being separated from the other by a layer of
areolar tissue. A diagram thus made would show a transverse division of
the intestine, and eight distinct if not all different parts. Beginning
from without, viz., serous or peritoneal, areolar or sub-serous;
longitudinal muscular, areolar; transverse muscular, areolar or
sub-mucous, and epithelial. The mucous coat in man has a peculiarity
not observable in animals, of ledges or shelves projecting into its
cavity.

When the mucous coat of the duodenum is examined with the naked eye,
the first part of its course presents a tolerably smooth appearance,
gradually, however, becoming irregular in transverse folds, which are
so numerous, marked, and regular in the jejunum and ileum as to have
obtained from the earliest times the name of valvulæ conniventes. They
are most strongly marked in the jejunum, and gradually disappear toward
the lower part of the ileum, the inner surface of the large intestines
being still smoother than any part of the small, although large pouches
or cells are formed in the colon by a peculiar arrangement of the
muscular coat. These valves never extend completely round the inside of
the intestine, and rarely more than half or two-thirds, although they
sometimes bifurcate. They have a velvety appearance, which has obtained
for this coat the name of villous as well as that of mucous.

Valvulæ conniventes are peculiar to man; none exist in the
ourang-outang or chimpanzee. In the frog there are valvular folds,
appearing, at first sight, like the valvulæ conniventes of the human
subject; but, on a careful examination, they are found to be mere
elevations, without villi. In the tortoise there are similar folds,
running however in a longitudinal or opposite direction. In the
rhinoceros the mucous membrane is raised up into villiform processes,
somewhat like the valvulæ conniventes, or large villi; but they are
not villi, as each process is covered with other projections which
really are villi. A valvula connivens consists of two layers of mucous
membrane and sub-mucous tissue, but the muscular coat is not continued
into it.

373. When examined microscopically, the velvety appearance is found to
consist of innumerable small processes which have been called villi,
each villus being composed principally of a very thin, transparent
_basement_ or _germinal membrane_, forming a sheath or case, inclosing
within it an artery, a vein, a capillary plexus, and an absorbent
vessel termed _lacteal_. A nerve has not been discovered, although
it is presumed to exist. These villi are longest in the duodenum,
and gradually diminish in number and in size from 1/25 to 1/50 of
an inch. Between these villi or projections, holes or openings are
observable, termed the follicles of Lieberkühn, who first described
them; they resemble inverted villi, being in some instances as deep
as the villi are long. Unlike the villi, they are found throughout
the intestines. The villi in every part in common with all mucous
membranes are covered, and the follicles are lined by epithelium, which
in this instance is the columnar, situated on the basement membrane,
each column being attached by its pointed extremity. A layer of this
epithelium extends between the villi, down to the lower part of each
follicle, each column being, generally speaking, shorter and rounder
than when covering the villi.

The office of the epithelium of the villi has been stated to be
_protective_, that of the follicles to be _secretive_. A villus, when
duly magnified, is seen to have a bulbous extremity without an opening,
and to be covered by epithelium when the intestine is in a state of
quiescence, uncalled upon for any purpose of digestion. When digestion
commences, the epithelium, according to the researches of Mr. Goodsir,
is separated and thrown off. As the chyme begins to pass along the
small intestine, an increased quantity of blood circulates in the
capillaries of the gut. In consequence of this increased flow of blood,
or from some other cause, the internal surface of the gut throws off
the epithelium of both villi and follicles, which is intermixed with
the chyme in the cavity of the gut. The cast-off epithelium, forming
19/20ths of the covering of the villus, is of two kinds, that which
covers the villi, and which from the duty it performs may be termed
_protective_, and that which lines the follicles and may be termed
_secretive_, each column having a nucleus situated at some part of it,
and bulging out that part.

The villi being now turgid with blood, erected and naked, and covered
by the chyme mingled with the cast-off epithelia, commence their
functions. The summit of the villus becomes at first somewhat flattened
and crowded under the basement membrane with a number of newly-formed
and perfectly spherical vesicles, varying from 1000 to less than 2000
of an inch in size. Toward the body of the villus or the inner edge
of the vesicular mass, minute granular or oily particles are situated
in great numbers, and gradually pass into the granular texture of the
substance of the villus. As the process advances lacteal vessels are
shown passing up from the root of the villus, subdividing and looping
as they approach the spherical mass, which in this stage has become
more distinctly vesicular, although no distinct communication can be
detected between them. The blood-vessels and capillaries shown in
injected preparations are now seen colored red with their own blood,
and running up to the basement membrane, looping with each other
immediately beneath it, and ending in one or more venous trunks. The
vesicles, quite distended and grouped in masses, push forward the
membrane, and give to it by these inequalities an appearance resembling
that of a mulberry.

The minute vesicles above noticed fulfill the important office of
absorption, by drawing into their cavities through their walls, by a
process called _endosmosis_, that portion of the chyme necessary to
form chyle; when filled with it they burst or dissolve, their contents
being thus discharged into the texture or substance of the villus, fit
to be taken up by the granular vesicles interspersed among the terminal
loops of the lacteals, and communicating with their trunks, running up
from the root of the villus in their center. Absorption is thus shown
to be effected by closed vesicles, and not by vessels opening on the
surface of the villus.

The _débris_ and the contents of the dissolved chyle cells, etc. pass
into the looped net-work of lacteals, as in other lymphatics. When the
gut contains no more chyme, the flow of blood to the mucous membrane
diminishes, the development of new vesicles ceases, the lacteals empty
themselves, the villi become flaccid, and the cast-off epithelium is
reproduced, apparently from the nuclei in the basement membrane, in
the intervals of digestion, showing that this function should only be
induced at regular periods, the presumed special use of the epithelium
being to prevent, in a measure, the absorption of any effete or other
matters which might exert a deleterious influence oh the system,
the epithelium of the follicles now secreting a mucus which may be
considered protective.

In the large intestines there are no villi, but the whole surface is
covered with follicles which must be capable of absorbing as well as of
secreting, as it is ascertained that persons can be nourished and kept
alive for many weeks by nutritious enemata which do not pass into the
small intestines.

374. On examining the mucous membrane of the stomach, its follicular
structure is immediately seen, the follicles resembling much in
appearance those of the intestine; but in the stomach minute tubes are
found opening into the bottom of each follicle, fulfilling in all
probability a different office, the follicles being lined by columnar
epithelium, the tubes by spheroidal or glandular epithelium; it is
therefore presumed that the gastric juice is secreted by the tubes,
the mucus by the follicles. The tubes differ in the middle and lower
parts of the stomach, by being longer or more deeply seated, and more
numerous as they approach the pylorus, showing in all probability a
difference of function between the upper and middle, and the pyloric or
lower extremity of the organ.

The intestines are supplied with glands, not apparently for the
purposes of absorption, but of secretion; these require attention. They
are the duodenal of Brunner, the agminated of our countryman, Nehemiah
Grew, and of Peyer, and the solitary, which are found in the lower part
of the small and in the whole course of the large intestines.

The _glands of Brunner_ are situated at the commencement of the
duodenum, within an inch of the pylorus, and are not visible until
the serous and muscular coats have been removed from without. They
appear to the naked eye like the little white eggs of an insect. Under
the microscope each little gland is found to be lobulated, very much
resembling a small portion of a salivary gland or pancreas, each lobule
having an excretory duct, which unites with those from other lobules
to form one larger one opening on the mucous surface of the bowel. The
lobules themselves are made up of vesicles, within which the secretory
cells are discernible.

The _agminated_ glands of _Grew_ and _Peyer_, by the latter of whom
they were more minutely described, occur in oval patches at irregular
distances throughout the jejunum and ileum, and are situated on the
side immediately opposite the part where the mesentery is united to the
bowel. Each gland resembles somewhat a Florence oil-flask in shape, the
small end or mouth, which is more or less pointed, projecting through
among the villi or the follicles. They are composed of cells, supplied
by capillary vessels, which Mr. Quekett says have the peculiarity
of being unsupported by areolar tissue, and are termed by him, in
consequence, _naked_. These are the glands which are found more or
less diseased after phthisis and fevers which have terminated fatally.
The oval form of the patches is retained, although considerably raised
above the general surface of the mucous membrane, and when injected
the parts around are more vascular, the ulcerated portion being less so
than usual.

The _solitary_ glands are best seen in the cœcum and appendix
vermiformis. They are well developed in the fœtus, projecting slightly
above the mucous membrane. Each gland may be considered as one of
the agminated form much enlarged, and when the free surface is very
flat, an opening may be easily seen in the center. These glands also
are frequently the seat of ulceration in fever and dysentery, and
particularly in phthisis. The follicles partake of this disease, and
the whole mucous coat may be destroyed. In some cases there is an
attempt at healing, and the edges of the ulcers become more vascular
and even villous.

The sub-mucous areolar tissue--the tunica nervosa of Haller, the
_fibrous lamella_ of Cruveilhier--separating yet connecting the mucous
with the muscular coat of the intestine, is composed of the yellow
elastic and of the white or non-elastic fibers, the latter of which
predominate. It is more firmly connected with the mucous than with the
muscular coat, and in it the blood-vessels and nerves are supported
prior to their distribution in the mucous membrane. This sub-mucous
tissue or structure prevails also in the stomach, and is often much
altered by disease, becoming thicker, and assuming a more dense and
sometimes an almost gristly hardness. It is an important part in the
surgical treatment of wounds of the intestines, being firmer, stronger,
and more elastic in reptiles, and more distinct in carnivorous than in
herbivorous animals or in man.

375. The muscular coat of the intestines is in two layers, the internal
being composed of fibers running transversely, the outer fibers running
longitudinally; they are thickest in the duodenum and rectum. They are
of the _involuntary_ or unstriped kind, as opposed to the _voluntary_
or striped, which are of large size, and characterized by striæ running
transversely and longitudinally.

The involuntary fibers, on the contrary, are much smaller in size,
are always more or less flattened, and present no trace of striæ or
stripes, although the interior appears granular, with an occasional
nucleus. The heart is a remarkable exception to this rule, being an
involuntary organ, with striped fibers differing in size, resembling in
this respect those of a voluntary muscle.

The peritoneal coat is formed of the white fibers, under a
structureless or basement membrane, covered by tesselated epithelium,
constituting a serous and secreting membrane.

376. Wounds and injuries of the abdomen are essentially of three
kinds--1. Affecting the paries or wall. 2. Opening or extending into
its cavity. 3. Wounding or injuring its contents.

The wall of the belly is, when severely hurt, liable to a permanent
defect, as the ordinary result of a severe bruise. It is the formation
of a ventral rupture. A division of the wall to any extent by a
sharp-cutting instrument is usually followed by a similar consequence;
and it never fails to occur in the openings made by a musket-ball
penetrating into or passing through the cavity.

Captain Tarleton, of the 7th or Royal Fusiliers, was struck on the
left iliac region by a large, flat piece of shell, at the battle of
Albuhera, in 1811. The surface was not abraded, although the iron
caused a very severe and painful bruise; the whole of that side of the
belly became quite black, and the remaining part much discolored. Some
months afterward he drew my attention to the part, and I then found
that the whole of the muscular portion of the wall had been removed
by absorption to the extent of the immediate injury from the piece
of shell, the tendinous parts alone remaining under the integuments.
These protruded on any effort, constituting a circular-shaped ventral
rupture, with a large base, which required the application of a pad and
bandage for its repression.

Mr. Smith, a deputy-purveyor, received a blow on the side of the fore
part of the belly from the end of a spanker-boom, which knocked him
down, and gave rise for some time to much inconvenience. He showed the
part to me in Lisbon, in 1813, in consequence of the formation of a
ventral hernia to the extent of the spot originally injured. In neither
of these cases was such a result expected; no rupture of the fibers of
the muscles was distinguished at the time, and it was supposed that the
sufferers would recover without any permanent defect. The absorption of
the muscular fibers was therefore a subsequent process; whether this
result may or may not be prevented in similar cases by a more active or
a longer-continued treatment, with the early application of a retaining
bandage, is yet to be ascertained. It may be that some muscular fibers
were actually ruptured and others bruised in these cases; but the
extent of the absorption was greater than the apparent injury would
seem to have warranted.

Abscesses form from neglected injuries of this kind, and give rise to
the most serious apprehensions of their bursting into the cavity of
the abdomen, which, however, they very rarely do. The safety of the
peritoneum and its capability of affording sufficient resistance to
the progress of the matter through it seem to depend upon the strength
of the fibrous structure on its outer or muscular side; the inner or
really serous surface being very delicate, and offering but little
resistance to the application of any moderate degree of force.

An officer, whose name I forget, was wounded at the assault of Ciudad
Rodrigo, in 1812, by a musket-ball, on the left side and fore part of
the abdomen, near the crest of the ilium: it made a wound about four
inches in length, cutting away the muscles of the abdominal wall so
deeply as to lead to the exposure, and, as I feared, to the ulceration
of the peritoneum, when the sloughs should separate. Under these
circumstances, although not belonging to my division, I took him with
me from the field to the divisional hospital at Aldea Gallega, some ten
miles from the battlefield. Granulations sprang up, however, from the
bottom and sides of the wound, which gradually closed in and healed
without further difficulty.

377. It has been supposed theoretically, to be a matter of importance
to discriminate between the orifice of entrance of a ball passing
through the abdomen or its wall, and that of its exit. Practically
speaking, it is a matter of indifference; the part on which the ball
impinges is usually distinguished by a more circular and depressed
appearance, while the opening of exit more frequently resembles a tear
or slit, the edges of which are rather disposed to protrude.

A ball striking obliquely against the wall of the abdomen has been said
to run sometimes nearly round under the skin, or between the muscles
and the peritoneum, a proceeding upon the recurrence of which little
expectation need be placed. It may, however, do something of the kind
for a considerable distance, passing even over or between the spinous
processes of the vertebra behind. In such cases, when they actually
occur, the course of the ball will usually be marked by a line on the
skin, more or less of a reddish-blue color; and the constitutional
alarm, if it should occur at all, will subside early. A ball may,
however, pass under and between the muscular layers of the wall of the
belly, (or run nearer to the peritoneum for several inches,) giving
rise to great anxiety, until the sloughs have separated from the
openings of entrance and of exit, at which parts they prevail to a
greater extent than in the middle of the track of the projectile. In
some few instances an opening will require to be made in the middle of
this track or course of the ball, for the evacuation of pus or of other
extraneous matters which may be detained in it.

When a ball lodges in the wall of the abdomen and is deeply situated,
it sometimes escapes notice, and when found is often better left alone
unless it prove troublesome. When it approaches the surface, it may
be removed if it cause inconvenience. When removed after the lapse of
twenty or more years, I have found some dense cellular membrane forming
a sac around and adhering to the ball, which is usually more or less
flattened and irregular.

378. Injuries of the wall of the abdomen from cuts or stabs affecting
the muscular and tendinous parts are said to be frequently troublesome,
and even dangerous, from their giving rise to pain, vomiting, and
severe general derangement. This only occurs when suppuration takes
place, and, from some accidental circumstance, the matter does not find
a ready exit, but collects between the muscles, or within or under
their aponeurotic sheaths. This is indicated by the pain and swelling
of the part, proceeding sometimes to the formation of an abscess, which
ought to be prevented, if possible, by an early enlargement of the
wound, so as to remove the cause of irritation, and the obstacle to the
free discharge of the secreted matter. If the swelling should become
prominent in a more convenient situation than the spot of injury, it
should be opened at that part.

In these and in all other serious injuries of the abdomen, the
recumbent position, with a relaxed state of the muscles, should
be observed for several days at least. The antiphlogistic plan of
treatment should be fully enforced, especially by leeching, bleeding,
and spare diet, and in due time the part should be supported by a
proper bandage.

The late General Sir John Elley was wounded in the last charge of heavy
cavalry at Waterloo, by the point of a sabre, which entered nearer
the extremity of the ensiform cartilage than the umbilicus, causing
a wound about two inches in length, penetrating the stomach. From
this he recovered in due time without any severe symptoms, but with
a small hernia of that organ, which remained until his death, giving
rise occasionally to some gastric inconvenience when he did not keep a
gentle pressure on it by a retaining bandage.

379. Severe blows, or contusions from falls or from the concussion of
foreign bodies, may give rise not only to injury of the internal parts
of the abdomen, followed by inflammation, but to rupture of the hollow
as well as of the more solid and fixed viscera, and death.

William Fletcher, of the 18th Hussars, a healthy man, thirty-seven
years of age, received a kick from a horse, immediately above the os
pubis, on the 15th of April, 1810, (about a league from Cartaxo, on
the Tagus;) great tension of the belly soon followed, with excessive
pain and vomiting. The pulse rose rapidly. He was bled to syncope
twice during the day, to the extent of sixteen ounces each time. In
the evening he was removed to Cartaxo, and taken into hospital; the
pain continued, accompanied by retching, without much vomiting; the
abdomen was constantly fomented with hot water, and injection was
thrown up, and two ounces of infusion of senna with salts were given
every two hours. In spite, however, of the most active treatment, he
died on the 17th. On dissection, the peritoneum was found to contain a
large collection of fluid, partaking of a fecal character; the bowels
appeared to have suffered to the greatest extent, and a laceration was
discovered in the ileum.

A child, just able to walk, was placed under my care in the Westminster
Hospital, in consequence of its having received some injury on the
side of the belly, from having been tossed up into the air by its
father with his right hand, and caught in its descent in the crutch
formed by the thumb and fingers of the left, on the thumb of which it
unfortunately at last fell; this caused the child great pain, which was
soon followed by considerable swelling and inflammation of the belly,
of which it died. On examination after death, the small intestine was
discovered to have been ruptured by the end of the thumb, from which
extravasation of its contents into the abdomen had ensued.

The first effect of a rupture of the intestine must be the
extravasation of such gas as may be contained in or secreted from it,
giving rise to the sudden swelling, as well as to the sudden effusion,
of part of its contents, but which, from the support of continuity,
and of the general pressure of the abdominal parietes, is perhaps more
gradually poured out. The rapid swelling and tension of the belly is
perhaps then a distinguishing symptom of a rupture of the intestines.

A Spanish soldier was brought to me, near the conclusion of the battle
of Toulouse, in consequence of having been struck obliquely by a
cannon-shot on the right side of the abdomen and back, which appeared
to be badly braised, although no abrasion of the skin had taken place.
The shock was great, however; he was unable to move his limbs, and
appeared likely to die, which he did in fact, in the course of the
night, having passed bloody urine, but without any reaction having
taken place. On making an incision through the skin, which was then
quite a blue black, although not torn, all the soft parts were found
reduced to a state approaching to the appearance of jelly; the spine
was injured, the right kidney ruptured, and the cavity of the abdomen
full of blood.

A soldier of the 40th Regiment was struck by a ricochet cannon-shot,
on the last day of the siege of Ciudad Rodrigo. He saw the ball, which
destroyed his left forearm so as to render amputation necessary,
strike the ground a little distance from him, before he was himself
injured. He thought, from the sort of shock he received, that it had
also struck his belly; but this I should not have credited, if it
had not been for a bruise across the umbilical region without actual
abrasion of the integuments, on which account my attention was drawn
to him on the fourth day after the injury, at the hospital of Aldea
Gallega. He had been bled in consequence of complaining of pain, and
because of the quickness of pulse and the fever which had ensued, and
which were attributed to irritation after amputation. The belly was
swollen and tender under pressure. Calomel, antimony, and opium were
given: he was bled again, and blisters were applied. The stump took
on unhealthy action, and he died a fortnight after the receipt of the
injury. The abdomen, when opened, was found to contain a quantity of
opaque serous fluid, mixed with shreds of coagulable lymph. The omentum
and intestines were of a dark color, and loaded with blood, distinctly
indicating the chronic state of inflammation which had taken place.

If the injury should not destroy the patient, but prove sufficient to
give rise, after several weeks, to effusion into the cavity, the fluid
should be evacuated by the trocar.

When the fixed viscera are ruptured by severe blows, such as those
received by falls or from cannon-shot, the sufferers usually die from
hemorrhage and not from inflammation. The arm has been carried away,
and the liver ruptured without almost a sign of injury to the skin of
the abdomen, death ensuing from hemorrhage.

380. When an incised wound is made through the wall of the abdomen
to any extent, except perhaps in the linea alba, the muscular parts
are rarely found to unite in a more perfect manner than when they are
ruptured and bruised. In those cases in which I have tied the common
iliac artery by an incision on the face of the lateral part of the
abdomen, the patients recovering afterward, the incision through the
muscular wall did not remain united, although union appeared to have
taken place in the first instance, and a herniary protrusion formed in
the course of the greater part of the line of the wound.

The constant occurrence of this non-union, except by skin and cellular
membrane, led me to repudiate the introduction of ligatures through
other parts for the purpose of keeping them in apposition, as it does
not lead to the permanent cohesion of the parts, while it exposes the
sufferers to all the dangers which the irritation of sutures commonly
occasions, thus offering another instance of the improvement surgery
owes to the war in the Peninsula.

Chelius recommends “several flat ligatures to be introduced through
the skin and muscles, the needle being placed close to the muscular
surface of the peritoneum.” Graëfe (section 514) is declared to be of
the same opinion, he recommending, however, that a soft tape should be
substituted for a ligature. Reference is made to Weber in support of
this practice, to which Mr. South, the translator, does not raise any
objection.

381. In all simple wounds of the wall of the belly of moderate extent,
the edges of the wound should be brought together by means of a small
needle and a fine silk thread passed through the skin and the loose
cellular membrane only which is in contact with it, by a continuous
suture without puckering, in the manner a tailor would fine-draw a hole
in a coat. This gives a certain degree of support to the parts beneath;
and if proper attention be paid to maintain a well-regulated, relaxed
position of the muscles, no great separation takes place in wounds of a
reasonable extent, and little or none in a wound of smaller dimensions.
An effective support should be also given by strips of adhesive plaster
extending to some distance around the body; a bandage rarely does good,
and will assuredly do mischief, unless it be very carefully applied and
watched, so as only to give support and not to make undue pressure. The
position of the patient is of the greatest importance; its essential
object is to bring the edges of the incision, and especially of that in
the peritoneum, as nearly as possible in apposition, so that the space
between them may be more easily filled up by the opposing peritoneum
forming the anterior layer of the omentum, or by the outer covering
of the intestine if the omentum should not intervene. This is to be
effected by the gentlest inclination of the body toward the wound which
may be supposed capable of keeping these parts in apposition; for
although the omentum and intestines are often capable of undergoing
a considerable degree of motion from side to side, independently of
that peculiar wormlike movement on themselves which in the intestines
is called peristaltic, they very frequently do not wander from place
to place in the manner which has been sometimes attributed to them,
but remain, under proper care, so far stationary as to admit of the
cut edges of the wounded peritoneum adhering to the healthy peritoneum
opposed to them, when they will be retained in contact with it. The
serous surfaces of the peritoneum which are in contact with each
other soon offer on one part, and accept on the other, the process
of adhesion through the medium of lymph or fibrin deposited between
them. If this adhesion take place, it extends for some little distance
from the wounded part, which it thus closes up and cuts off from all
communication with the general cavity of the belly; the previous
admission of air--the bugbear of surgeons of the olden times--being
of no sort of consequence. The adhesive process is the effect of
inflammation extending to a certain point, and ending in the deposition
of fibrin. When it exceeds this, the secretion of a quantity of serous
fluid, together with threads of flocculent matter, marks the excess of
inflammation; it is diffused over more or less of the peritoneum lining
the wall of the belly, covers its contained viscera, and prevents that
adhesion from taking place which is the safeguard of the patient.

382. Absolute quietude is no less to be observed. It must, however,
be steadfastly continued; the slightest alteration of position should
be forbidden. Motion should not on any account, nor for any reason
whatever, be allowed, if it can by any possibility be avoided. In
the position in which the patient is placed he should be rigorously
maintained until adhesion has been effected or all hope of it has
passed away. The practice of the older surgeons was to purge such
persons vigorously, in order to remove from their bowels any peccant
matters that might be in them; in the same manner they recommended
persons should be purged who had undergone the operation for
strangulated hernia--both which proceedings the experience of the
war enabled me to condemn, as being not only contrary to the right
medical treatment of such cases, but to the physiological and surgical
principles on which it ought to be founded, a condemnation the accuracy
of which is now universally admitted, although the source from which it
is derived is not so universally acknowledged. No purgative medicine
whatever should be given to a person with a penetrating wound of the
abdomen. No food should enter his mouth; and no more water even should
be allowed than may be found requisite to moisten the lips and allay
any intolerable thirst which may ensue. This precaution need not be
carried out so strictly if it could be readily ascertained that an
intestine was not wounded; but as this knowledge, however satisfactory
it would be, cannot always be obtained, and ought not in the generality
of instances to be sought for, the restriction should be fully observed
if possible. In all cases of injury of the belly there is more or less
shock, alarm, and anxiety. It is sometimes remarkably great, even
when the mischief has not been considerable. When little or no injury
has been inflicted on the intestines, the natural and usual action of
expelling the contents is generally delayed beyond the time at which
in health it would in all probability have occurred. When nature shall
point out by the sensations of the patient an inclination to perform
this function, it may be assisted by an injection of warm water or
of any mild laxative which may facilitate the process and prevent
any unnecessary action of the abdominal muscles, against which the
patient should be cautioned. The attendants should be forewarned that
the position of the patient is not to be interfered with under any
circumstances, the necessary arrangements being made by bedsteads of
a proper construction, or by other simple means which are sufficiently
well known.

383. The custom of directing a man to be bled forthwith, as well
as purged, because he has been stabbed, was another error much in
esteem by the older surgeons, but which experience did not sanction,
and it could not therefore be approved. The abstraction of blood
before reaction has taken place delays its occurrence as well as the
commencement of that inflammatory stage which is to be so salutary in
its result in favorable cases. It tends to prevent the agglutinative
process from taking place, and thus aids the diffusion of inflammation
over the whole surface of the peritoneum. The general abstraction of
blood is to be ordered, and regulated as to quantity by the symptoms
of inflammation which may accompany or follow reaction. The quantity
of blood required to be taken away in these cases is usually large,
particularly at an early period. With the army in the Crimea, the
abstraction of large quantities could not in general be borne and has
not been found serviceable, nor has it been found so necessary to
repeat the bleedings as in persons more favorably situated. It is,
however, often a nice point to determine when blood enough has been
abstracted with advantage, as too much may be taken away as well as too
little--the former being marked, after death, by the general diffusion
of a slight degree of inflammation, without the concomitant sign of
effusion of serum. Leeches applied in considerable number will often be
found more beneficial, particularly at a late period, when the sufferer
may not be able to bear a general abstraction of blood. The patient,
after leeches have been once applied and their good effect has been
ascertained, will often ask for them himself on the recurrence of pain
or on its increase; and from twenty to sixty, or even eighty, may be
applied in some instances of great danger with advantage.

The pulse is by no means a guide in the management of these cases; a
small, low, and sometimes not even a hard pulse being more strongly
indicative of an overpowering state of inflammation than is a quick
and full pulse; much more depends on the pain, the anxiety, and the
general oppression than on the apparent state of the circulation.
Before general and local bleeding cease to be employed with advantage,
calomel, antimony, and opium will render essential, nay, most
important, service.

The extensive incisions made of late years into the abdomen for the
removal of ovarian tumors, with fair success, confirm what I have
constantly repeated in my lectures for the last thirty-five years, that
penetrating wounds of the abdomen, without injury to the viscera, when
properly treated, are not so dangerous as they were generally supposed
to be.

384. In penetrating wounds of the belly, the offending instrument
frequently passes in for a considerable distance, sometimes separating
or pushing the viscera aside without injuring them, at others
inflicting upon them wounds more or less severe. In fatal cases of
stabs from knives and sharp instruments, the intestines have been
usually injured by the point, although when the lapse of three or four
days before death takes place, the small wound is not readily perceived.

W. Carpenter, private, 1st battalion, 43d Regiment, was accidentally
wounded, March 19th, 1812, by a comrade, the small end of a ramrod
entering about two inches below the navel, passing in a direction
upward, penetrating the second lumbar vertebra, and protruding an inch
and a half on the opposite side.

On examining the wound, the ramrod was found firmly fixed in the bone.
It was endeavored at first to extract it by a gentle turn, making
extension at the same time, but this failed. Force was then applied on
the opposite side, by fixing the broad end of a ramrod on the point of
the protruding one, which was laid bare by an incision, when by a smart
stroke with a stone it was driven back and removed. Bleeding to twenty
ounces.

March 20th.--Has slept several hours during the night; passed urine two
or three times; suffers slight pain occasionally on turning himself in
bed; has the perfect use of his lower extremities; pulse rather full;
skin cool; repeat bleeding to twenty ounces.

22d.--No evacuation since the 20th; pulse rather full; bleeding to
twenty-two ounces; sulphate of magnesia, one ounce. Seven o’clock A.M.:
Medicine operated three or four times; feels no pain in passing water.

23d.--Has passed a good night; wounds dressed; is allowed a small
proportion of bread with his tea.

28th.--So far recovered as to be able to be removed to Elvas.[5]

That a blunt instrument, like the small end of a ramrod, should be
forced between the loose viscera of the abdomen without wounding any
of them, may be easily conceived, but that balls or sharp-pointed
swords should do so, is not to be understood so easily. Ambrose Paré,
our own Wiseman, Ravaton, Lamotte, Muys, and others, however, have
related instances of this kind, in which the patients recovered in an
inconceivably short space of time; but these and other recoveries of a
similar nature must be considered as exceptions to general rule.

[Footnote 5: He marched with his regiment, in the summer, to
Valladolid, and was drowned in the Douro.--G. J. G.]

385. Wounds penetrating the wall of the belly, when made by cutting or
lacerating instruments, or by musket-balls, are usually followed, if
to any extent, by a protrusion of some portion of the contents of the
cavity, generally of the omentum or intestine, if not of both. This
may take place at the rounded orifice of entrance of a ball, as well
as at the more slit-like opening of exit, which, if the patient should
recover, becomes closed by a thin tendinous-like expansion, under the
cicatrix formed by the common integuments. These soon yield to the
general pressure on the abdominal cavity, and admit of the formation
at the part of a ventral rupture, requiring the application of a
restraining bandage.

386. When a piece of omentum only protrudes, the direction given by
the latest writers on surgery is, that it shall be returned into the
cavity of the abdomen whence it came, the finger following to ascertain
that it is quite free; after which the wound is to be carefully closed
by sutures applied close to the peritoneum, so that the omentum
may not again protrude through it. Having objected already to the
manner of employing the suture, I now object to the treatment of the
omentum, and do not approve of its being so dextrously returned by
the finger within the peritoneum to its natural loose situation. I
desire, on the contrary, that it may be retained between the cut edges
of the peritoneum, but without the slightest pressure or possible
strangulation, in order that by its retention it may more readily
adhere to these edges, and thus form a more certain barrier against the
extension of inflammation than is likely to take place when moving
at liberty in the cavity of the abdomen, however closely it may be
supposed to be applied to the inner surface of its paries.

It sometimes happens that a portion of omentum is altogether without
the cavity of the abdomen, and the opening through which it has
protruded seems too small to allow its restoration to the cavity.
The latest authors on this subject recommend a blunt director to be
introduced between the upper edge of the wound and the protruded
part, be it omentum or intestine, or both, upon which a blunt-ended
bistoury is to be passed into the cavity as far as the enlargement of
the wound seems to require, after which the director and the bistoury
are to be withdrawn together. I altogether dissent from this. It is
scarcely ever necessary to enlarge the opening in the peritoneum,
the obstacle to reduction being situated in the tendinous expansion
or aponeurosis of the wall of the belly, a slight division of which
will give sufficient space for the restoration of the protruded part
in almost every instance. I have unavoidably opened into the cavity
of the peritoneum, and have seen it done in other instances, but no
inconvenience follows small openings not exceeding a quarter of an inch
in length, when they are properly covered over by the healthy parts.
It is therefore important in all cases to have as small an opening as
possible in the peritoneum, and certainly no addition should be made to
the size of a small opening if it can by any possibility be avoided,
however indifferent half an inch, more or less, may be in the length of
a large one. All protruded parts, whether omentum or intestine, should
be gently cleansed with warm water, and the fingers of the surgeon
should be wetted in a similar manner, the mesentery being returned
first if protruded, then the intestine, and lastly the omentum; the two
former under all circumstances; the latter not so, if it be adherent
or inflamed, torn or jagged, or in a state of suppuration or gangrene.
It should in these cases be left to itself, and treated in the most
simple manner; a ligature should never be applied to it, neither should
it be spread out and cut off, as was formerly recommended, as it will
gradually retract and be withdrawn into the cavity of the abdomen. If
suppuration should take place in its substance, and the swelling of the
part lead to its constriction, or the formation of matter under the
integuments or between the layers of muscular or tendinous fibers,
these may be carefully divided.

Evan Thomas, aged seventeen, was admitted into the Westminster
Hospital, Sept. 1st, 1828, having been stabbed with a dinner-knife
immediately above the umbilicus; the wound was three-quarters of an
inch long; the omentum protruded and could not be returned until the
skin, cellular membrane, and fascia had been divided; the opening in
the peritoneum was then distinctly seen, against the inside of which
the omentum was left, the wound in the skin being sewed up by the
continuous suture. In the evening he was bled to sixteen ounces, and,
as he had thrown up his dinner, an enema only was administered. On the
2d, the belly being tense and slightly painful, although he was not in
constant pain, the blood drawn before being buffy, twenty-two ounces
more were taken away, a purgative enema administered, and, as the bowel
was not believed to be injured, four grains of calomel and six of the
compound extract of colocynth were given, with a draught of senna and
salts every four hours. 3d. The bowels open; no pain and scarcely
any uneasiness on pressure; abdomen soft. No food; barley-water and
gruel; pulse 84. On the 6th the sutures were removed, the wound having
reunited. He was then made an out-patient, having a comfortable home.

A soldier of the Second Division of Infantry received several stabs
from a lance in different parts of the body, at the battle of Albuhera,
as the lancers rode past him, while lying on the ground, one only being
of any importance: it was on the right side and lower part of the
belly, and through it a portion of omentum protruded. On this being
reduced, the epigastric artery, which had been divided, bled freely; a
ligature was readily applied, and the wound closed by the continuous
suture. The patient, after undergoing a very rigorous treatment,
recovered.

A Spanish soldier was wounded in a scuffle in Madrid, in 1812, at
the gate of the British Hospital, near the Prado, into which he was
brought, with a wound on the right side of the abdomen, near and below
the umbilicus, through which a portion of omentum protruded about
the size of a small orange. As this could not readily be returned, I
carefully enlarged the wound at its under part, some three or four
hours afterward, by dividing the skin, and then found that it was
the aponeurotic or tendinous expansion of the muscles going to form
the sheath of the rectus, which prevented the return of the omentum
into the belly; on the division of this part it slipped back without
difficulty, but as it did not recede further than the peritoneum I
left it there, and closed the wound, which was about an inch long, by
sewing it up in the manner described. He was bled and starved, and was
delivered up to the proper authorities out of danger, with his wound
nearly healed, when the army evacuated the place.

A Spanish soldier was wounded at the battle of Toulouse by a
musket-ball, which passed in on one side and came out at the other,
carrying with it a portion of omentum which gradually became as large
as an orange, in which state I saw it four days after the accident.
Little had been done; he had not suffered much pain, although the
abdomen was tender; he had vomited; passed blood with his motions;
was feverish and ill. I visited this man every three or four days;
he suffered from privations of every kind, yet each time I found him
better. The protruded omentum gradually diminished in size, and was at
last drawn into the wound in the abdomen and covered by granulations.
He left Toulouse before me, nearly well.

If the omentum be greatly bruised or injured it may be cut off, and the
vessels tied if bleeding; but it should not be returned further than
the edges of the peritoneum, over which the external wound is to be
closed.

Ravaton wrote a hundred years ago: “The views of a surgeon must be
very confined who advises the application of a ligature to the omentum
when protruding from the cavity of the belly in a healthy state. It
is a cruel and deadly maneuver, contrary to reason and experience.
To restore it to its place is so simple, just, and reasonable, that
I am surprised it does not occur to every one. The reduction is
easily effected. It is sometimes difficult to retain the reduced part
except by sutures. I admit that when the omentum is strangulated,
gorged with blood, black, and about to become gangrenous, the result
of its restoration to the cavity may be doubted: yet experience has
demonstrated that it is the safest mode of proceeding, taking care not
to close the wound entirely, but to leave an opening at the lower part
to give vent to any effusion or suppuration that may take place.”

387. When a portion of intestine is protruded without being wounded,
it is to be returned, whatever may be its state, unless it be soft
and unresisting between the fingers, of a dull blue or black color,
and to every surgical eye deprived of life or mortified. At any state
previous to this (to Englishmen) almost certainly fatal condition, it
should be restored into the cavity of the abdomen. When a portion of
intestine is thus returned, three directions are given by most modern
surgeons, and especially by Chelius, section 517, on which his English
editor makes no comment; and which may therefore be considered to be
those which are commonly taught in London, but of which I entirely
disapprove. The first is, that the peritoneum is to be divided in cases
where an obstacle is interposed to the return of the intestine; this I
aver to be less necessary for the intestine than for the omentum. The
second is that, “after the reduction, the forefinger must be introduced
into the cavity of the belly in order to ascertain that the intestines
have not passed into the interspaces of the muscles”--a precaution
which is unnecessary, and may do much mischief. The third is, that the
patient is then to be placed “in such a posture as that the intestines
should least press against the wound,” to which direction I object. The
surgeon should certainly take care that the intestine does not pass
between the layers of muscle, nor anywhere else than into the cavity of
the belly. So far, however, from the intestines being pushed away from
the cut peritoneum, the most favorable position for it would be to be
applied against the edges of the cut membrane, and even rising up for
the least possible distance, without or above it, the great object to
be desired being to facilitate adhesion by as perfect an apposition of
these parts as possible, while the external wound is accurately closed
by the continuous suture, and duly supported by adhesive plaster,
compress, and a bandage, provided it be methodically applied. The next
best thing which can happen is that, every part being relaxed, and the
patient perfectly quiescent, the intestine should press so steadily and
yet so gently against the wounded peritoneum that it will be kept in
constant apposition with it without protruding through it.

A soldier of the Artillery was stabbed in two places, in 1812, with a
long knife, by a townsman, late in the evening, and was carried into
the hospital for the sick and wounded French prisoners in Lisbon. The
wound in the belly was situated somewhat more than an inch to the right
side of the umbilicus, and was about an inch in length from above
downward; through it a considerable protrusion of small intestine,
without any omentum, had taken place. This was distended by flatus,
and of a dark-brown color when I first saw it, some time after the
receipt of the injury. The bowel being constricted by the tendinous
expansion of the muscular fibers, the latter was carefully divided by a
blunt-pointed curved bistoury passed under its upper edge, and resting
on the back of the nail of the forefinger, by which the intestine was
guarded; the flatus having been pressed out of the intestine, which
was gently washed with warm water, it was restored to the cavity of
the abdomen. Of the part which had apparently first protruded, the
peritoneal coat and a few fibers of the longitudinal layer of muscle
were divided to the extent of half an inch, the remaining portion of
the gut being unhurt. The skin was then sewed up by a fine continuous
suture, and adhesive plaster and a compress duly applied. A good deal
of alarm was evinced, the pulse was very small, and the man faint.
The other wound was in the back, about half an inch in extent, and
near the inferior angle of the right scapula. It appeared to be a
penetrating wound, but not giving rise to any peculiar symptoms, he
was placed in bed on his back, with his legs raised, and the body
slightly bent. Early the next morning, the officer on duty found it
necessary to bleed him largely, to forty ounces, according to my
directions, on account of pain which had come on in his bowels and in
his back, accompanied by difficulty of breathing, the skin being hot
and the pulse quick and hard. The cellular membrane around the wound
in the back was emphysematous; there was a slight cough, accompanied
by an expectoration slightly tinged with blood. The bleeding removed
the essential symptoms, but the pain and difficulty of breathing
returning next day, it was repeated to eighteen ounces, with an equally
good effect. It was necessary to repeat it on the third, fourth, and
fifth days, when the pain ceased to return, and the pulse, instead
of being small and hard, became softer and fuller. The bowels were
open naturally on the third day, and the emphysema had gradually
disappeared, no food being allowed, and very little drink for some
days, and then only in small quantities of the simplest kind. The
threads were removed with scissors on the sixth day, and the man was
free from complaint, although very weak, at the end of five weeks.

Madame Doucet was applied to a hundred years ago, by a soldier, who
having been struck by a halbert, had a wound made across his abdomen
from above the ilium, through which a quantity of intestine protruded,
which he carried in his hat, enveloped in his shirt. Having had to walk
between three and four miles, in the heat of July, to the old lady, his
bowels were as dry as parchment by the time he arrived. She therefore
bathed them in warm milk and water until they became soft and natural
in appearance, returned them into the cavity of the belly, and sewed
up the wound with a well-waxed silken thread--thus setting an example
which ought to be followed in 1855. The man recovered.

388. When the protruded intestine is wounded, the case is complicated,
and much depends on the size of the wound. A mere puncture, or a
very small cut, is often of no consequence, and does not require any
treatment; the bowel should merely be returned to the cavity of the
belly, and the symptoms of inflammation closely watched, and, if
possible, steadily subdued.

It is advisable, in investigating this subject further, to consider the
abdomen as devoid of cavity during life and health, the contained parts
being so gently pressed upon by the containing and retaining muscular
parietes around as to enable them all to carry on their ordinary
functions, unless suffering from some derangement, exclusive of that
which might arise from a deficiency of the pressure usually exercised
upon them; but that this pressure can, or generally will, prevent the
effusion of the contents of a bowel when ruptured, if the wound be half
an inch in length, or that it will prevent the extravasation of blood
from an artery or vein of moderate dimensions, if torn, is contrary to
facts now considered indisputable, as I have frequently had occasion
to verify. That a mere puncture of the intestine does not allow the
effusion of air, much less of the contents of the bowel, is not
doubted. When the contents of the bowel have been poured out, without
an external opening in the paries through which they might escape,
inflammation and death have ensued at no long distance of time. When
blood is poured out from the great vessels, as in rupture of the liver
or spleen--of which instances will be adduced--the general cavity may
be filled; but when the injury is less extensive, or the lesion less
important, the blood usually gravitates toward the back or sinks into
the pelvis. It is possible that blood may be effused in small quantity,
and be then confined, under the general pressure of the wall of the
abdomen and the resistance offered by its contents, to a particular
spot, whence it may be absorbed after coagulation; or, by commencing
decomposition, give rise to irritation, and be discharged through the
external wound, if one exist, or through the bowel with which it may
happily be in contact.

A soldier, belonging to the Second Division of Infantry, was wounded
by the Polish Lancers at the battle of Albuhera, in several places
slightly, and in the abdomen severely, a penetrating wound having been
made an inch long, between the umbilicus and the crest of the ilium on
the left side. Brought to me the day after at Valverde, the edges of
the wound were stitched together and dressed simply. He said it had
bled freely at first, and was then painful. Treated antiphlogistically
and sharply, the inflammatory symptoms gradually subsided. The bowels
were relieved by gentle aperients, there being no reason to suppose
they had been wounded. A small, oval swelling was soon perceived under
the wound, which was tender to the touch, indicating mischief of some
kind. The edges of the wound, which did not unite fully, although
they were retained in contact, at last separated, and allowed about a
wineglassful of bloody matter to pass out, which reduced the swelling
and removed the uneasiness and pain of which he complained. After this
he gradually recovered, and was discharged to Elvas, and thence to
Lisbon.

389. Whenever large effusions of blood have occurred, the sufferers
have usually been lost, from the occurrence of peritoneal inflammation.
That small ones may be absorbed, cannot be doubted. I have seen
instances of their having been discharged by the bowel, although I have
never been so fortunate as to see a general formation of matter from
effusion, and to have opened the abdomen for the evacuation of its
contents with success; nevertheless, I do contemplate that such cases
may occur, and surgery may come to their relief with good effect.

The important conclusions to be deduced from the observations of
those who have made experiments on the intestines of living animals
are--First, that wounds not exceeding four lines in length, (or the
third part of an inch,) no matter what their direction may be, are not
so apt, as might be supposed, if left to themselves, to be succeeded by
extravasation of the contents of the intestinal tube; and that, in the
majority of cases, nature, properly aided by art, is fully competent to
effect reparation. Secondly, that wounds of the bowels to the extent
of six lines, whether transverse, oblique, or longitudinal, are almost
always, if not invariably, followed by the escape of the contents of
the bowel, and the consequent development of fatal peritonitis. It may,
therefore, be concluded, from experiments made on animals, as far as
they can be relied upon with reference to man, that every wound in the
bowel, of such an extent as shall not admit of its being temporarily
filled up by the protrusion and eversion of its internal or mucous
coat, which always takes place as an effort of nature to close the
wound, ought, if possible, to receive assistance from art, and that can
only be given with advantage in the first instance.

Mr. Travers tied a thin ligature firmly round the duodenum of a living
dog; the ends were cut off, the parts returned, and the external wound
properly closed. On the fifteenth day, the cure being completed, the
dog was killed. A portion of omentum, connected with the duodenum, was
lying within the wound, and the folds contiguous to the tied part of
the intestine adhered to it in several points. A slight depression was
observed around the duodenum, the internal or mucous surface of which
was more vascular than usual; a transverse fissure marked the seat of
the ligature. “The lymph,” Dr. Gross observes, “which is effused upon
the external surface of a bowel, consequent upon such an operation,
gives the part at first a rough, uneven appearance; but, if the animal
survive several months, it is generally no easy matter to determine
the seat of the injury from the external appearance of the part.
Internally, the cicatrization is almost as complete, the continuity of
the mucous membrane being everywhere established, leaving scarcely even
a seam at the original seat of constriction. The rapid manner in which
the ligature cuts its way from without inward obviates the evils which
might arise from the occlusion of the passage. In an experiment, in
which the dog was killed upon the eleventh day after the application of
the ligature, the canal of the bowel was completely restored, and the
bond of connection between the divided parts was firm and organized.”

Similar effects are produced when a small ligature is applied around
the edges of a wound from two to three lines in diameter, provided
it be drawn with sufficient firmness not to slip off. The process of
reparation is not, however, so speedily completed, owing to the breach
being much wider than when a ligature is simply placed around the tube.
The mucous membrane requires a longer period for its reproduction, and
the quantity of lymph deposited around and inclosing the ligature is
proportionally greater.

390. The idea of sewing together, and thereby restoring the continuity
of a wounded bowel, is attributed to four master surgeons, as they were
called, of Paris, in the thirteenth century, who, having united their
efforts for the relief of the sick poor in that city, procured, it is
said, a portion of the trachea of an animal, one end of which they
introduced into the upper part of the divided bowel, and the remaining
piece into the lower, and then brought the divided ends into contact,
and retained them by as many sutures as appeared to be necessary. Their
writings, in which this operation is described, are lost. Peter de
Argelata, who lived about the middle of the fifteenth century, says
that Jemerius, Roger, and Theodoric supported the intestine by a canula
of elder-wood, while Gilbert de Salicetti condemns both the use of the
trachea and the elder-wood tube, and recommends, if anything be used,
that it should be the dry and hardened bowel of some animal. These
ancient surgeons believed that a transverse division of the intestine
was necessarily a fatal injury, and only resorted to the methods they
recommended when the division was less complete. Duverger de Maubeuge,
in the beginning of the eighteenth century, apparently unaware of what
had been done before his time, brought forward this method of the four
masters as an invention of his own. He cut off a portion of mortified
intestine in a case of strangulated hernia, introduced a piece of the
trachea of a calf, brought the divided intestine over it, and fastened
it by a suture. The trachea was passed on the twenty-first day, and the
external wound was closed by the forty-fifth, the patient recovering.

Ramdohr, a German surgeon, who lived in the early part of the last
century, seems to have been the first to join the ends of a divided
bowel by introducing the upper end within the lower. He removed two
feet of mortified intestine in a case of strangulated hernia--performed
this operation on the ends of the bowel, retained the parts by
stitches, and his patient perfectly recovered. Heister says the
mortified parts were in his possession. (Haller, _Disputat. Anatom._,
vol. vi., _Observ. Med. Miscel._, 18.) Since his time, many of the
most eminent surgeons of France, Italy, America, and Great Britain
have turned their attention to this subject; but the conclusion at
which I have arrived is that the continuous suture is, in all cases of
serious injury, the most simple and the best.

391. In making a continuous suture, a fine needle and a waxed silken
thread should be introduced through the gut, beginning on the inside
close to one end of the cut part, and bringing it out on the peritoneal
surface a little more than a line distant from where it entered. The
needle is then to be carried to the opposite side through the bowel
from without inward, and the sewing thus continued until completed,
each stitch being about the sixth part of an inch asunder, and about
that distance from the edge of the cut. The threads or stitches
should not be drawn close until the whole are inserted, when, on
being drawn moderately tight one after another, the cut edge of the
intestine should be turned inward by a blunt probe, so that the
peritoneal surfaces shall be in contact under the stitches and in the
best situation for union, the mucous coat forming a ridge within, the
outside being perfectly smooth, the stitches not being too tight, while
the end may be secured by a knot made by a turn of the thread over the
needle. This done, the intestine should be returned into the cavity
of the abdomen, and events awaited. Recoveries more frequently follow
wounds of the colon than of the jejunum or ilium; but the result must
always be doubtful, being dependent on many causes which the surgeon
can neither foresee nor control.



LECTURE XXVIII.

TREATMENT OF INCISED WOUNDS, ETC.


392. When an incised wound in the intestine is not supposed to exceed a
third of an inch in length, no interference should take place; for the
nature and extent of the injury cannot always be ascertained without
the committal of a greater mischief than the injury itself. When the
wound in the external parts has been made by an instrument not larger
than one-third or from that to half an inch in width, no attempt to
probe or to meddle with the wound, for the purpose of examining the
intestine, should be permitted. When the external wound has been made
by a somewhat broader and longer instrument, it does not necessarily
follow that the intestine should be wounded to an equal extent; and
unless it protrude, or the contents of the bowel be discharged through
the wound, the surgeon will not be warranted in enlarging the wound
in the first instance to see what mischief has been done. It may be
argued that a wound four inches long has been proved to be oftentimes
as little dangerous as a wound one inch in length; yet most people
would prefer having the smaller wound, unless it could be believed that
the intestine was injured to a considerable extent. Few surgeons, even
then, would like to enlarge the wound to ascertain the fact, unless
some considerable bleeding or a discharge of fecal matter pointed out
the necessity for such an operation. When the wounded bowel protrudes,
or the external opening is sufficiently large to enable the surgeon to
see or feel the injury by the introduction of his finger, there should
be no difficulty as to the mode of proceeding.

393. A puncture or cut which is filled up by the mucous coat so as to
be apparently impervious to air does not demand a ligature. An opening
which does not appear to be so well filled up as to prevent air and
fluids from passing through it cannot usually be less than two lines
in length, and should be treated by suture. When the opening is small,
a tenaculum may be pushed through both the cut edges, and a small
silk ligature passed around, below the tenaculum, so as to include
the opening in a circle, a mode of proceeding I have adopted with
success in wounds of the internal jugular vein without impairing its
continuity; or the opening, if larger, may be closed by two or more
continuous stitches made with a very fine needle and silk thread, cut
off in both methods close to the bowel, the removal of which from the
immediate vicinity of the external wound is little to be apprehended
under favorable circumstances. The threads or sutures will be carried
into the cavity of the bowel, as has been already stated, if the person
survive, and the external part of the wounded bowel will either adhere
to the abdominal peritoneum or to one or other of the neighboring parts.

When the intestine is more largely injured in a longitudinal or
transverse direction, or is completely divided as far as or beyond the
mesentery, the continuous suture is absolutely necessary.

394. When the abdomen has been penetrated, and considerable bleeding
takes place, but not from the intestine, it is necessary to look for
the wounded vessel. When it comes from one of the mesenteric arteries
or from the epigastric, the wound is to be enlarged until the bleeding
artery be exposed, when ligatures are to be placed on its divided ends
if they both bleed, the external wound being accurately closed. I have
seen the epigastric artery tied several times with success.

A Portuguese caçador on picket was wounded at the second siege of
Badajos in a sally made by some French cavalry. He had three or four
trifling cuts on the head and shoulders, and one across the lower part
of the belly on the right side. He bled profusely, and, when brought
to me, had lost a considerable quantity of blood which came through
a small wound made by the point of a sabre. This wound I enlarged
until the wounded but undivided artery became visible; upon this
two ligatures were placed, and the external wound was sewed up. The
peritoneum was open to a small extent, but the bowel did not protrude;
and the patient (not being an Englishman, and therefore not so liable
to inflammation) recovered after being sent to Elvas.

A soldier of the same regiment, cut down at the same time, died as soon
as he was brought into camp, having been severely wounded in the chest
and abdomen. He was said to have died from hemorrhage, from a wound in
the belly, two inches in length, made by one of the long-pointed swords
of the French dragoons. I had the curiosity to enlarge the wound, and
found one of the small intestines had been cut half across, another
part injured, and that the blood came from an artery which had been
opened by the point of the sword in going through the mesentery, which
wound had caused his death.

395. When this operation cannot be done successfully or with advantage
to the patient, whose life is in jeopardy from the continued drain,
the wound should be closed by suture, and a compress laid over it and
retained by a bandage methodically applied for the purpose of aiding
the muscular parietes in keeping up that pressure on the viscera which
may be useful in arresting the flow of blood from the wounded part. If
the bleeding continue, or, having been arrested, should recur, and
the belly become in consequence distended, the sutures being evidently
so tense as to be likely to cut their way out, or if the blood should
ooze out between the stitches, they may be in part removed in order
to give immediate relief. When the belly becomes very painful, tense,
and manifestly full after a punctured wound, and not tympanitic from
the extrication of air or the distention of the bowel by it, the wound
should be enlarged to allow the evacuation of the extravasated blood,
which cannot be absorbed when in such quantity. The orifice of a small
gunshot wound, which is not sufficiently direct to communicate with the
cavity and to allow the issue of blood extravasated in the quantity
alluded to, should be enlarged to such an extent as to effect that
object.

396. Blood effused in moderate quantity, and circumscribed by the
pressure exercised upon the contents of the abdomen by its parietes,
may readily be evacuated by the wound, provided it be sufficiently
open; and the patient may recover, if the inflammation which must
necessarily ensue should not be communicated along the peritoneum
throughout the cavity, or if it should be subdued in time. If the blood
be in small quantity, it coagulates, and may be absorbed; but if in
such a quantity as cannot be absorbed, or from any other cause which
may prevent its removal by this means, it becomes after a time a source
of irritation, and nature sometimes commences early to cut it off from
the general cavity by surrounding it with fibrin--a result which,
however desirable, can rarely be expected.

When extravasated blood is thus cut off from the general cavity, and
cannot be absorbed or be by accident carried off through an opening
in the bowel, a change takes place by which it ceases to be bland
and harmless, and causes it to excite inflammation and its ordinary
consequence, suppuration, if the patient survive so long. This
occurs, for the most part, after the first inflammatory symptoms
have subsided, from the tenth to the twelfth, or even to a later,
day, when the renewal of irritation is accompanied by an increase of
the general symptoms, by a more local pain, and by a circumscribed
swelling of some part near the wound, in which fluctuation may perhaps
be distinguished even during the existence of the general tenderness
of the whole abdomen. Under such circumstances, when it is proposed
to make an incision into this part, if it should be thought advisable
to do such an operation, it may safely be preceded by an exploring
needle or a very fine trocar and canula, which will demonstrate the
fact of the purulent and sanious depot, without doing in such a case
perhaps any mischief, if the expectations of the surgeon should not be
realized. If the exploring needle should show that a bloody, purulent,
or other fluid is really distending the abdomen, no doubt ought to be
entertained about enlarging the original wound and making a depending
opening.

Ravaton, in his twenty-fifth observation, relates the case of a soldier
who was wounded five days before by the point of a sabre, to the
right of the umbilicus. When the man was brought to him, the belly
was swollen, hard, and very painful, with vomiting, hiccough, etc.,
announcing the approach of death. Believing that the abdomen contained
a fluid, either effused or secreted, he made an opening into the cavity
immediately above Poupart’s ligament or the outside of the internal
opening of the ring of the right side, when, finding that nothing came
from the cavity, he passed his finger upward along the iliac vessels,
and, after tearing up some membranous adhesions, evacuated a pint of
coagulated blood and fetid, serous fluid. He then introduced a dossil
of lint into the wound to keep it open, fomented and oiled the belly,
round which he applied a bandage, and placed the patient on his face.
The bad symptoms diminished during the night, and the patient declared
himself better in the morning. From the fifth to the tenth day of the
wound he was in extreme danger. On the eleventh, the bed was inundated
with a purulent matter of an almost insupportable smell. The cavity
of the abdomen was injected and cleansed, the ordinary dressings
applied, and the greatest cleanliness observed. He was subsequently
dressed three times a day in a similar manner; portions of omentum
were occasionally drawn away with the forceps. His strength was well
supported by every kind of nourishment. The night-sweats continued
until the thirty-third day, and on the seventy-second he was discharged
from the hospital, cured. The discharge at first was serous, and only
became purulent on the sixth day after the operation.

Thomas M’Mahon, 76th Regiment, aged twenty-two, was admitted into
the Garrison Hospital, Portsmouth, upon the 13th of June, 1845, with
all the symptoms of strangulated inguinal hernia of the left side,
of two days’ standing, for which the usual operation was performed.
Everything went on favorably till the morning of the fourth day after
the operation, when he made a sudden effort to go to the close-stool,
which was immediately followed by the descent of a considerable portion
of intestine and omentum, accompanied with profuse hemorrhage from a
small artery on the surface of the intestine, which was taken up and
tied, and the parts returned into the abdominal cavity. The greatest
excitement followed, with all the symptoms of acute inflammation.
These were treated by general bleeding to the extent of fifty ounces,
and sixty leeches to the abdomen, with other antiphlogistic remedies.
On the morning of the seventeenth day from the performance of the
operation, a piece of intestine came away with the fecal contents of
the bowels, after which the patient experienced relief in all his
symptoms, and appeared to gain health and strength, and after a time
the wound seemed disposed to close, three weeks after the sloughing
of the intestine. On the sixth day afterward the evacuations ceased,
attended with acute tenderness of the abdomen, which began to swell
fast. The means adopted had not the slightest effect, and the patient
was considered past relief, unless it could be obtained by an external
opening. I accordingly made an incision over the site of the former
wound, and carefully opened the intestine, to the extent only to
allow the tube of the stomach-pump to be inserted, when there was an
immediate discharge of flatus and some feculent matter, and the patient
expressed himself relieved. By the further use of the stomach-pump
apparatus, I was enabled to extract a quantity of feculent matter by
the artificial opening, and after some hours the patient was completely
relieved from the dangerous symptoms he was suffering from. The
artificial opening was left patent for two months, when the bowels
again gave evidence of acting naturally. The artificial wound was not,
however, closed till the 22d of August, 1845; a week after the bowels
appeared to act freely and naturally.

The patient from this time got well and strong, and was discharged to
his duty on the 10th of October, 1845, since which period he continued
to perform all the duties of a soldier most efficiently, without
experiencing any inconvenience to his general health or constitution,
until the 6th of October, 1846, when he died of inflammation of the
brain, at Fort George, in Scotland. On dissection, the abdominal
viscera, including the intestinal canal, appeared perfectly healthy;
but on a minute examination of the portion of small intestine (found
to be the ileum) situated in the inguinal region of the side operated
upon, directly opposite to the cicatrix of the external wound, it
was discovered to be firmly attached to the abdominal parietes, by
an adventitious membrane, to the extent of two lines, which then
diverged, and formed itself _into a canal of a funnel shape for about
five inches and a quarter in length, of a homogeneous structure, which
united itself with the continuous intestinal tube_. By this wonderful
provision of nature the healthy functions were uninterruptedly carried
on, and permanently continued, without any pain or detriment to the
patient’s general health. On appearance, Jan. 23d, 1847.

  A. Maclean, M.D., late Surgeon, 76th Regiment.

Cases of extravasation or of effusion, terminating by the formation of
a sac, pouch, reservoir, or _foyer_ surrounding it, while the rest of
the cavity remains free from inflammation, are so rare in natives of
our northern climates that I am indisposed to infer that they do take
place, except as very accidental circumstances. The fact that such
things do take place should be borne in mind, and surgery should not
be wanting in giving its aid, under all well-considered and reasonable
circumstances. It is easier to do nothing than to think and to act.

The general treatment to be pursued in the acute period of all these
cases of inflammation has been sufficiently marked--antiphlogistic to
the utmost extent consistent with propriety, by bleeding, leeching, and
cupping; the repeated administration of enemata; the early exhibition
of mercury and opium, and subsequently of gentle aperients.

397. Continental surgeons, and by pre-eminence Baron Larrey, who is
followed on this point by most French surgeons, inculcate the necessity
of enlarging the wounds made by a musket-ball in the wall of the belly,
although the Baron is particular in confining it to the muscular
parts; M. Baudens, one of the latest writers on the subject, points
out the additional tendency this gives to the formation of hernia, and
furnishes therefore the soundest reason for not doing it without an
especial cause. When a slip of the muscular or tendinous structures
interferes with the quiescence of the wound; when it is desirable to
introduce a finger to make an examination; when it is necessary to
divide a portion to allow the restoration of protruded parts, no one
will doubt the propriety of the direction. But when neither these nor
any other good or sufficient reason can be given for such an operation
as that of enlarging the wound (_débridant la plaie_) simply because
it has been usual so to do, at the risk of making a large hernial
protrusion instead of a smaller one, it is unnecessary. It gives rise
to some bleeding, but that is really nothing; it makes a cut instead of
a hole, by which nothing essential is gained; and as this enlargement
of the wound can always be accomplished when it may become necessary
from a sufficient cause, such interference, especially on the fore part
or the sides of the abdomen, may be safely omitted.

398. When a musket-ball, passing across the abdomen, comes out behind
through the thick muscles of the back, with perhaps a slit-like
opening in the skin, through which some urine, and perhaps fecal
fluid or matter may also pass, such wounds should be enlarged both
superficially and deeply. There is here an object to be gained, and
the operation is necessary. There is no objection to its being done
when it is even supposed that these fluids or matters are likely to
be soon or ultimately discharged through it, as it is desirable that
any secretions or effusions which cannot be evacuated by the natural
passages should have every reasonable opportunity offered of making
their escape.

399. When it is obvious, from internal hemorrhage, or from the
discharge of fecal matter, or from the introduction of the finger, by
which it can be felt, that a large hole or rent has been made in an
intestine, the wound should then be enlarged so as to allow its being
brought into sight, when the edges should, if required, be smoothed,
and the continuous suture applied in the manner directed, Aph. 391.

400. When a musket-ball penetrates the cavity of the belly, it may
pass across in any direction without injuring the intestines or solid
viscera. It usually does injure one or the other, and it has been
known to lodge without doing much mischief. The symptoms are generally
indicated by the parts injured, although in all the general depression
and anxiety are remarkable; their continuance marks the extent if not
the nature of the mischief.

The following cases of the survivors of hundreds who died under
similar wounds, during the war beginning with the battle of Roliça in
Portugal, in August, 1808, and ending with that of Waterloo, in June,
1815, may be read with a melancholy interest, as showing what sometimes
will happen in a few rare instances, and even then as more dependent on
the wantonness of nature than on the united efforts of science and of
art.

A soldier of the brigade of heavy cavalry, under General Le Marchant,
advancing in line to charge the French infantry at Salamanca, on
which occasion the general was killed, was struck by a musket-ball,
which entered in front, between the umbilicus and the ilium of the
left side and came out behind on the opposite side above the right
haunch-bone, thus traversing the body. The bowel protruded in front,
but was uninjured, and was easily restored to its place. He remained at
the field hospital with me for the first three days and was rigorously
treated, as well as afterward in the San Domingo Hospital, where he
gradually recovered, and was ultimately sent to the rear.

Captain Slayter Smith, of the 13th Dragoons, being engaged at Campo
Mayor, on the 25th of March, 1811, was shot by a pistol-ball, which
entered at the left hip, three inches and a half from the junction of
the ilium with the sacrum, an inch and a half below its crest, and came
out about three inches below the navel, and one inch to its right side.
He felt a terrible shock, but did not faint or fall from his horse.

“There was a protrusion of bowel from the wound in front of about
three inches; but little blood issued from it. The hemorrhage from the
wound in my back was very copious. A French officer, with three or
four of his men, were so near me that he called out ‘Rendez vous, mon
officier,’ to which I replied, ‘Pas encore, monsieur,’ and rode away
with my bowel in my hand.

“I reached the field hospital shortly afterward, when the protrusion
was returned without enlarging the orifice, and _no_ stitch was put
into the wound then or afterward. It was dressed merely with lint and
adhesive plaster. I begged earnestly for a glass of Madeira, which,
after a little hesitation on the part of the surgeon, was given to me;
but they afterward thought it necessary to bleed me; but little blood
followed the insertion of the lancet. This was the _only_ time I was
bled. In the morning I found the bed saturated with blood, which had
trickled through to the floor, and had escaped from the wound behind.

“Before a month had elapsed I and all the wounded were removed to Elvas
on _bullock-cars_, and a desperate journey it was.

“On my arrival, inflammation began in the wound in front, accompanied
with great swelling and pain. The swelling was laid open and a quantity
of matter was evacuated, followed by an angry-looking protrusion,
which was carefully washed with warm water, and poulticed; when the
inflammation had subsided, the wound was dressed as before, with lint
confined by adhesive plaster. When the protrusion was touched by the
hand I experienced a nauseous and disgusting sensation, to which in
comparison the application of the knife or lancet was a flea-bite.

“I arrived in England in June, and in September went to Brighton. Soon
afterward I felt terrible pains in the _right_ side of my back, in a
line with the wound, through the ilium, or rather above it, where a
kind of tumor formed. For several days I suffered agony from it; and
one night, completely worn out, I fell into a long and deep sleep, and
awaking late in the morning I found all pain and excrescence gone, and
nothing remaining but a tenderness of the part on pressure with the
finger. I underwent much from violent spasms in the stomach, which I
never had before I was wounded. I recovered, however, sufficiently
to rejoin my regiment the following spring in the Peninsula, and was
soon afterward again wounded in a skirmish by a spent shot in the left
shoulder, which, however, was of no moment, though I was compelled
to return to England on sick leave, in October, 1812, as the spasms
increased with greater severity, incapacitating me from doing my duty,
and at times rendering me totally helpless.

“I now gradually recovered my health, and in the spring of 1815,
accompanied the 10th Hussars to Belgium, and served at Waterloo.

“My health gave way again in 1821, and I certainly was in a precarious
state for three or four years, but I gradually recovered, and by dint
of great care and attention to diet I am now (1853) in robust health,
and can take the strongest exercise with impunity.”

John Richardson, of the 1st Royal Dragoons, was wounded at the battle
of Waterloo by a musket-ball, which entered two and a half inches
above the umbilicus, and passed out on the left side, close to the
lumbar vertebræ. He threw up a considerable quantity of blood, and the
stomach was so irritable that nothing would remain on it. He complained
of pain, which cut him right across, as he termed it; his eyes were
suffused and face flushed; had headache; pulse 130. Thirty ounces of
blood were taken from the arm, emollient injections thrown up the
rectum, and poultices applied to the wounds.

June 20th.--Some blood came away with the injections during the
night; great pain in the right side and shoulder; saline draughts are
returned tinged with bile and blood; pulse 130. Bled to sixteen ounces;
injections and poultices continued.

21st.--A draught was ejected mixed with blood, and a quantity of
bilious fluid; diarrhœa during the night; the feces were mixed with
blood; pulse 120; skin hot. Bleeding to twelve ounces; blood sizy.

22d.--Slept a little during the night; had several alvine evacuations
of a bilious fluid mixed with blood. The tension of the belly is not so
great. He still complains of pain. Tea remains on his stomach. Bleeding
to twelve ounces; fomentations and poultices to the belly; chicken and
beef broths; injections frequently.

24th.--Feels considerable relief from the tension of the abdomen having
subsided; threw up his tea and a quantity of clotted blood this morning.

26th.--Had a bad night; pulse 125, and full. Complains of great pain in
the hepatic region, and backward toward the spine. Bleeding to sixteen
ounces. ℞.--Hydrarg. chlorid. gr. iv; conf. rosæ. gr. ix; to be made
into two pills, one to be taken twice a day.

30th.--Vomiting in the night, mixed with blood; tea, etc. remain on the
stomach this morning; pulse 108.

July 5th.--The adnatæ have a yellow tinge; in other respects he is
doing well. ℞.--Chlorid. hydrarg. gr. x; extr. colocynth. comp. ʒj: to
be made into ten pills, one to be taken three times a day.

20th.--The wound perfectly healed; is cleaning his accoutrements,
boots, etc. Was discharged on the 28th of July, perfectly recovered.

Owen M’Caffrey, aged thirty-three, first battalion 95th Regiment,
was wounded on the 18th of June at the battle of Waterloo, by a
musket-ball, which penetrated the cavity of the abdomen on the right
side, about midway between the superior anterior spinous process of
the ilium and the linea alba. When admitted into the Minimes General
Hospital three days after, he was in the most deplorable state; the
whole abdomen was tense and exquisitely tender; the pulse small and
wiry; vomiting incessant, with hiccough and ghastly visage. From this
period to the 24th, he was thrice largely blooded, and the strictest
antiphlogistic plan was laid down and rigidly adhered to. Laxative
injections were administered, the whole of the abdomen was frequently
fomented, and opiates were administered to allay the irritability of
the stomach, and to procure ease and rest. On the 25th the wounded
intestine sloughed, and the feces escaped by the external orifice, _the
adherence of the two surfaces of the peritoneum_ preventing any, even
the smallest portion, getting into the cavity of the abdomen.

26th.--The high inflammatory action having been reduced, milk, rice,
and sugar, and the farinaceous part of the potato were allowed.

July 1st.--No very alarming symptom remains. Half a fowl ordered for
his dinner, and the greatest attention to personal cleanliness directed
to be paid.

7th.--Strength slowly but gradually returning. The action of the large
intestines is daily kept up by stimulating injections.

14th.--Progress to recovery satisfactory. The injections are daily
repeated, and the discharge by the natural passage increases. The wound
contracts and looks healthy. Is enabled to sit up, and has recovered
his cheerfulness.

28th.--Still improving; ultimately recovered.

The situation of the ball was never ascertained.

A soldier of la Jeune Garde Imperiale was struck by a ball, which
entered to the right and a little below the umbilicus and passed out
on the left or opposite side, about two inches above the crest of the
ilium. It was supposed to have passed along the canal of the great
arch of the colon. Fecal matter, much tinged with bile, passed by both
openings. The symptoms of inflammation were severe for the first few
days, but gradually yielded to the means employed, when the bowels
began to act regularly by the aid of mild injections, and the discharge
from the wounds gradually lessened; the man was much reduced, but
otherwise in good health, and was sent to France from Brussels, nearly
well.

A soldier of the Third Division of Infantry was wounded during the
assault of Ciudad Rodrigo, by a ball which entered and lodged in the
left side of the back, about midway between the spine and a line drawn
to the upper part of the crest of the ilium, from which opening the
contents of the bowel were discharged. Left among the dead and those
who were supposed to be dying at the field hospital, in the rear of
the trenches, I sent him, with all those of different corps who were
wounded, to my own hospital at Aldea Gallega, some ten miles off. Here,
under a sufficiently vigorous treatment, of which bleeding, starvation,
and quietude were the prominent features, he gradually recovered. On
the fifth day the ball passed per anum, and on two or three different
occasions afterward portions of his coat, flannel shirt, and breeches.
Fecal matter passed readily through the wound, while the bowels were
gently solicited by common injections for some time; but the wound
gradually closed in, and the man regained his health, and was sent to
the rear with a slight colored discharge from the wound, not quite free
from odor.

Ensign Wright, 61st Regiment, was wounded by a musket-ball, on the
morning of the 10th of April, at Toulouse. The ball passed through the
abdominal parietes on the right of the linea alba, nearly half way
betwixt the umbilicus and the pubes, and lodged. Sense of debility,
tremor, nausea, small, feeble pulse, and pain in the lower part of the
abdomen were the immediate symptoms.

Peritonitic and enteritic symptoms of considerable violence having
begun to manifest themselves on the 11th, copious and repeated
evacuations of blood were made by order of Mr. Guthrie, the Deputy
Inspector-General in charge of all the wounded. Fomentations were
applied to the belly; abstinence in food and drink was strictly
enjoined, and the most rigid antiphlogistic regimen followed. The same
practice was pursued during the 12th, 13th, and 14th, venesection being
performed either two or three times every day, as the augmented state
of the local and general inflammatory symptoms seemed to require.
The bowels during the above period had continued perfectly free, and
the dejections were tolerably natural in color, but rather dark, and
extremely fetid. He had been frequently troubled with nausea and
vomiting of bilious matter. Two small doses of castor-oil had been
exhibited.

Toast and water, tea, boiled milk-and-water, with a little soft bread
soaked in it, and mutton and chicken-broth in small quantities at a
time, were all that was allowed him for food and drink.

April 15th.--Pulse above 100, weak and small; temperature natural; the
tongue clean. Continued affected with a degree of nausea and vomiting,
after drinks especially; and some diarrhœa was present.

17th.--Was bled last night to twelve ounces, in consequence of
increased pain of abdomen and augmented pyrexia; to-day quiet and easy,
and has had several stools.

18th.--Diarrhœa and tenesmus troublesome during the night; _ball voided
with the feces at six_ A.M.; it is somewhat flattened, as if from
impinging on a stone; has felt easy since. Continue antiphlogistic
regimen.

19th.--Diarrhœa abated; but the abdomen is tense and painful on
pressure. He is distressed with nausea and vomiting; pulse 100, and
sharp; great thirst; tongue dry. Bleeding to sixteen ounces; abdomen
fomented.

20th.--Bleeding was repeated last night from persistence of the
symptoms of peritonitis. Blood drawn very buffy; has had several loose
stools during the night. He is to-day easy; abdomen now scarcely
painful. Fomentations continued.

29th.--This morning the abdomen was tense and painful on pressure; he
was affected with nausea, and had had vomiting repeatedly during the
night; thirst and pyrexia. Fomentations were applied from time to time,
and yielded relief. Suspect that he has not observed the prescribed
regimen.

May 1st.--Pain of abdomen and bilious vomitings during the night; has
had three loose stools. Pulse 110, hard and small; thirst urgent. Blood
let to fainting; fomentations continued.

2d.--Last night he was again bled to two ounces, when fainting
supervened. He passed a quiet night; had two liquid stools; abdomen not
painful, nor is he sick at stomach, nor thirsty. To keep himself warm,
particularly the belly.

11th.--Suspect he has been rather irregular in diet. Passed a bad
night, partly in delirium; has vomited much; has obviously pain on
pressure of the abdomen, but appears studious to conceal it; pulse 112,
small and not soft; temperature increased; tongue red; thirsty; three
liquid stools. The stomach to be kept warm; ten drops of tincture of
digitalis in half an ounce of mist. acaciæ, to be taken three times a
day; diet of milk and farinaceous food; for drink, infusion of tea in
small quantities. Eight o’clock.--Pulse 120, soft; feels easier, and
has not vomited. Ordered a foot-bath.

13th.--Molested by pains, nausea, and vomiting during the night;
pulse 110, not soft; skin cool, but is thirsty, and his tongue is of
a vermilion color, and arid; confesses that he has hitherto disguised
his feelings, as well as other circumstances connected with his case,
particularly his manner of living. Digitalis continued; blister to be
applied to the epigastric region, and the foot-bath repeated in the
evening.

14th.--Bad night; pulse 112; skin hot; pain of abdomen not urgent;
no vomiting, but is affected with nausea. Digitalis continued. Four
o’clock.--Pulse 100; feels nauseated; no pain of abdomen. Digitalis
occasionally.

16th. Eight A.M.--The tendency to vomit continues. One grain and a half
of chloride of mercury with a grain and a half of opium, made into
a pill, to be taken in the morning; to be bled. Seven P.M.--Vomits
whatever he swallows in any quantity; skin hot; thirst great; tongue
red; two motions; says abdomen is not painful; pulse 112. A blister to
be again applied to the epigastrium; foot-bath in the evening; repeat
the mucilaginous mixture for cough.

17th.--Rested ill; blister has not risen; cough has been severe and
continues so; two motions; pulse 120, and not soft; cough augmented by
deep inspiration, and pain produced. Take blood from the arm to eight
ounces; foot-bath in the evening; continue pill.

18th.--Bad night; cough gone; respiration easy; pulse 100; skin cool
and moist; no thirst; one motion of a natural kind. Repeat mucilage and
the calomel and opium pill.

24th.--Has this morning experienced a severe attack of dyspnœa,
attended by cough and pain of chest, both increased by full
inspiration. Pulse 120; face flushed; says he caught cold from exposure
to the night air. Bled immediately, and as much blood taken as his
strength would permit; foot-bath repeated in the evening.

25th.--Six ounces of blood drawn; surface buffy; bad night; cough,
pain, and pyrexia abated this morning; in the evening severe dyspnœa;
cough and pain of chest have recurred; pulse 120. Six ounces of blood
to be drawn, should strength permit; mucilaginous mixture to be
continued; another blister to be applied to the chest.

28th.--In a fair way of recovery; was discharged for England in June,
with little or no complaint.

  John Murray, Surgeon to the Forces.

Sergeant Matthews, of the 28th Regiment, was wounded at Waterloo by
a musket-ball, about an inch below the umbilicus, a little to the
right side, which lodged. He walked to a village in the rear, where
he remained for three days, having been bled each day to fainting,
before he was removed to Brussels, where my attention was particularly
attracted to him, in consequence of his having passed the ball (a small
rifle one) per anum, three days after his arrival, or the sixth from
the receipt of the wound. The wound was healed by the end of August;
and he felt so well that he marched to Paris with other convalescents,
to joint his regiment. After some weeks he got drunk, and suffered
from an attack of pain in the bowels, in the situation of the wound,
requiring active treatment. On attempting one day to have a motion, he
found, after many efforts, that something blocked up the anus, and on
taking hold of and drawing it out, he found it was a portion of the
waistband of his breeches, including a part of the button-hole--a fact
verified by Staff-Surgeon Dease, who wrote to me an account of this
peculiar case. After this the man recovered without further difficulty,
although, as in all such cases, there was a herniary projection. He was
afterward subject to costiveness, to pain in the part after a copious
meal, probably from the stretching of the adhesions formed between the
intestine and the abdominal peritoneum, which inclined him to bend his
body forward to obtain relief.

In all such cases, the extraneous substance having lodged, and mainly
injured in all probability the vitality of the part which assists in
the lodgment, the ball becomes covered with a layer of coagulable
lymph or fiber, capable of retaining it in its new situation, whence
it is gradually removed by ulceration, or by the sloughing of
the injured parts into the cavity of the bowel; much in the same
manner as an abscess in the liver is evacuated into the duodenum or
neighboring intestine, to which it may become attached. It is always
fortunate when the canal from the external wound is cut off by the
deposition of lymph, as it expedites the cure, and renders the injury
less formidable; but if this should not take place, the contents of
the bowel are discharged through it for a greater or shorter length
of time, until the canal between the parts gradually closes, and
cicatrization takes place, in default of which an artificial anus may
remain in addition to the natural one, the functions of the bowels
generally being performed with more or less difficulty.

The two following very interesting cases of abdominal injury having
been received while these pages were passing through the press, are
here inserted:--

A man in the 19th Regiment was wounded through the abdomen, and
survived nineteen hours, the ball entering near to the umbilicus, and
passing out close to the sacrum. On the post-mortem examination, the
small intestines were found to have been wounded no less than sixteen
times by the ball in its passage. When wounded, he was stooping in the
act of defecation.

  T. Alexander, Deputy Inspector-General.

  _5th August, 1855._

On the evening after the battle of Alma, as my regiment was halting on
the brow of a hill, previous to bivouacking, a wounded Russian officer,
apparently in great pain, was perceived on the other side of the
ravine. Passing over to where he lay, I found that he had been wounded
by a musket-ball, that had entered the lumbar region directly over
the spine. As he was enabled in his agony to crawl on his hands and
knees, it was evident there was no paralysis, and on passing a probe
I found the ball had avoided the spine, but as I could not pass in
the instrument more than an inch, I was left in uncertainty as to its
further course.

He was removed to my hospital tent, when I tried, but with little
success, to remove the excessive pain from which he was suffering.
In about two hours after he took my finger and placed it on a hard
substance imbedded in the walls of the abdomen, and on cutting down on
this I perceived a musket-ball. Previous to extracting it, however, I
observed a white, glistening substance oozing from the wound, which, on
carefully removing with the probe, proved to be a portion of tape-worm,
about a yard and a half in length. I then extracted the ball, and again
another portion of the worm presented, which measured about two yards
and a half in length. It was now complete, though cut in two evidently
by the ball, and the two portions, one containing the head and the
other the tail, were soon writhing on the table.

The patient experienced immediate relief; the pain had ceased; he
slept well, and on the following morning he was free from thirst,
with a tolerably quiet pulse. Unfortunately the order arrived for all
prisoners and wounded to be sent to the rear, and I lost sight of the
case.

What was the cause of this agony of pain? Evidently the writhing of
the worm, or why should it so suddenly cease on the worm’s liberation?
The abdomen must have been entered by the ball, or how could the
worm’s exit have been effected? Nevertheless, but for its presence,
the patient was so free from constitutional symptoms on the following
morning that a surmise might really have arisen that the ball had
passed round the abdomen without injury to the peritoneum.

  Rt. De Lisle, Surgeon,
        4th K. O. Regiment.

  _Camp before Sebastopol, August 8th, 1855._



LECTURE XXIX.

ABNORMAL OR ARTIFICIAL ANUS, ETC.


401. In some cases of wounds of the intestine the continuity of the
bowel is not sufficiently re-established; the external wound remains
open, and becomes indurated and fistulous, giving passage to the fecal
matters, and rendering the sufferers very miserable. These cases are of
rare occurrence among the hardy natives of Great Britain and Ireland,
and comparatively little has been done or even recommended in this
country for the relief of this misfortune.

When an intestine has lost a more or less considerable part of its
substance at a particular spot, and an artificial anus is about to
be formed, it adheres to the peritoneum around the inside of the
external wound, although the adhesion is of little extent or width,
and forms but a narrow barrier for the protection of the cavity of
the abdomen. The upper end of the bowel is more open than the lower,
the caliber of which is contracted in size, and is sometimes even
difficult to find; while its opening is partially closed by a sort of
septum extending across, or from where the two portions of a divided
gut have come irregularly in contact with each other by their sides,
without uniting in the first instance in their length; or from the
falling in especially of the posterior part of the lower end, to which
the upper has become united. The projection thus formed in the tube is
called by the French _eperon_ or _promontoire_, valve or spur, ridge or
septum; it directs the fecal matter through the external wound, while
it obstructs its passage into the lower part of the bowel. There is
generally great difficulty in ascertaining the fact of the existence
and exact situation of this valve during life; in distinguishing the
upper from the lower end of the intestine, as well as the nature and
extent of the adhesions by which the injured intestine is retained in
its situation. If the absence of such a valve can be satisfactorily
made out--and it is sometimes wanting--the external opening may be
successfully closed by compression, or by operation. If the valve
should exist, its removal by a preliminary operation is necessary; it
has been attempted in France with various but somewhat doubtful success.

402. When a portion of small intestine has been lost by mortification
or otherwise, and the patient has recovered with an unnaturally
situated or artificial anus, the intestine, although at first in
contact with the wall of the abdomen, is gradually, in many cases
though not in all, retracted into the cavity--it has been supposed by
the dragging of the mesentery upon it at the point of union of the
divided extremities outside where the _eperon_ or valve is formed; and
it is said that this dragging has even led to the gradual disappearance
of the valve, admitting thereby of the contents passing more readily
from the upper part of the intestine into the lower, and consequently
laying the foundation for a cure. This dragging of the intestine,
or its movements under the different motions of the body, in some
cases cause an elongation of the membrane formed under the adhesive
process, by which the intestine is attached to the inside of the wall
of the abdomen in the same manner as adhesions are elongated between
the pleuræ, and a sac or pouch is thus formed between the cut ends
of the intestine and the fistulous external opening which Scarpa was
the first fully to demonstrate and explain, and which he called an
_entonnoir_, _infundibulum_, or funnel. If, then, in an old case, a
small portion of the wall of the abdomen be removed in the form of a
V, the internal opening at the apex of the V, if small, would be made
into a sort of funnel, while the outer incision would remove all the
hardened fistulous parts--an operation which is sometimes required to
be done when the external opening is not free, and fecal matters have
insinuated themselves between the aponeurotic parts, giving rise to
abscesses and other small fistulous openings in different directions.
It is necessary to bear the formation of this pouch in mind as well as
that of the valve, in order to understand the operations proposed for
the relief or cure of this complaint.

If simple compression fail in the first instance to prevent the passage
of the feces, which never can be thoroughly controlled from the want
of a sphincter and the uncertainty of pressure, the method of Desault
may be adopted. This consists in gradually dilating the external wound
so as to enable the operator to discover the open ends of the bowel,
when a tent is to be introduced into the lower end, and afterward
into the upper, being fastened by a thread passed around its middle.
A pyramidal-shaped pad is then to be placed over the opening, and
compression made by bandage upon it so as to press the whole inward.
The size of the tent is to be gradually enlarged until the contents of
the gut begin to pass downward with ease, when a well adjusted pressure
is to be made on the fistulous opening only, to prevent all oozing from
it until the internal parts have had time to close.

403. Dupuytren invented a pair of forceps, consisting of a male and
female branch, to be applied separately, one on each side of the valve
or _eperon_, to the extent of an inch or an inch and a half at most,
when they were to be closed by a screw until they had compressed the
part between them sufficiently to destroy its life. The separation of
the valve included within the forceps would take place by the usual
processes of ulceration in its immediate proximity, and by adhesion
of the parts external to the bowels to those surrounding them. The
inflammation, however, did not always stop at the adhesive stage, and
death has been the result as well as a successful cure.

404. Mr. Trant has invented an instrument he calls a propeller, for
pressing back the eperon, an account of which is given in the _Dublin
Medical Press_, May 14th, 1845. He used this in one case with complete
success. The instrument by its formation admits of being passed
through the artificial anus, and of being placed on the _eperon_ at
the bottom of the wound, where it can be retained for a considerable
time without producing the slightest inconvenience. It does not, while
in the intestines, offer any obstruction to the passage of the fecal
matters flowing along the cavity of the tube. It acts as a forceps in
retaining the anterior wall of the intestine in close contact with the
posterior surface of the abdominal parietes, while the propeller is
pressing back the _eperon_ toward the spine; consequently the danger
of separating the delicate adhesions in this situation is prevented,
otherwise a fatal extravasation into the cavity of the abdomen might
ensue. The instrument was made by Mr. Reed, of Dublin, and merits
further trial, being apparently less dangerous than the other methods
recommended in similar cases. Whatever may be the method employed for
the cure of an artificial anus by operation, it cannot be doubted
that the patient must be exposed to all the dangers which may result
from inflammation, for which he must be prepared beforehand, and the
symptoms of which must be met and subdued as they arise; or, if this
cannot be accomplished, the mechanical means, if any be used that can
be taken away, must be removed, and quiet, if possible, restored by
their abstraction and by the treatment adopted. In successful cases,
a small aperture will frequently remain, constituting a fecal fistula
instead of an artificial anus. This will sometimes become irritable,
inflame, ulcerate, or burst, discharging the solid contents of the
bowel, although, on the subsidence of the irritation, the part under
pressure usually returns to its former state.

405. _Wounds and injuries of the liver_, whether incised or
penetrating, occurring from blows or from musket-balls, are very
serious, although not _necessarily_ fatal. Some few persons recover
altogether, some few with more or less of permanent disability. The
remainder die during the first or inflammatory stage, or in the
secondary one, which follows from the twelfth or fourteenth day after
the primary symptoms have in some measure subsided.

The symptoms which ensue after a wound of the liver are those common to
inflammation of the cavity of the abdomen, with the addition of those
peculiar to the organ--pulse often smaller and less perceptible than
in peritonitis; discoloration of the skin, eyes, and urine, amounting
even to jaundice, although this is not an immediate symptom, neither is
it always present. The pain is not confined to the part, but extends
to the umbilicus, while the pain symptomatic of inflammation of the
liver--viz., pain in the top of the right shoulder--is felt early, and
is often accompanied by cramps of the muscles of the arms and numbness
of the fingers. The usual symptoms of anxiety and depression are
present, and the stomach shows by its irritability that it has partaken
of the shock given to the system. The bowels are usually confined, but
I have known blood passed from them when it was not supposed that the
stomach or intestines had been wounded; the discharge from the wound is
either of blood or bile, or both, mixed with a serous effusion which
afterward becomes purulent. Wounds of the gall-bladder are, as far as
is known, fatal--the effusion of bile which immediately takes place
giving rise to inflammation which, with other causes, destroys the
sufferer at the end of a few days. If the gall-bladder be adherent to
the peritoneum from any previous inflammation, a wound in it need not
prove mortal, as the effusion would be avoided, and there is no reason
to believe that an injury to this part would be otherwise more vital
than that of any other of the viscera of the abdomen.

The late Lieut.-General Sir S. Barns, when Lieut.-Colonel of the
Royals, was wounded at the battle of Salamanca by a musket-ball,
which injured the cartilages of the false ribs, a portion of the rib
being removed and passed out through the liver. A bilious discharge
continued several weeks from the wound, and his life was saved with
great difficulty. He returned to his duties, although suffering from
a dragging pain and weight in the side, which any exertion increased.
In the autumn of 1819 he was attacked by acute inflammation; the pain
in the right side, extending over the stomach and umbilicus, was
constant and acute, and increased on pressure; the pulse small, indeed
scarcely perceptible; the extremities cold; the countenance depressed
and anxious; bowels confined; stomach rather irritable. A number of
leeches were applied, and other remedies administered. The constant
pain, which was increased by pressure, could only be relieved by loss
of blood, although every other symptom seemed to forbid depletion.
Twenty ounces of blood were taken from the arm, which caused a
diminution of the pain, and gave relief for an hour; the pain then
returned, and twelve ounces more blood were taken away, with the most
beneficial effect; a blister was applied over the part, and a dose of
calomel and opium was repeated. Shortly afterward he became tranquil;
the extremities lost their coldness; and, although the pain continued
in a slight degree for several hours, and much soreness remained for
many days, he quickly recovered. Two months afterward he had another
and equally severe attack, in consequence of walking about two miles
rather hastily; from that he was relieved in a similar manner. Whenever
he bent his body, a portion of the rib appeared to press in upon the
liver, and often gave him acute, darting pain; and one day, on pulling
on his boot in haste with some bodily exertion, a third attack ensued.
In order to prevent the bending of the body forward, and to confine the
motion of the liver, which seemed liable to injury from the irregular
points of bone which could be readily distinguished above it, stays,
made with iron plates instead of whalebone, were adapted to his body,
and from these he derived great comfort.

Corporal Macdonald, first battalion, 79th Regiment, was wounded on
the 16th of June at Quatre Bras, by a musket-ball, which entered the
abdomen, splintered the eighth rib on the right side, passed through
the liver, and was supposed to have lodged on the opposite side, as he
says he felt the ball strike the left side, on which he was not able
to lie for a long time. Lost but little blood at the time; was dressed
superficially, and arrived in Brussels on the 19th, laboring under
considerable fever. Bleeding to thirty-six ounces. For seven successive
days the bleeding was repeated, to from twelve to sixteen ounces each
day, when a large, bilious, and purulent discharge took place from the
wound, on which the inflammatory symptoms appeared to subside, until
the 30th of June, when bleeding took place from the wound during the
night to the extent of twenty ounces, and then ceased spontaneously.
On the 15th of July the hemorrhage recurred with so much fever as to
warrant twenty ounces of blood being taken from the arm, and this was
repeated the next day. The bilious discharge ceased in the middle of
August, and on the 2d of September he was discharged convalescent.

Lieutenant Edward Hooper, first battalion, 38th Regiment, was wounded
by a musket-ball on the 9th of December, 1812. It passed through the
anterior edge of the liver, and, glancing round the ribs, was cut out
about two inches from the spine.

On his being wounded, he could scarcely believe his shoulder was
not the part affected. His pulse was intermitting; the breathing
hurried and laborious, and in a short time the tunicæ conjunctivæ
became yellow. He was _very largely_ bled, and warm fomentations were
applied to the abdomen, from which, and the bleeding, he received some
temporary relief; but, in consequence of his removal that night to the
rear, the symptoms were much aggravated on the morning of the 10th. He
complained of acute pain over the whole abdomen, increased on pressure;
vomiting; quick, hard, and wiry pulse, (no pain referred to the wound.)
The bleeding was repeated ad deliquium, warm fomentations and an
enema also repeated, and a saline mixture, with a _very few_ drops of
tincture of opium, to allay the irritability of the stomach. On the
following evening the vomiting had ceased; his pulse was less frequent
and hard; pain less. On the 11th, after passing a very restless night,
the pulse again rose; the abdomen became tense but not very painful,
and he made ineffectual efforts to stool. He was again bled, a large
blister was applied over the abdomen, and an ounce of castor-oil was
given immediately. The blister acted well, and the purgative gave him
three copious stools of dark and fetid feces. On the 12th he complained
of twitching pains, referred to the right shoulder, and was ordered one
grain of calomel, with two of antimonial powder, three times a day.

Jan. 13th.--Was free from pain; pulse fuller and less frequent; urine
clear; tension of abdomen subsided. The calomel and antimony were
continued, and some light nourishment was allowed. From this day a
gradual amendment took place. The calomel was continued until his mouth
became slightly affected; and, as his bowels were in general torpid,
from the deficient secretion of bile, a mild purgative was given every
two or three days, as occasion required, and an ounce of the infusion
of calumba, with quassia, three or four times daily.

A soldier of the 48th Regiment was struck by a musket-ball at Albuhera,
on the upper part of the right hypochondrium, over the liver; it
came out behind, at a point immediately corresponding to that in
front. Blood and bile were discharged from the wounds in considerable
quantity, and his case was considered to be hopeless. Brought to me at
Valverde, the next day, he was bled largely several times; the wounds
were dressed simply, and he was kept perfectly quiet, and his bowels
gently open. The skin became of a yellow color, his strength failed
under the treatment, and he became thin, and looked ill. At the end of
three weeks he was sent to Elvas, where he gradually improved, and was
forwarded thence to Lisbon and to England, with his wounds healed.

An officer was wounded in one of the battles in the Pyrenees,
by a musket-ball, which penetrated the outer part of the right
hypochondrium, at the edge of the false ribs, and lodged. Blood and
bile flowed in considerable quantity; the skin became yellow, the pain
and swelling of the abdomen were considerable, and he was given over as
lost. Under a vigorous and careful treatment he gradually recovered,
so as to be sent to England, with a fistulous opening at the orifice
of entrance. I examined the wound in 1817, three years afterward, and
found that a large blunt probe passed inward toward the stomach and
liver for the distance of five inches, where it ended apparently in a
sort of sac. Purulent and bilious matters were constantly discharged
from the wound; his countenance was sallow; his digestion bad; he
suffered from constant uneasiness, if not pain, and was altogether out
of health. I saw him once annually for several years, and found that
I could sometimes strike the ball with the probe; that he frequently,
after an attack of pain and derangement, passed matter by stool,
after which the pain and uneasiness about the wound ceased. I had
hopes the ball would some day pass through the opening thus made, and
had thoughts of enlarging the external wound, and of endeavoring to
extract the ball with a long pair of forceps. He ceased at last to pay
his annual visit, and I suspect he died in one of the attacks I have
alluded to. This ball must have passed very close to, if it did not
penetrate, the gall-bladder.

I have never had an opportunity of extracting a ball from the liver
during life, although I have seen persons live many weeks into whose
livers balls had penetrated; and I have been acquainted with three
persons who had been wounded through the liver, to whom little
subsequent inconvenience was occasioned.

406. Portions of the liver have been removed in some instances; in
one case, related by Blanchard, a small piece of liver was removed
with the forceps. The patient dying of fever three years afterward, a
small piece of the liver near the external wound was found wanting.
Dieffenbach gives a case in which a small protruded portion was cut
off with scissors, without any bad consequence. Dr. Macpherson, in the
‘_London Medical Gazette_’ for January, 1846, has related the case of
a Hindoo, a large piece of whose liver protruded through a wound an
inch in length, made by a spear in the right hypochondriac region. A
ligature was applied tightly around its base, and the piece cut off,
rather than make such an enlargement of the wound as might allow the
restoration of the protruded liver. The arteries bled from the cut
surface, and required to be tied, and a double ligature was put through
the stump of liver and tied on each side. The part was not pushed back
into the abdomen, but allowed to remain in the wound. The symptoms were
mild, the ligatures came away on the ninth day, and the man returned to
his home in three weeks.

These cases may be considered exceptions to the general rule, which
directs the return of all protruded parts. The retention of the part
from which the piece was cut off within the divided parts of the wound
was agreeable to the principles I have inculcated with respect to
wounds of all the cavities.

407. _Wounds of the stomach_ are usually fatal, although some persons
escape when these injuries are confined to its anterior and upper
surface, and do not penetrate both sides, in which case effusion into
the cavity of the abdomen, and consequent inflammation, can scarcely
fail to ensue. It is fortunate for the patient, when they occur, that
the stomach should be empty. If it should not be so, the contents may
possibly be ejected shortly after the receipt of the wound, but it is
not advisable to excite vomiting by remedies, or by means adapted for
that purpose. In a perfectly quiescent state, the general compression
of the contents of the abdomen by its walls may prevent effusion under
ordinary circumstances, and this state should be maintained as rigidly
as possible. The apparent course of the wound indicates the probable
mischief, which is especially confirmed by vomiting of blood, great
anxiety, depression of countenance, a cold, clammy skin, pain in the
part, hiccough, and by the discharge of the contents of the stomach,
if the wound be sufficiently open to allow it; pulse low and sometimes
intermittent. If effusion of the contents of the stomach should not
occur, the external wound, if an incised one, should be closed by
suture, and the patient kept in the utmost state of quietude, in a
somewhat elevated position, the abdominal muscles being relaxed.
Neither food nor drink should enter the stomach, although thirst should
be allayed by wetting the tongue and mouth. The bowels should be
relieved by enemata, and the belly fomented. Bleeding and leeching, as
frequently repeated as the symptoms appear to require, must be carried
to the greatest extent that can be permitted with safety.

When the external wound is so large as to enable the wounded stomach to
be seen, the cut edges of the wound in it should be brought together
by the continuous suture, as in the intestines; and the external
wound should be closed in a similar manner, the end of the ligature
on the wound of the stomach being cut off close to the viscus, that
organ being left perfectly free, with the hope that the thread will be
carried into its cavity, while the outside adheres to the peritoneum
opposed to it.

When the stomach pours its contents through an external opening, too
small to allow its being examined, it is desirable that the wound
should be enlarged, if a doubt be entertained of the passage being
free. It is a sufficient reason for such an operation to allow the
opening in the stomach to be seen. It is very probable that effusion
will take place into the cavity of the abdomen if it be not done, and
the death of the patient will follow. It is very probable he will
die if it be done, and therefore in such cases little has hitherto
been attempted. I am of opinion, however, that in the case I have
last alluded to, a blunt hook may be sometimes introduced through the
wound into the stomach, so as to keep it stationary while the external
opening is carefully enlarged, and that it ought to be done in such
cases, and the wound in the stomach closed in the manner recommended.
I have never had a case under my care in which I could have done this;
but I have seen some die in whom it might have been done; and it
deserves to be considered when surgeons shall be in sufficient numbers
on the field of battle to attend to such recommendations, and to the
after-treatment these cases require.

When the stomach is injured by a musket-ball, and its contents are
discharged externally, the edges of the wound, not being in a condition
to unite, must remain open for several days. The person should be
placed in the mean time in the most easy and comfortable position
which may enable the contents of the stomach to be readily passed
out externally, if they show any disposition to be thus evacuated.
The external wound should be dilated as far as the peritoneum, if it
should be required, so as to admit of the passage being direct, and
symptoms must be awaited and treated as they arise. If the patient
should survive the first or inflammatory stage, he should be supported
by clysters composed of strong beef-tea or veal broth, given five
or six times during the twenty-four hours. When it may be expected
that the wound in the stomach has closed, or that the injured portion
has adhered to the neighboring parts, warm jellies and light broths
may be frequently given in small quantities, but solid food should
be forbidden until complete recovery has taken place. I have seen
inattention to this precaution in more than one instance prove fatal.

408. Fistulous openings have been known to follow wounds of the
stomach, and to continue for years. The case related by Dr. Beaumont of
the American army, of St. Martin, who, in 1822, received an extensive
wound in the stomach, which became fistulous, admitting of a variety of
most interesting inquiries being made into the process of digestion, is
remarkable.

Hevin has related some of the most interesting cases of those who had
swallowed knives, etc., by design or by accident, and whose stomachs
were opened for their removal. The most ridiculous story of the whole
is an instructive one, however. Some young students, desirous of
punishing a young woman who had offended them, cut short the hair of
the tail of a large pig, and when frozen hard, forcibly pushed it up
her anus, leaving a couple of inches only hanging out of the small
end or tip. The hairs having been cut short caught in the gut when
attempts were made to draw out the tail, and gave her inexpressible
pain. The most serious symptoms followed during six days, and every
attempt having failed, Marchetti was applied to. He prepared a hollow
tube two feet long, large enough to receive the thickest part of the
pig’s tail, to the end of which he fastened a strong waxed cord, which
he drew through the tube. This he carefully introduced into the anus,
pushing it over the pig’s tail, until he drew the whole of it into the
tube, which he then brought away, including the tail, to the great
relief of the sufferer.

409. The necessity for an operation so grave as that of opening the
stomach must be shown by the presumed impossibility of the foreign
substances being dissolved, or of their passing out of it by any other
means, while the continued distress they occasion more than equals the
risk which is likely to be incurred. The offending substance ought
to be felt through the wall of the abdomen, and the incision for its
removal should be made between the recti muscles in the linea alba,
unless the foreign body have actually pierced the stomach, and can be
felt to the outside of the rectus muscle, at which part the incision
ought to be made obliquely in the direction of the fibers of the
external oblique muscle, all bleeding vessels being secured before the
peritoneum is opened. This having been accomplished, the protruding
body should be extracted by such an enlargement of the opening in the
stomach as may be actually necessary. When the substance does not
protrude, although it can be felt through the wall of the stomach,
it will be advisable, if possible, to draw it toward the upper or
smaller curvature of the stomach rather than to the lower, avoiding
the coronary vessels, and taking a medium distance for the opening
from the cardiac orifice, and thereby such advantage as may be derived
from gravitation. The wound in the stomach should be united by the
continuous suture, and the external wound should be closed in a similar
manner. The patient ought to be kept in bed in an easy erect position.

410. _Injuries of the spleen_ have been usually fatal, from hemorrhage
filling the general cavity of the abdomen, especially when they have
arisen from rupture of that organ, which I have several times seen
occur in consequence of falls, or from blows from cannon-shot, which
have not opened into the cavity or exposed the viscus. Wounds from
musket-balls have for the most part destroyed the sufferers, either
from hemorrhage or from inflammation. I have not seen nor heard, during
the Peninsular war, of a wound in the abdomen through which the spleen
protruded, the patient recovering. Instances have occurred in which
this part has been removed in man after its exposure by injury. A case
is said to have taken place after the battle of Dettingen, in which
the spleen, covered with dirt, was cut off, and the patient recovered.
In another case the spleen, found without the wound at the end of
twenty-four hours, was cold, black, and mortified. The surgeon placed
a ligature above this part, and cut off three inches and a half of
the spleen; a large artery was tied, and the remaining portion of the
viscus was returned into the cavity of the belly, the ligature hanging
to it, and the patient got well.

Wounds from stabs with a bayonet, or a sabre, or long-pointed sword
are frequently fatal, either from hemorrhage or from inflammation;
but I have seen accidentally, after death, cicatrixes in the spleen
corresponding to external marks, indicative of a former wound. The
treatment, in all such cases, should be to encourage the discharge of
blood from the part, in the first instance; then to close the external
wound if an incised one, to place the patient on the injured side, and
to subdue all unnecessary inflammation by bleeding, leeching, absolute
rest, and starvation. The application of warm fomentations where an
oozing of blood may be expected to take place cannot be recommended,
and cold should be substituted if agreeable to the feelings of the
patient. When the blow or wound does not cause the death of the
individual by hemorrhage or acute inflammation, a chronic state of
disease may supervene, which, if not duly combated, will ultimately
destroy him. The early administration of calomel and opium, and the
repeated application of blisters, will, in these cases, as well as in
those of wounds of the liver, be of the greatest service. Effusion or
suppuration may take place as well as in those cases which have been
noticed, when other viscera have been injured; although instances of
such terminations are not recorded, it does not follow that they have
not taken place.

411. _Wounds affecting the kidney_ have been less fatal than those
of the spleen, although they are scarcely less dangerous, from the
complications by which they are attended; the successful cases on
record are not numerous, and the practice to be pursued can only be
general. The results, when not fatal, have been for the most part
unknown, from the patients either lingering on or recovering after they
have been discharged from the service. I saw two cases of this nature
after the battle of Waterloo. In one, the ball had passed through the
abdomen, entering a little below and to the left of the umbilicus, and
coming out behind nearly opposite and close to the spine. No fecal
matter was discharged from the front wound, but some came through the
posterior one, accompanied by a small quantity of urine, indicating a
lesion of the kidney or of the ureter at its upper part. The symptoms,
at first severe, had subsided under proper treatment, and there was
every probability that the sufferer would eventually recover, although
I was unable to trace the case after the man left Brussels. In the
other, pain was principally felt in the testis and the spermatic cord
of the side injured.

An officer was wounded on the right side, on the 9th December, 1813,
the ball being cut out behind; his case was considered hopeless. An
hour afterward, on being moved to the fire, he desired to make water,
and then passed what appeared to him to be a quantity of blood.
Carried to the rear on a wagon for three leagues, he suffered beyond
description, passed bloody water again, and on his arrival in quarters
was bled and had an enema administered. He then became delirious, was
bled several times, had blisters applied to the abdomen, suffered from
pain at the top of the right shoulder, and took no other nourishment
but tea for fourteen days. He gradually recovered, and at the end of
seven weeks was sent to England. After remaining some time in London,
he joined the depot of his regiment. In consequence of this exertion,
he suffered an attack of fever and peritoneal inflammation; and a
tumor formed in the site of the posterior wound, which was opened, and
discharged several ounces of matter of a urinous odor. Another abscess
formed, and was opened. During this time he suffered great pain and
became greatly emaciated; the urine diminished in quantity with the
frequent calls to pass it. He lingered in this state until the end of
July. The flow of matter from the wound was great, and had a urinous
smell. The desire to make water was incessant; but it passed only by
drops, and brought him to a state of frenzy; the discharge from the
wounds, which had been lessening for two days before, suddenly stopped;
the pain and pressure of urine became intolerable; he remained at last
in a state of the greatest torture for about three minutes, when,
during an effort, a burst of urine took place, colored with blood,
forcing out with it a hard lump, shaped like a short, thick shrimp,
three-quarters of an inch long, which proved, when examined next day,
to be the cloth which had been driven in by the ball. It must have
passed from the pelvis of the kidney or the ureter into the bladder. It
was hard, was covered by a black crust, and was thought to be a stone
when passed. It could not, however, have been long in the bladder, or
it would have been covered by the triple phosphates, and have formed
the nucleus of a calculus requiring to be removed by operation.

Le Capitaine Negre, of the French Infantry of the Line, was struck
on the left side above the hip, at the battle of Albuhera, by a
musket-ball, which went through the upper part of the sigmoid flexure
of the colon, and came out behind, injuring apparently the fourth and
fifth lumbar vertebræ. As urine came through this opening, the ureter
or lower part of the kidney must have been wounded; and, as he had
lost the use of one leg and much of that of the other, the spinal
marrow must also have been injured. He was left on the field of battle,
supposed to be about to die, and was brought to me to the village
of Valverde, three days afterward, in a most distressing state. The
inflammatory symptoms had been and were severe; the pain he suffered on
any attempt to move him was excessive; the discharge of feces from the
anterior wound, and of urine from the posterior one and by the usual
ways, rendered him miserable, and he at last implored me to allow the
box of opium pills, of which one was given at night to each man who
stood most in need of them, to be left within his reach, if I would not
kindly do the act of a friend and give them to him myself. He died at
the end of ten days, after great suffering, constantly regretting that
our feelings as Christians caused their prolongation.

412. _Wounds of the spermatic cord_ are of infrequent occurrence, and
rarely lead to fatal, although often to inconvenient consequences.

I have removed the bruised and shattered remains of a testis and
epididymis to expedite the cure, and I have been obliged to do so
at a later period in consequence of the wounded portion becoming
enlarged and diseased. These occurrences are rare; the wound in the
testis usually heals kindly; but the portion which remains, however,
is probably of little use, although the patient does not like to lose
it. A gentleman in perfect health was struck accidentally in the right
testis by two shot, while out shooting partridges. The shot lodged,
and gave rise to uneasiness, and after a time to an enlargement, which
could not be distinguished from medullary sarcoma. I removed the
testis, and the wound healed kindly. The lumbar glands had, however,
taken on the disease, and he died of their great enlargement and the
general mischief which ensued within the year. The preparation is in
the museum of the College of Surgeons.

I have not had occasion to tie an artery, even when the penis has been
as good as amputated. If bleeding should take place in the progress of
the cure, a large catheter should be introduced into the urethra, as
a point on which pressure may be made laterally; for I am not aware
of any other use it can be, unless the urethra be also torn, when a
moderate-sized catheter should be kept in it permanently, if it can be
borne, to aid in the healing of the surrounding parts with as little
contraction as possible of the canal. When the corpus spongiosum has
been carried away or sloughs with the urethra, there is usually some
injury done at the same time to the corpora cavernosa, and the part
becomes contracted and curved when distended. I have not seen any of
these cases since the introduction into practice of the methods which
have been recommended by Dieffenbach and others for the formation of a
new urethra by borrowing from the neighboring parts; but several might
certainly have been benefited by such treatment.

A married soldier, of the 29th Regiment, was wounded on the heights of
Roliça, in August, 1808, by a small musket-ball, which went through
both corpora cavernosa from side to side. The man suffered very little
inconvenience, and the wounds healed very well. He seemed to consider
the injury as of no importance to himself, but had some idea there
might be a difference of opinion in another party. There is usually a
deficiency of substance at the part after such wounds, and sometimes on
inconvenient curve or twist, such as often takes place when the corpora
cavernosa and the corpus spongiosum are injured or ruptured from other
causes.



LECTURE XXX.

WOUNDS OF THE PELVIS, ETC.


413. _Wounds of the pelvis_ from musket-balls injuring its contents are
of common occurrence, and, although frequently fatal, often permit a
considerable length of treatment before they destroy the sufferers or
admit of their recovery. In many instances fistulous openings remain
for years. The orifices of entrance and of exit of the ball lead to
little information. It is only from the absence of paralysis or of
hemorrhage, or of those signs which indicate the lesion of any of
the organs contained within the pelvis, that the surgeon can form an
estimate of the evil which has been committed; even when parts of the
greatest importance are injured, such as the bladder or the rectum, the
general symptoms are occasionally of little moment.

When paralysis occurs, which it rarely does unless the spinal marrow
be injured, the functions of the bladder and of the rectum are
implicated, and there is but little pain. When the nerves only are
injured, the paralysis is not complete; it usually affects one side
more than the other, is a numbness rather than a paralysis, and is
accompanied by severe pain, sometimes at the seat of injury, but more
usually extending to the thigh and to the extremities of the nerves in
the foot. I was consulted in a case of wound from a pistol-shot, in
the last dorsal or upper lumbar vertebra, of several years’ standing,
in which the paralysis of both limbs was complete. The patient had a
great desire to have the cicatrix opened, and the ball followed and
extracted, and would willingly have submitted to such an operation, but
he could not find any one in London or Paris willing to attempt it.

When a ball appears to cross or pass even from side to side of the
pelvis, it is not always easy to say whether it has penetrated the
cavity or not, until symptoms indicative of such injury appear; the
less done to such wounds the better. When a ball enters, strikes a
bone, and lodges, it is very desirable to ascertain its situation, in
order that it may be at once removed, if it can possibly be done with
but little comparative danger; for balls which lodge in these flat
bones may often be removed, and the comfort of the patient assured by
a timely operation, instead of proving the source of much torment and
misery for many years by their being allowed to remain.

The late Colonel Wade, one of the most distinguished officers of his
rank in Spain, was wounded at the battle of Albuhera, in 1811, by a
musket-ball on the left side; it passed through the ilium, and was
supposed to have narrowly avoided opening into the cavity of the
abdomen. It could not be followed beyond the bone. The inflammatory
symptoms were subdued in the usual time, and he gradually recovered
his health, some pieces of bone coming away from time to time. A small
fungous protrusion and discharge continued from the wound for several
years, with a certain degree of pain, and of occasional lameness in
the leg and thigh. The wound closed sometimes for a few months, and
reopened after an attack of pain, with great lameness and swelling
of the hip, and a discharge of matter from the original site. An
abscess at last formed under the gluteus maximus, and was opened at
its anterior and lower edge. This gave great relief and prevented the
irritation of the upper and anterior original wound, the matter finding
a more ready passage. I often assured him I could distinguish the ball
very deeply seated; and in the summer of 1846, thirty-five years after
the receipt of the injury, it had descended so far that I passed a
probe under it at the distance of two inches and a half from the lower
opening. He was to have come to London as early as his duties would
possibly permit, in the spring of 1847, to have had it removed, when he
was suddenly cut off by apoplexy, to the great regret of all who knew
him.

The late General Sir Hercules Packenham, G.C.B., was wounded at the
assault of Badajos by a musket-ball, April 6th, 1812, which deprived
him of the use of the thumb and little finger, and partially of the
hand; and by another which struck him on the right iliac region,
passing in just below Poupart’s ligament and outwardly through the
ilium. Eight pieces of bone came away at Elvas, and eleven more,
in 1813, in London. He went to Baréges in 1814-15-16-17, with the
hope that the ball might be loosened and removed, but in vain; it
never could be found. A small quantity of inoffensive glutinous
matter, sometimes streaked with blood, was discharged occasionally
from the seat of the injury. At times the wound became painful and
very troublesome for a week or ten days together, after which little
inconvenience was felt in the limb.

Colonel Sir J. M. Wilson, now of Chelsea Hospital, was wounded in
seven different places by three musket-balls on the left hip, at the
Chippewa, near the Falls of Niagara, on the 5th of July, 1814. One,
which struck him a little before the trochanter, passed upward through
the ilium, (from which several pieces of bone came away on four or
five different occasions,) and lodged against or in the spinal column,
rendering the left leg quite powerless, and impairing the power of the
right. He fell. Shortly after an Indian warrior came up, placed his
foot on his neck, drew out his scalping-knife, seized his hair, and was
in the act of beginning to scalp him, when a shot passed through his
chest and laid him prostrate by the side of his intended victim, who
thus happily escaped. The numbness and inability to put the limb to the
ground continued from eighteen months to two years, during which time
he was on crutches. After this he gradually recovered, always suffering
more or less. The pain in the back is often most excruciating, coming
on without any apparent cause, except perhaps from change of weather.
He limps after walking a couple of miles, and if exercise be continued,
pain ensues. He married in 1824, has several children, and is obliged
to lead a very regular, quiet life, without which he breaks down. The
great suffering he experiences, at the end of near forty years, is,
however, from the pain in the back, sense of coldness in the left leg,
and numbness accompanied by pain in the course of the nerves. He is
equally sensible to heat in a close atmosphere, which he is obliged
to avoid. The alvine and urinary secretions, etc. have always been
impaired or deranged since the wound was received. He is troubled with
painful affections and a train of nervous feelings of the whole system,
attributable to the injury. The ball can of late be felt at the bottom
of a soft swelling in the loins; but the colonel, since the affair of
the Indian, has no predilection for cold steel, and protests as loudly
against the scalpel of the surgeon as the scalping-knife of the Indian.

A soldier, of the Fourth Division of Infantry, was wounded at the
battle of Salamanca by a musket-ball, which entered immediately above
the right ilium, passed across, and made its exit nearly opposite
on the left side, going nearer to the back than to the wall of the
abdomen. He was supposed to be killed, but had recovered a little
life when brought to me at the field hospital some hours afterward.
The belly was swollen, generally tympanitic, and some hemorrhage had
taken place from the wound of entrance, and he was unable to move the
leg of that side. On reaction taking place, he was bled repeatedly,
and treated antiphlogistically with the aid of calomel, opium, and
antimony. He was removed to the San Domingo Hospital, and on the sixth
day the bowels were relieved naturally. A small quantity of fecal
matter was passed for several days with the discharge from the wound,
but this gradually ceased, and the man ultimately recovered without any
particular defect, except weakness and occasional pain and derangement
of bowels, on any irregularity.

John Bryan, 1st Light Battalion of the King’s German Legion, was
wounded on the 17th of June near Quatre Bras by a musket-ball, which
entered at the groin, and made its exit behind. He was transported
to Brussels, with his foot and leg in a state of mortification. Wine
and other stimulants were freely given, and he rallied a little
on the 23d and 24th. On the 25th, the stomach rejected everything
except brandy and opium. On the 26th, a line of separation seemed
to be about to form between the dead and the living parts, although
he was evidently failing. He died on the 28th, eleven days after
the receipt of the injury. On examination after death the ball was
found to have completely divided the external iliac artery; about a
pint of coagulated blood, mixed with some excessively fetid pus, was
collected in the pelvis; the ends of the wounded artery had receded
considerably from each other, and a coagulum had formed in each, which
was easily squeezed out, the orifice of the upper end only being a
little contracted. There were signs of some peritoneal inflammation
having taken place; the intestines had not been wounded, and the ball,
in passing out, had splintered the upper edge of the back part of the
ilium.

General Sir Edward Packenham was killed instantaneously at New Orleans,
by hemorrhage from a nearly similar wound, in which the common iliac
artery was divided.

414. I have removed balls on different occasions which have lodged
in the bones of the pelvis, and always with the greatest advantage,
when done early. I have seen much evil result from their being allowed
to remain, as they caused not only frequent distress, but at last
gave rise to disease in the bone, derangement of the general health,
and death. When the ball can be felt impacted in the bone, incisions
through muscular parts of little consequence should not be spared to
expose it. If an error exists at this moment, it is that too little
is done, rather than too much. Too great reliance is placed on the
efforts of nature, and not enough on the resources of art. The constant
meddling with a wound is not recommended; nevertheless, much may be
done by careful investigation from time to time, of which La Motte
gives a good example in his fifty-first observation.

A grenadier was wounded at the battle of Dettingen, in 1743, by a
musket-ball, which entered above Poupart’s ligament, near the opening
of the external oblique muscle on the left side, and lodged. Thirteen
days after his reception into the hospital at Landau, La Motte felt
with the probe what he thought was the ball lying on the outside
of the psoas muscle against the bone. He made the patient lie on
his face, and touched the foreign body every day in order to loosen
it. On the thirty-fifth day he was satisfied it was the ball, and
on the forty-fifth, after many attempts, it was at last extracted.
His fifty-second observation relates to a case as nearly similar as
possible to those of Sir H. Packenham and Colonel Wade. He made several
deep and long incisions in search of the ball, which he could not find;
the wound became fistulous, and at the end of a year closed, in all
probability to reopen from time to time.

The difference in practice between 1743 and 1855 ought to be, that in
1855 the ball should be found first, and the deep and long incisions
made afterward for its extraction; which do not preclude any previous
external openings that may be necessary to facilitate the first
examination.

Captain Campbell was wounded by a pistol-ball, on the 5th of September,
1805; it penetrated the abdomen on the middle of the right side,
and was extracted from nearly the same situation on the left; from
its irregular denticulated shape, it would appear to have impinged
against a vertebra. He complained of violent pain in the loins and
belly, with numbness and pain of the left leg and thigh, and suffered
also from the greatest oppression, anxiety, and sickness. An enema
was administered, and twenty-four ounces of blood were taken from
the arm; lower extremities nearly paralyzed; anxiety and oppression
great at night. Blood-letting to ten ounces. Cannot pass his urine;
hot fomentations; and at twelve at night sixteen more ounces of blood
were drawn. At three P.M., had three motions, the two last containing
apparently a pint of pure blood. Pain and other symptoms being urgent,
eight ounces more blood were taken away. At six P.M., passed urine for
the first time, highly tinged with blood; has had two motions, also
mixed with blood. Pain continuing, ten ounces of blood were abstracted,
although occasionally almost fainting on any movement; belly fomented.
At eight at night, sixty drops of laudanum. At ten, being very
restless, twenty drops more, which procured some sleep, although he
vomited frequently; belly relieved by the fomentation; three stools
mixed with blood.

Sept. 6th.--All the symptoms relieved; passes blood with his urine;
sickness and vomiting troublesome; pulse 90, rather firm than feeble.
One o’clock.--Complains of violent pain in the left leg and thigh,
belly, and loins; pulse 116, full and strong. Blood-letting to sixteen
ounces. Barley-water with niter for common drink. Six P.M.--Pulse 96;
bowels open, with discharge of blood; symptoms generally relieved.
Tincture of opium, twelve drops at night.

8th.--Slept better; less pain; paralysis continues. In the evening
symptoms aggravated; lost twelve ounces of blood; enema, etc. repeated;
pulse 120.

9th, 10th, 11th, 12th.--Pulse 96; bowels open; urine bloody; is
generally better.

15th.--Wound of exit healed; urine bloody; bowels open. Chicken-broth
for the first time.

20th.--The opening of entrance having nearly closed was enlarged, and a
free exit allowed for the matter.

Oct. 20th.--Wounds quite closed; is free from pain, is able to move
about the house on crutches; warm, stimulating applications to the
limbs seem to have given most relief.

Nov. 20th.--Paralytic affection gone; he can now mount his horse, and
has only a feeling of numbness and torpor in the left leg and thigh.

415. The general opinion which formerly prevailed, that _wounds of
the bladder_, by musket-balls, were for the most part mortal, is now
known to be erroneous. When the bladder is wounded below, where it is
not covered by the peritoneum, persons do sometimes recover by what
may be considered the almost unaided efforts of nature. A large number
of cases came under my observation at Brussels and at Antwerp, and
many had already died. Persons rarely recover in whom urine has found
its way into the general cavity of the abdomen. They generally die of
inflammation in from three to six days.

When the bladder is wounded where it is covered by the peritoneum,
and the opening or openings do not by some accident permit the urine
to flow into the cavity of the abdomen, the patient may be free from
immediate danger for a short time, although very anxious and greatly
depressed in countenance and manner, and even sick to vomiting. The
pain is not commonly severe at first, and if he can make water, which
in all such cases it is desirable to prevent by having recourse to
the catheter, it is more or less colored or mixed with blood. If the
urine should not escape into the cavity of the abdomen, the ordinary
inflammation which must necessarily ensue takes place and affects the
internal surface of the bladder. The desire to pass urine becomes
greater, and is frequently insupportable, while it can in some cases
be only passed by drops. In others these symptoms are less urgent.
Nevertheless, the natural action of the bladder, or, in those severe
cases, the additional efforts which are made for its expulsion by the
abdominal muscles, may cause the urine to be forced through the wound
into the cavity of the abdomen, whence the advantage to be obtained
from the early use of the elastic catheter. When the orifices of
entrance and of exit are free, and low down in the pelvis, the urine
may run out without much immediate mischief ensuing. But as this cannot
always be known, an elastic gum catheter should be introduced from
the first and fixed in the bladder, in every case where the nature of
the injury is doubtful, until the urine ceases to flow through the
wounds. It must, however, be recollected that in some cases in which
it has caused great irritation, by being introduced too early, while
the bladder was very sensitive, the patients have been much relieved
by its removal. The principle is nevertheless incontrovertible in all
doubtful cases; the urine should be allowed to drop out of the catheter
nearly as fast as it passes into the bladder, when this organ is
very irritable; great pains should also be taken that the end of the
instrument should be within, but not too far within the bladder, so as
to excite irritation by rubbing against its sides, or to allow its end
rising above the urine which might in this way collect below it, and at
last escape through the wounds.

416. The inflammatory actions are to be subdued by general bleeding,
the application of leeches, the administration of diluent drinks
in moderate quantity, the exhibition of gentle aperients, such as
castor-oil, and by enemata. Opium in all these cases is an important
remedy, principally in the shape of morphia. Opium in substance, when
introduced into the rectum in the shape of a suppository, or dissolved
in half an ounce or an ounce of water as an enema, should be repeated
in such quantities, beginning with two grains, as will procure ease.

417. The urine, in most cases of injury below the peritoneum, flows
readily through the wound of entrance, if not of exit, in the first
instance, and care should be taken, by enlarging the posterior wound,
that no obstacle within reach shall prevent it; but after inflammation
has been established, the parts swell, and as the sloughs begin to
separate, its passage is often obstructed; the elastic catheter, if not
used before, will then render important service by allowing the sloughs
to be separated without the healthy parts being irritated by the urine
being retained. After a time the urine may be only drawn off in small
quantities through the catheter, as frequently as circumstances may
render advisable. The permanent use of the catheter in these cases will
often prevent the urine from forming any devious paths as it proceeds
outward, ending in abscesses and fistulous openings, causing much
discomfort and even misery. It is not common for blood to be poured
into the bladder in such a quantity as to cause much inconvenience;
it coagulates with equal proportions of urine, and a silver catheter
should be used, by which it may be broken up and rendered more easy of
solution by injections of warm water. When the neck of the bladder or
the prostatic part of the urethra has been divided so that a catheter
cannot be efficiently used, surgery must come with more immediate aid
to the assistance of the sufferer, by making a clear and free opening
from the perineum for the evacuation of the urine and of the discharge
from the wound. If a ball lodge in or near the bladder, or in the
prostate, it must be removed by an operation in the perineum.

A soldier of the Light Division was wounded on the heights of Vera,
in the Pyrenees. A musket-ball had entered behind near the sacrum
and lodged. He was bled twice, in consequence of suffering pain in
the part, but was not otherwise much disturbed. There was at first a
difficulty in passing urine, but this gradually subsided, although
he always suffered pain in micturition, which was frequent and
distressing. He remained in this state until December, when he passed,
with considerable effort and after much difficulty, a hard piece of
his jacket about half an inch in length, larger than the orifice of
the urethra, through which it was forced. As it was not incased by
calcareous matter, it could not have been long in the bladder, but must
have been lodged near it before it ulcerated its way in, giving rise to
the constant desire and irritation which he had so long experienced.
His symptoms then subsided, although they had not entirely disappeared
when he left for England.

A French soldier was wounded by a musket-ball on the back part of the
right hip, at Almaraz, on the Tagus, was taken prisoner, and sent
to Lisbon in the autumn of 1813. The ball had lodged, but gave him
little inconvenience at the time beyond some pain in the course of the
sciatic nerve, subsequently followed by defect of motion on the right
side. Four months after the injury pain came on about the region of
the bladder, with great desire to pass urine, which he could not do
when standing, but which dribbled away when lying down. When quiet
he suffered little, but great pain followed any attempt at continued
motion. A catheter could be introduced, but with great difficulty when
it reached the prostate gland, which was exceedingly tender to the
touch. After a time the instrument could not be passed, and the man was
in great agony until something appeared to give way, and a discharge
of matter took place, when the urine followed, and he was relieved. An
abscess had formed, in all probability from the proximity of the ball,
which still could not be felt. The man recovered, retaining, however,
his former state of lameness and defect of power, although relieved
from the vexatious irritation of the bladder.

A soldier of the Fourth Division of Infantry was wounded at the battle
of Toulouse, while entering a redoubt, by a musket-ball, which entered
at the left groin, and, crossing the pelvis, came out on the upper
part of the opposite hip behind. The urine flowed from both wounds and
from the rectum, indicating that the ball had passed between these
parts, and a little feces came from the posterior wound for three
weeks. The pain and suffering were not great, and principally arose
from retention of urine, requiring the use of the catheter, which was
left in, and changed from time to time, until the urine flowed by the
side of it, instead of through the wounds, which it did occasionally
for some weeks in drops, but not in any quantity; after which the
wounds gradually closed, and the man was sent to England cured.

A soldier of the Cavalry of the King’s German Legion was struck, at the
battle of Salamanca, by a musket-ball, which entered just above the
pubes a little to the right side, and came out below on the opposite
nates. The urine flowed readily through both wounds for the first three
days, and he suffered afterward from great pain and distress about the
region of the bladder, from which he could not expel any urine, neither
would it pass by either wound. I immediately introduced a catheter,
drew off a moderate quantity of urine, and then fixed it in the
bladder, desiring him to draw off his urine every hour when awake. This
he did, often leaving the stopper out at night. The urine flowed after
a few days through the posterior wound, and then ceased. The catheter
was washed from time to time, and was at last withdrawn, as the urine
began to flow by the side of it, and the wound had finally closed when
he left the San Domingo Hospital.

Captain Martin received a wound from a musket-ball at the siege of
Ciudad Rodrigo; it entered just above the pubes, passed through the
bladder and rectum, and came out behind, splintering the sacrum, the
contents of both viscera being freely discharged through this opening.
As he suffered but little inconvenience from the urine, very little
of which passed by the urethra, that passage was not interfered with
in the first instance. Inflammatory symptoms were kept within due
bounds, the rectum was carefully washed out by emollient enemata,
and his food rendered as light as possible. Under this treatment he
gradually improved; the anterior wound first healed, and subsequently
the posterior one, leaving him comparatively well when he left me for
Lisbon on his way to England.

418. These cases give, however, a brighter view of the nature of
these wounds than they frequently justify; extravasation of urine,
inflammation, and death are not of infrequent occurrence in cases to
which strict attention is not paid; and great misery is often caused
from the irritation of the bladder and the discharge which follows,
until the constitution is undermined and death ensues.

Captain Sleigh, of the 100th Regiment, was wounded at the battle of
Chippewa, on the 5th of July, 1814, by a musket-ball, which entered
the left groin immediately over Poupart’s ligament, by the side of
the spermatic vessels, injuring in its course the anterior brim of
the pelvis. It thence passed through the bladder obliquely across
the pelvis, and terminated its course beneath the integuments in the
right buttock, whence it was immediately extracted. Blood and urine
flowed incessantly from the groin; the quantity of blood lost was
considerable. He complained much of pain in the hypogastric region;
the abdomen was tense and painful to the touch, and he had an almost
continued inclination to micturate; but his attempts, after the most
painful efforts, were entirely frustrated. The anxiety was great,
the respiration hurried, and the pulse quick and fluttering. He was
bled to the extent of thirty ounces; an enema was given; fomentations
applied to the belly; and the catheter introduced--all which afforded
him some relief. The next day he was removed to the rear, a distance
of seventeen miles, in an open wagon, partly during the inclemency of
the night, and was quite worn out by so long a journey. He was carried
thence on board ship, and landed at York on the morning of the 9th of
July, the fourth day after he received his wound.

July 9th.--Abdomen tense and painful to the touch; severe pain in the
perineum; great inclination to void urine, but fruitlessly; wound
in the groin sloughy, discharges urine and blood mixed with a small
quantity of pus; posterior wound healthy, no discharge of urine from
it; catheter attempted to be passed without success. Ordered an ounce
and a half of castor-oil immediately.

10th.--Passed a restless night; had two copious stools; voided a few
drops of urine by the urethra; still great inclination to pass urine.
Ordered two grains of extract of opium made into a pill.

11th.--All the painful sensations much relieved; abdomen less tense; a
small piece of bone extracted from the urethra about an inch in length,
of the thickness of a crow-quill; a little urine followed more freely.

15th.--Complains of severe pain in the spermatic cord; discharge from
groin more offensive; wound filled with large maggots; bowels open.

19th.--Wound of groin looks clean; a small piece of bone discharged by
the urethra, and a piece of cloth extracted from the groin.

24th.--A small piece of bone extracted from the groin.

August 5th.--Passes a good deal of pus and urine by the urethra.

29th.--Posterior wound much inflamed and very painful upon pressure. A
poultice to be frequently applied.

Sept. 1st.--An abscess has burst; a piece of cloth has been extracted;
urine and pus are discharged by both wounds.

12th.--Doing well; wounds closing.

16th.--Bladder resuming its power; discharge of matter from groin very
trivial.

Oct. 4th.--Posterior wound closed.

30th.--Wound of groin closed; urine, passed by the natural passage,
mixed with pus.

At first it was supposed that only the fundus of the bladder was
wounded; but when the collection of matter took place in the right
buttock, and a piece of cloth was extracted from it, the urine
following, it was evident that both sides of the bladder had been
transfixed by the ball; and that, probably, the urine from the
commencement had been prevented flowing posteriorly by the intervention
of this foreign body. An elastic gum catheter could not be passed into
the bladder on account of the piece of bone which had forced its way
into the urethra, and from its being obstructed afterward by smaller
pieces of bone.

When I saw this gentleman some time afterward, it appeared to me that
the purulent discharge from the urethra was not from the inner membrane
of the bladder, but was probably caused by some dead bone of the pelvis
having a communication with the bladder by a fistulous opening.

A soldier, of the King’s German Legion, was struck, at Waterloo, by a
musket-ball, which entered a little way above the pubes, and lodged.
The symptoms which immediately followed were by no means severe,
although he passed a little bloody urine at first; the external wound
closed without difficulty. He complained of pain at the neck of the
bladder, and had a great desire to pass urine, with other signs of
stone in the bladder, which induced me to pass a sound, when I found
that the ball was lying loose in that viscus. On his arrival at the
York Hospital, at Chelsea, from Brussels, he became, with the French
soldier, whose thigh had been amputated at the hip-joint, an object of
great attention. I performed the operation for the removal of the ball
in the presence of a large concourse of military and medical persons.
It was done in less than two minutes; but the calculus, composed of
the triple phosphates, which had formed around the ball, yielded, and
broke under the forceps. The pieces were removed separately. The ball,
being heavy, fell below the neck of the bladder, which, being healthy,
yielded to the pressure, and allowed it to sink on the rectum, where
it could not be caught by the forceps, until it had been raised by a
finger in the bowel. The bladder was then well washed out, so as to
remove all the pieces that might remain, and the man was placed in bed.
He was bled once in consequence of some apprehension of pain; but he
had not a bad symptom, and rapidly recovered.

The symptoms of irritation did not, however, entirely pass away, as
could have been wished, and I began to fear that some small pieces of
calculus had been overlooked; when, one morning, after considerable
effort, he passed a ring of sandy calcareous matter, which had formed
around the orifice of the bladder, and which, being dislodged, had
fortunately entered the urethra, along which it was forced by the
urine. It was evidently formed of the phosphates in minute portions,
which had become agglutinated together, around the meatus of the
bladder. This he took with him to Hanover, where it, himself, and
the cicatrixes of his wound, and of his operation, attracted great
notice. The ball, which was flattened on one side, I kept in a small
box, together with the pieces of calculus which were extracted, and
showed them annually at my lecture on this subject for many years. One
evening, however, I unfortunately left my little box on the table after
lecture; and when I recollected, and returned for it, I found that some
gentleman had borrowed it, and has not yet returned it. At the battle
of Chillianwallah a similar wound took place; the ball formed the
nucleus of a calculus, and was removed successfully by a gentleman in
the service of the East India Company, whose name I have not been able
to learn.

The following case, from Baron Percy, is in point: A young man was
wounded by a pistol-shot, which entered just above the os pubis,
through the linea alba, wounded the bladder, and lodged. The belly
swelled; a tumor formed in the perineum; no urine passed; the bowels
were confined, and fever ran high, with a tendency to delirium.
Believing that the tumor in the perineum, and the fluctuation he
thought he perceived, might be caused by extravasated urine, he
punctured it with a trocar, and evacuated a large quantity of bloody
urine. This induced him to enlarge the opening, and carry it on to the
bladder, through which he brought out the ball, some shirt, and several
clots of blood. The man was bled nine times in all; the urine after a
time passed in the ordinary way, and the patient slowly recovered.

An officer was wounded near Bayonne, by a musket-ball, on the left
side; it passed through the ilium across the pubes, and made its exit
through the gluteus maximus of the opposite side, but lower down. Urine
flowed through both wounds at first very readily, but none of any
moment came by the urethra, from which some blood occasionally oozed.
The attempt to pass a catheter failed, although the desire to make
water was urgent and painful. After a few days the passage of urine
by the external wounds became obstructed, apparently by the sloughs;
great pain and misery were experienced; fever ran high; rigors and
delirium followed extravasation of urine, and death closed the scene.
The mischief here arose from the catheter not having been passed into
the bladder, which could not be effected, from the prostatic part of
the urethra or the neck of the bladder having been injured.

419. Surgery in such, or in nearly similar cases, requires a catheter
or staff to be passed down the urethra as far as it will go; an
incision should then be made upon it, from the center or across the
perineum, and the urethra divided on the staff until the finger rests
upon the wounded parts, when, in all probability, a straight catheter,
with the aid of the forefinger in the rectum, can be carried through
them into the bladder. The urine will then have a direct passage
outward, instead of coming indirectly from the bladder by the wounds.
If the straight catheter cannot be passed, which can scarcely occur,
the central incision is to be continued from the point of obstruction
into the bladder, guided by the finger in the rectum. A free opening
from the bladder offers the only hope of safety.

420. The _rectum_ may be wounded without any other organ being injured
within the pelvis; of this I have seen several instances. Captain
Gordon, of the navy, was struck by a rifle-ball toward the lower part
of one side of the sacrum, after being knocked down by one he had
received on the head, and by another in the neck and back. The ball,
which passed into the rectum, made its exit on the opposite side of
the sacrum, and stercoraceous matters were evacuated by both wounds.
The pain was severe; the limbs were deprived of much of their power
of motion, and the next day the bladder was incapable of expelling
its contents. This was relieved by the catheter, and the rectum was
kept clear by warm, mild enemata, while the inflammatory symptoms were
subdued by bleeding, opium, starvation, and rest. At the end of three
months he was able to walk, but with some difficulty, on account of
defective power in one leg. Some small pieces of bone came away and
the wounds closed, although he was subject to an occasional slight
opening of the orifice of entrance, from which a little matter was
discharged, when it again closed. He remained more or less lame until
his death, which took place with the loss of the ship he commanded, in
a hurricane, on the coast of North America.

A French soldier was wounded at the battle of Salamanca by a ball,
which entered by the side of the sacrum, and lodged. Having been rode
over and bruised, he was taken prisoner, and brought to me on the field
of battle. From this wound he suffered comparatively little, except
from a difficulty of passing urine. On the third day after his arrival
at the San Carlos Hospital, or the sixth from the receipt of the
injury, he passed the ball per anum. The wound quickly closed, and he
aided his comrades as an orderly in the hospital afterward.


CONCLUSIONS.

421.--1. Severe blows on the abdomen give rise to the absorption of
the muscular structures, and the formation of ventral hernia, in
many instances; this may, in some measure, be prevented during the
treatment, by quietude, by the local abstraction of blood, and by the
early use of retaining bandages.

2. Abscesses in the muscular wall of the abdomen, from whatever cause
they arise, should be opened early; for although the peritoneum is
essentially strong by its outer surface, it is but a thin membrane, and
should be aided surgically as much as possible.

3. Severe blows, attended by general concussion, frequently give rise
to rupture of the solid viscera, such as the liver and the spleen,
causing death by hemorrhage. When the hollow viscera are ruptured, such
as the intestines or the bladder, death ensues from inflammation.

4. Incised wounds of the wall of the abdomen to any extent rarely unite
so perfectly (except, perhaps, in the linea alba) as not to give rise
to ventral protrusions of a greater or less extent.

5. As the muscular parts rarely unite in the first instance after being
divided, sutures should never be introduced into these structures.

6. Muscular parts are to be brought into apposition, and so retained
principally by position, aided by a continuous suture through the
integuments only, together with long strips of adhesive plaster,
moderate compression, and sometimes a retaining bandage.

7. Sutures should never be inserted through the whole wall of the
abdomen, and their use in muscular parts under any circumstances is
forbidden; unless the wound, from its very great extent, cannot be
otherwise sufficiently approximated to restrain the protrusion of the
contents of the cavity. The occurrence of such a case is very rare.

8. Purgatives should be eschewed in the early part of the treatment of
penetrating wounds of the abdomen. Enemata are to be preferred.

9. The omentum, when protruded, is to be returned by enlarging the
wound through its aponeurotic parts if necessary, but not through the
peritoneum, in preference to allowing it to remain protruded, or to be
cut off.

10. A punctured intestine requires no immediate treatment. An
intestine, when incised to an extent exceeding the third part of
an inch, should be sewn up by the continuous suture in the manner
recommended, _Aph._ 391.

11. The position of the patient should be inclined toward the wounded
side, to allow the omentum or intestine being closely applied to the
cut edges of the peritoneum. Absolute rest, without the slightest
motion, should be observed. Food and drink should be restricted, when
not entirely forbidden.

12. If the belly swell, and the propriety of allowing extravasated or
effused matters to be evacuated seem to be manifest, the continuous
suture or stitches should be cut across to a certain extent, for the
purpose of giving this relief.

13. If the punctured or incised wound be small, and the extravasation
or effusion within the cavity seem to be great, the wound should be
carefully enlarged, and the offending matter evacuated.

14. A wound should not be closed until it has ceased to bleed, or until
the bleeding vessel has been secured, if it be possible to do so. When
it is not possible so to do, the wound should be closed, and the result
awaited.

15. A gunshot wound penetrating the cavity can never unite, and must
suppurate. If a wounded intestine can be seen or felt, its torn edges
may be cut off, and the clean surfaces united by suture. If the wound
can neither be seen nor felt, it will be sufficient for the moment to
provide for the free discharge of any extravasated or effused matters
which may require removal.

16. A dilatation or enlargement of a wound in the abdomen should never
take place, unless in connection with something within the cavity
rendering it necessary.

17. If the epigastric, circumflexa ilii, or other artery in the wall
of the abdomen, be injured and bleed, the wound should be enlarged,
and the bleeding vessel secured by ligature. If the main trunk or the
external iliac artery be sought for and tied, the patient will in all
probability die.

18. When balls lodge in the bones of the pelvis, they should be
carefully sought for and removed, if it can be done with propriety and
safety.

19. In a wound of the bladder, an elastic gum catheter should be kept
in the urethra, frequently without a stopper, until the wound is
presumed to be healed--unless its presence should prove injurious, from
excess of irritation, not removed by allowing the urine to pass through
it by drops as it is brought into the bladder.

20. In all cases in which a catheter cannot be introduced, in
consequence of the back part of the urethra or the neck of the bladder
being injured, an opening for the discharge of the urine should be made
from the perineum into the bladder. It is essential to the preservation
of life.

21. The treatment of all these injuries must be eminently
antiphlogistic, principally depending on general and local
blood-letting, absolute rest, abstinence from food, and in some cases
almost even from drink, the frequent administration of enemata, and the
early exhibition of mercury, and especially of opium, in the different
ways usually recommended, with reference to the part injured.

422. As the operation for opening into the colon may be necessary,
after an injury of that part, as well as from disease below it, the
following method, recommended by Mr. Hilton, is briefly transcribed
from the Reports of Guy’s Hospital. A line drawn parallel to the
spinous processes directly downward from the angle of the seventh,
eighth, or ninth rib across the costo-iliac space to the crest of
the ilium, will correspond with the outer edge of the erector spinæ
muscle and the apices of the transverse processes. A measured inch
outwardly corresponds with the outer edge of the quadratus lumborum
muscle. A vertical incision, two inches long, made at the extremity
of the measured inch, should divide the skin, cellular tissue, and
the tendon of the internal oblique muscle, and expose the outer edge
of the quadratus lumborum muscle. Any bleeding vessels to be secured.
The last dorsal nerve, if seen lying across the upper part of the
incision, should be divided, to prevent the occurrence of pain from
its being engaged in the cicatrix. The transversalis abdominis muscle
is then to be divided vertically to nearly the same extent of two
inches, parallel to the edge of the quadratus, when a quantity of loose
lobulated fat will be seen, which should be partly removed and partly
displaced by the blunt end of a director, in the vertical direction
of the original incision, when the intestine will be brought into
view. Any bleeding vessels should be secured, and pressure made on
the abdomen, which will cause the intestine to become more prominent
at the bottom of the incision. A silk ligature is now to be passed
into the bowel and through the integuments at the upper part, so as to
fix the intestine above, when a second ligature is to be applied in a
similar manner below. The intestine is then to be opened between them,
care being taken to apply another ligature above and below it, if
the intestine should not appear to be firmly held in its place. If a
vessel in its wall should bleed, it must be tied. Inflammation, pain,
and restlessness should be obviated as far as possible by fomentations,
opiates, and diaphoretics, and strict attention paid to cleanliness and
the comfort of the patient, until the first symptoms have passed away,
and he is able to assume the erect position.

423. These commentaries are restricted to those points which
constitute, in a great degree, what the French call _la haute
chirurgie_. They are published that every soldier should have the
opportunity of knowing how he ought to be treated, when suffering for
a country not too grateful for the services rendered by her bravest
sons; and I have labored with the hope that some few of them, when
they find that their limbs, perhaps their lives, have been saved under
the precepts I have laid down, may acknowledge, when I am beyond that
bourn whence no traveler returns, that they owe them, under the will
of God, to those efforts I, more than any one else, have made, and
continue to make, for the adoption of that practice which led to their
preservation.



ADDENDA.


Several reports and cases having reached me from various medical
officers in the Crimea, too late for publication in their proper
places, I have thought it best to notice some generally as to results,
others particularly. Chloroform has been freely administered in all the
Divisions of the army save the Second, and has been generally approved;
one death only, as far as is known, having occurred directly from its
administration, of which Staff-Surgeon Gordon, P.M.O. of the Second
Division, has favored me with the following report:--

Martin Kennedy, 62d Regiment, aged 32 years, a healthy soldier, having
accidentally wounded one of his fingers by his musket going off, and
the medical officer in charge considering it necessary to remove it,
was brought under the influence of chloroform, but, according to his
(the surgeon’s) statement, only about ʒij could have been inhaled. He
had commenced the operation, when the patient suddenly expired. On the
post-mortem examination, beyond a little fatty deposit on the external
surface of the left ventricle, together with a degree of hypertrophy
of the same, no morbid appearance existed. The usual restoratives were
resorted to, but ineffectually.

The following case, furnished by Assistant-Surgeon Hannan, 49th
Regiment, is given as an illustration of the success of amputation
without chloroform in the Second Division:--

Patrick Kenny, 49th Regiment, aged 22. This soldier, while on duty
in the trenches on the 21st of July, received a compound comminuted
fracture of the right humerus, extending from its middle third to the
head of the bone. The integuments of the outer and upper part of the
shoulder were carried away. There was also a contused and lacerated
wound of the left knee, opening into the joint, with comminuted
fracture of the patella, these injuries being caused by pieces of
shell. He was seen a quarter of an hour after admission by Dr. Gordon,
P.M.O., who removed the arm at the shoulder-joint, making a sufficient
flap from the integuments of the axilla. The thigh was then amputated
in its lower third. These operations were performed in immediate
succession without the administration of chloroform. The thigh healed
nearly by the first intention--all the ligatures having come away by
the fourteenth day. The shoulder healed by granulation--the ligature
of the axillary artery coming away on the twenty-first day. During the
progress of treatment he had not any constitutional disturbance further
than three slight attacks of diarrhœa. He is now up and about, and goes
to England by the next opportunity.

In the worst cases of amputation at the hip-joint, or at the upper
third of the thigh, chloroform has appeared to cause insensibility
to pain without diminishing the powers of the sufferer, when given
with due caution or not carried so far as to affect the pulse or
respiration. (See _Aphor._ 51.) The evidence on this point is
sufficient to authorize surgeons to administer it in all such cases,
with the expectation that it will always prove advantageous, an
accidental death, such as has been observed from its use, being
independent of the nature of the injury. The amputations performed
at the hip-joint, at least six in number, have not been successful
as to the result, although the sufferers bore them well in the first
instance, offering every prospect of recovery for days and even for
weeks.

Deputy Inspector-General Taylor informs me, and his opinion is
corroborated by all the medical officers, that the labors the
troops had to perform, the privations they suffered, the frequent
insufficiency of their food, the want of proper clothing, with other
depressing causes, had so deprived them of that power British soldiers
generally possess, that all the operations of importance performed on
the lower extremities were more or less unsuccessful, while those on
the upper were as remarkable for their success. This deprivation of
power, it is said, was even more observable in the French army; and
he informs me that most of their surgeons had declined performing any
of the great operations usually done on the upper third of the thigh,
in consequence of their almost certain failure, preferring to let
the injuries take their course, even unto the death of the sufferers,
rather than hasten their dissolution by any operation usually
considered and often found to be conservative; a lamentable state of
things from which governments may draw an inference of the utmost
importance, viz., that to guard against the effects of disease as well
as of injuries, the utmost pains should be taken to preserve the health
and maintain the vigor of their soldiers. A matter of expense as well
as of arrangement.

This statement is corroborated by Deputy Inspector-General Alexander,
who informed me, on the 3d of August, 1855, that “during the whole of
this campaign, where we have had ample opportunities of testing the
use of chloroform, both after the battles of the Alma and Inkerman, as
well as throughout the whole siege operations before Sebastopol, up to
the present period, no operations whatever of any consequence (save
with one or two exceptions, and then at the patients’ own request,)
have been performed in the Light Division, without first placing the
patient under the influence of chloroform, and in no single instance
have either the medical officers of the Division, or myself, seen any
bad results follow, or had to reject its use, but quite the contrary.
Of course, in such a campaign, many operations of the most serious
character, both on the upper and lower extremities, have been performed
in the Division by the different medical officers as well as by myself.
At the Alma, I operated upon three patients at the hip-joint, two
being our own men and the third a Russian. All the three patients were
first placed under chloroform, with the results above stated. In the
case of a soldier of the 90th Regiment, whose right arm I removed at
the shoulder-joint on the 10th of July, for great destruction of the
soft parts and extensive injury to the humerus, the patient was so
low when placed on the table that brandy and water was given to him,
and he was then immediately afterward placed under chloroform. When
I had finished, it was found that his pulse was stronger than before
commencing the operation. In Sir T. Trowbridge’s case, in which I had
to remove both feet, one at the ankle-joint and the other above it, he
was placed under chloroform for both operations, a few minutes having
been allowed to elapse before giving it to him again for the second
operation, and with the best results. Both feet were much injured
by round shot, the bones of both being completely smashed with great
destruction of the soft parts, so much so, that in the case at the
ankle-joint I had to form the flap from the cushion of the heel. I,
however, did not remove the articular surface of the lower end of the
tibia, as recommended by Mr. Syme, and the wound healed well. Of the
three cases mentioned at the hip-joint, two were performed on the 21st,
and the Russian on the 22d of September. At one of the former I was
assisted by the late Dr. Mackenzie, from Edinburgh. All three were
carried down on the 22d, to be placed on board ships for conveyance
to Scutari. It has been reported to me that one of the two operated
on, on the 21st, Peter Sullivan, 33d Regiment, died at Scutari General
Hospital on the 11th of October, three weeks from the date of the
operation, ‘from excessive debility.’ Nothing could be ascertained
about Peter Cleary, 23d Fusiliers; it is therefore most likely that he
died on the passage.

“The Russian died on the 22d of October, ‘from great debility and
extensive sloughing.’

“A shoulder-joint case in the 90th Regiment never had a bad symptom,
and the wound is all but healed. The flap in this case was made from
the axillary portion of the arm, the deltoid having been all but
destroyed.

“The flap operation has been invariably performed in the Light
Division, with but two exceptions, viz., one of the arm and the other
of the thigh.”

Excision of the head, neck, and trochanter of the femur, with portions
of the shaft, has been performed at least six times before Sebastopol.
The result has been unfavorable in five, although in all there were
well-grounded expectations of success for weeks. In one case by Mr.
Blenkins, of the Grenadier Guards, he informs me, it was for the first
three or four weeks very favorable. The man, however, sank at the end
of the fifth week from deposition of matter in the knee-joint. (See p.
42 et seq.) Of the second case, which occurred in the general hospital
in the camp and ended fatally, I have no further notice. The third, in
the 68th Regiment, in charge of Mr. O’Leary, the operation performed on
the 19th of August, was going on most favorably on the 5th of October.

Private Thomas M’Kenena, aged twenty-five, was struck by a fragment of
shell, on the 19th of August, over the great trochanter of the left
femur. The wound, nearly an inch in length, extended down to the bone,
which was distinctly fractured. Some loose scales could be felt at
the bottom of the wound. On examination, the injury appeared to be a
transverse fracture of the neck of the thigh-bone, apparently involving
the joint.

After a consultation with superior medical officers, it was decided
that excision should be performed, which was done without difficulty.
No vessels required ligature, although the man lost a considerable
quantity of blood.

The excised parts, which are herewith forwarded, show that the nature
of the injury was different from what it was supposed to be, and that
the head of the bone was intact.

After the wound, about five inches long, had been sewn up, the limb was
placed in a sling made of strong canvas, and was swung from a beam over
the man’s cot, the bed being raised.

This method of treatment was adopted with a view to encourage
approximation of the upper end of the bone to the pelvis, and by
pressure on the sides of the limb to prevent the accumulation of matter
among the tissues. The man progresses favorably.

Diet was very generous.

  J. C. O’LEARY,

  _Surgeon, 68th Light Infantry_.

 Camp, 4th Division, Crimea, Sept. 14, 1855.

The bones removed are in the museum of the Royal College of Surgeons.

The fourth case is given at length by Staff-Surgeon Crerar, as
follows:--

Private William Smith, First Battalion First Royals, was brought to
hospital from the Greenhill trenches, in front of Sebastopol, about
twelve P.M., on the 6th of August. On questioning him, I ascertained
that an hour or so before he was struck by a fragment of an exploded
grenade, which first broke into small pieces a water canteen which
was suspended over the left hip, and then made an opening or wound
about the size of a shilling nearly a quarter of an inch posterior
to the great trochanter. Crepitus was quite distinct on moving the
limb; and I easily ascertained, on exploring the wound with my
finger, that a fracture through the trochanter had taken place, but
was quite unable to ascertain to what extent upward and downward the
fracture extended. I accordingly solicited a consultation with Deputy
Inspector-General Taylor and Staff-Surgeon Paynter. After a careful
examination, (the patient being under the influence of chloroform,)
the femur was discovered to be comminuted. Excision at the hip-joint
being recommended by these officers, in which opinion I concurred, I
proceeded to perform the operation by commencing an incision, nine
inches in length, in a line with and two inches posterior to the
anterior superior spinous process of the ilium, and carrying it down in
a straight line directly over the trochanter major; a second incision
about two and a half inches in length was made, commencing immediately
below the trochanter backward through the gluteus maximus; by a little
easy dissection the seat of fracture was exposed, the trochanter was
found broken into several portions, detached and imbedded in the
contused muscles around, from which they were at once removed. The
fracture was found to extend obliquely inward about an inch and a
half along the shaft of the bone. The femur was now protruded through
the wound, and I sawed off the whole of the fractured bone, leaving a
smooth, clean surface; I then proceeded to disarticulate the head of
the femur, which was effected without difficulty. Scarcely three ounces
of blood were lost, and little or no shock was induced; only one small
bleeding point was secured near the tail of the wound, and the divided
parts were brought together by two sutures and bands of adhesive
plaster.

At twelve A.M., two hours after the operation on the 7th instant, his
pulse being rather feeble, he was ordered some wine and water.

7th, vespere.--Countenance cheerful, voice strong; says he intends
keeping up his pluck, and is sure he will get well; has no inclination
to take the beef-tea ordered for him, but has had some arrow-root and
wine. To have a morphia draught at bedtime.

8th.--Passed a good night; limb in a good position; retracted about two
inches; wound looks healthy; pulse 100, soft; has made urine freely;
skin moist; bowels were opened freely in the night.

9th.--Slept well at night; says that he feels very comfortable; skin
moist; pulse 120; sutures were removed, and the wound allowed to gape;
it has a remarkably healthy appearance. To go on with the simple water
dressing, chicken-broth, arrow-root, and wine.

Vespere.--Has been very cheerful all day; limb has retracted about
another half inch; pulse 112.

10th.--Passed a more restless night, in consequence of not having the
morphia draught as early as the previous night; has had several hours’
sleep this morning, and is more refreshed; pulse, on waking, from 114
to 120, skin comfortable; no sign of distress in his aspect; wound
suppurating healthily; bowels were opened again once last night.

10th, vespere.--Has been very easy all day; skin cool; tongue normal;
pulse 120, soft and regular; has had to-day two eggs, one ounce of
arrow-root, two gills of wine, and two pints of chicken-broth, all
of which he relished much. To have a grain of acetate of morphia in
solution at bedtime.

11th.--Slept soundly all night; when I visited him, at six A.M., he had
just awoke; pulse 115, soft; appears contented and comfortable.

Vespere.--Doing well; wound continues to look healthy; position of
limb good; has consumed a fair quantity of chicken-broth, beef-tea,
arrow-root, and three gills of sherry to-day; pulse 113 at eight P.M.

12th.--Bowels were opened in the night; the introduction of the bed-pan
gave him a good deal of annoyance; the air of the hut was rather
stagnant last night, and he did not sleep as well as usual; pulse 120,
soft; tongue continues clean and moist; there is more discharge from
the wound to-day.

Vespere.--The progress of the case is most satisfactory; had a fresh
egg, tea, and toast for breakfast, his own selection, which he appeared
to relish greatly; at twelve he had two mutton-chops and a glass of
wine, and at five P.M., a pint of chicken-broth, with bread, and a
second glass of wine. The morphia draught as usual.

13th.--Continues to look happy and contented. Healthy-looking
granulations are evident over two-thirds of the wound; swelling of limb
subsiding; discharge from wound healthy; pulse 114, regular and soft;
all the symptoms are so very favorable that I have every reason to
expect a successful issue.

14th.--A small slough at the lower part of the wound, remainder healthy
and clean; tongue a little too dry this morning, and he has more thirst
than usual; pulse 118. To have effervescing draughts of bicarbonate
of potassa and citric acid three times a day; to continue simple water
dressing.

Vespere.--Thirst not so urgent; tongue cleaner and moister; has a
feeling of fullness in the abdomen. To have his usual morphia draught
and an ounce of castor-oil at bedtime.

15th.--Passed three large stools in the night, with great relief;
aspect resigned, and his spirits continue good; slough has come away;
pulse 118, soft and regular; skin tolerably cool.

Vespere.--Felt a good deal exhausted to-day from the heat, which was
very great--ninety-two degrees.

16th.--Looks heavy and out of spirits this morning; discharge has
increased, but is of a better quality since the slough separated;
tongue dry, inclined to brown; pulse the same, skin rather hot;
continue effervescing draughts every third hour.

Vespere.--Tongue more moist, less thirst. When asked how he felt, he
replied, with a great deal of life in his countenance, “I am very well,
and I feel very comfortable;” asked for a mutton-chop early in the day,
which he got, and appeared to like; he had at different times in the
day arrow-root, chicken-broth, and wine.

17th.--Wound looks very healthy, and the general symptoms very
favorable to-day; tongue clean and moist; less thirst; skin cooler; had
him removed to a fresh bed without a great deal of pain or trouble;
limb retracted less than three inches; position now good since he was
shifted.

18th.--Very much worse this morning; had a rigor about ten A.M.
yesterday; features now sharpened and pinched; tongue dry and brown;
pulse thready, about 125.

Vespere.--Continues in a very low state; wound has a very healthy
appearance; discharge healthy, but not as abundant as it was; has had
besides wine, a pint and a half of porter, mutton-broth, and a chop
to-day; zinc lotion to the wound.

19th.--When I visited him at six A.M. to-day, I was much pleased
to find him looking quite cheerful; pulse soft, 112; skin cool and
moist, paler than usual; wound doing well. Continue zinc lotion to
the sore, and to have his choice to-day of mutton-broth, beef-tea, or
chicken-broth; arrow-root to be given twice, four gills of sherry or
port as usual.

Vespere.--No change to report.

20th.--Looking rather pale, and features pinched; pulse better, about
100, soft; skin cool; tongue more coated than usual, inclined to be
dry. I fear this case is a bad one, not likely to terminate as we so
much desire.

Vespere.--Has been very uneasy all day; skin hot; tongue dry.

21st, six A.M.--Has just awoke, having been asleep since nine last
night; says that he feels stronger; aspect certainly improved since the
last visit; coating on the tongue thicker, brown; the pulse has more
strength than it had yesterday; no feeling of uneasiness; wound looking
remarkably well, and discharging laudable pus; asks for cold drinks;
to have his choice of iced soda, tamarind, toast or rice water; diet
the same as yesterday.--Eleven A.M.: has fallen off very much since
the morning, features pinched and blue; pulse irregular, small, and
wiry.--Twelve nocte: continues to sink; died at half-past twelve P.M.

Examination of the limb six hours after death.--Cut surfaces of femur
perfectly smooth; bone easily denuded of its periosteum; acetabulum
smooth; muscles infiltrated with pus; nature had not made the slightest
attempt to repair the loss.

What would the result have been if amputation at the hip-joint had
been performed? The same. The vis medicatrix naturæ is not sufficient
to carry our sick through such formidable operations; it is no fault
of the surgeons. A better and a more liberal allowance of animal and
vegetable food during health is required, if England expects her
soldiers to survive severe operations, disease and wounds. An attempt
to save the limb, for the very same reason, would, most undoubtedly,
have been a failure. Our Minié rifle-ball fractures of the femur all
sink under conservative surgery. Our amputations above the middle of
the thigh have a like issue; it is truly disheartening.

  J. CRERAR, _Surgeon_, _68th Regiment_.

 Camp before Sebastopol, 24th August.

 Dr. Crerar was greatly distressed by the loss of this man, and the
 manner in which he expresses his grief is declaratory of his feelings.
 The excised bones are in the museum of the Royal College of Surgeons.

The fifth, by Dr. Hyde, ended fatally on the sixth day.

Corporal Benjamin Shehan, 41st Regiment, advanced with his corps, about
twelve o’clock, on the 8th of September, to storm the Redan. Having
succeeded in getting into the work, the regiment was afterward obliged
to retire; in the retreat to our trenches he was wounded, and lay on
the field till the following day, when he was brought to the hospital
of the Royal Sappers and Miners. On examining the wound, it was found
that a grape-shot had entered at the great trochanter, and, passing
inward and a little forward, had passed out at the groin of the same
side, about an inch below Poupart’s ligament, externally to, and a
little in front of, the femoral vessels. The lower fragment of the
fracture protruded through the external wound, and the introduction of
the finger discovered a comminuted state of the neck of the bone.

Excision of the joint having been decided on, the operation was
performed in the presence of Deputy Inspector-General Taylor,
Staff-Surgeon Dr. Paynter, and Surgeon Elliot, Ordnance Department.

Operation performed about one P.M. 9th of September.--An incision,
about four inches in length, commencing a little above the trochanter,
was carried downward along the outer side of the femur. The lower
fragment, for about an inch of its extent, was cleared of its
attachments. An assistant holding the thigh below, and pushing the bone
upward and outward, so as to bring the fragment through the incision,
about an inch of the bone was then sawed off. The head of the bone
was next dissected from the socket; this part of the operation was
considerably facilitated by an assistant catching a firm hold of the
neck by means of a pair of tooth forceps, then rotating the head,
and using slight force to dislodge it from the cavity, the operator
dividing the capsular and round ligaments, the latter of which is
more easily and safely divided at the lower and outer side of the
articulation. The upper part of the trochanter was next dissected out,
and several small spiculæ of bone removed. The edges of the incision
were then brought together by sutures, and a bandage applied. It was
not found necessary to tie any vessel, and there was very little
hemorrhage. The man bore the operation well, and was returned to his
bed in good spirits, and with a good pulse.

10th.--Passed a good night; slept pretty well; pulse 106, soft; skin
cool; in good spirits.

11th.--Slept some hours; pulse 106, soft; bowels open; tongue furred,
but moist. Wound dressed and looking well; some healthy discharge.

13th.--Going on apparently very well; pulse still 106; countenance
good. Vespere: Complains of an increase of pain in the hip, but
otherwise says he feels much as usual; pulse small and rapid. Ordered
wine and arrow-root.

14th.--Died at six this morning.

The autopsy showed a considerable cavity filled with sanies in the
situation of the operation, but no other fractured bone was discovered.
The articulating surface of the acetabulum was coated by a fetid, pasty
substance.

  GEO. HYDE, M.D., _Staff-Surgeon_.

 The sixth, by Staff-Surgeon Coombe, also ended fatally.

Private James Nadauld, aged twenty-one, First Battalion Rifle Brigade,
was admitted into the Castle Hospital, Balaklava, upon the 16th of
July, 1855, five days after the receipt of a gunshot injury of the
right shoulder. Upon the 19th of July the head of the humerus was
excised, and the ball was found impacted in it. The healing process
went on most favorably, and the man was discharged upon the 26th of
August, quite well, for the purpose of proceeding to England. The
excised bone is in the museum of the Royal College of Surgeons.

  W. H. McANDREW, M.D.,
  _Surgeon, 57th Regiment_.

 Camp, Sebastopol, Sept. 14th, 1855.

Private John Purcell, 57th Regiment, aged twenty-one, was wounded
upon the 18th of June, in the unsuccessful assault upon the Redan,
by a Minié rifle-ball, which passed directly through the head of the
humerus, but did not touch the glenoid cavity. Upon the 22d of June,
the head of the bone was excised; and upon the 26th of August, the man
was discharged from hospital, quite well, for the purpose of proceeding
to England. The excised bone is in the museum of the Royal College of
Surgeons.

  W. H. McANDREW, M. D.,
  Surgeon, 57th Regiment.

 Camp, Sebastopol, Sept. 14th, 1855.

The following case of wound of the larynx is instructive:--

Lieutenant Charles H. Evans, 55th Regiment, aged nineteen years, was
wounded on the evening of the 5th of August, 1855, about eleven o’clock
P.M., while on duty in the trenches. The ball entered the right side of
the neck, close to the angle of the jaw, and passed apparently between
the hyoid bone and the arytenoid cartilages, and then downward, having
its exit below the cricoid cartilage on the left side. The pharynx
and larynx were wounded, and the trachea was contused and displaced.
Respiration somewhat hurried; a quantity of mucus collects in the
trachea, and is expectorated in fits.

About seven o’clock P.M. of the 6th, the respiration becoming more
difficult, with a degree of lividity of the lips, indicative of the
non-oxygenation of the blood, it was deemed advisable to have recourse
to tracheotomy, which, in consequence of the displacement of the parts
and the swelling, was effected with considerable difficulty. The
usual tubes were found too short for the purpose, and a large silver
catheter was inserted, through which the air passed freely. Whenever
he attempted to drink, the liquid passed into the trachea through the
openings caused by the ball. From the operation no benefit arose, and
he continued very restless until within an hour of his decease, which
took place about twenty-six hours after the receipt of the wound. The
voice was never heard above a whisper.

Post-mortem examination, twelve hours after death. The ball would
appear to have passed through the hyo-thyroid membrane, fracturing and
shattering the thyroid cartilage. The membrane lining the glottis was
torn and destroyed. The vessels escaped without injury, the ball having
passed anteriorly.

  ARCHD. GORDON. M.D.,
  _Staff-Surgeon, 1st Class, in Med. Charge, 2d Division_.

 Camp before Sebastopol, September 3, 1855.

Deputy Inspector-General Taylor, who was present during the operation,
adds: “The want of a longer tracheal tube than is commonly supplied
for such operations was obvious, and is a good practical hint. For
the first time in my life I found my two forefingers transfixing a
man’s neck from side to side. The fingers did not cause any cough or
irritation, but those symptoms were occasioned by the least attempt to
swallow water. The thyroid cartilage was separated into two pieces.”

The following cases, one of wound of the profunda femoris, the other of
the popliteal, deserve attention:--

Late in the afternoon of the 14th of August, Private George Irvine,
aged twenty-five, was brought from the trenches, having been struck by
a Minié-ball of the largest size, which had penetrated the left thigh,
about two inches below Poupart’s ligament, just in the course of the
femoral artery. The ball passed slightly outward, fracturing the femur,
and was cut out at the back of the limb, completely flattened. As there
was considerable hemorrhage, both venous and arterial, no examination
with the finger was permitted. Dr. Taylor, superintending the Division,
having been informed of the case, a consultation was held.

Amputation at the hip-joint was forbidden by the prostration of the
man, who had lost much blood before he was brought to camp. Excision
of the head of the femur was also inadmissible, from the evident wound
of a large artery, with probably that of a large vein. Search for
the wounded artery, for the purpose of applying a ligature, was then
determined upon, but before the operation had well proceeded, the
hemorrhage was so great that it was found impossible to continue it,
and pressure by means of graduated compresses was resorted to, with
complete success.

On the following morning an operation was still out of the question.
Prostration continued, with great irritability of stomach, and a small,
quick pulse. No return of hemorrhage, though the pressure of the
tourniquet was but very slight.

On the 16th, the pulse was more quick and irritable, with the same
irritability of stomach, and urgent thirst. He had passed a better
night, however. At the consultation this morning, the circulation
through the posterior tibial artery was so evident that the question of
the femoral artery being wounded was set at rest. It was decided, as
no return of hemorrhage had occurred, that the case should be left to
nature.

On the 17th, he suffered from starting pains in the thigh. There
was less irritability of stomach, but the pulse was very small and
weak. During the night there was slight hemorrhage, owing to his
restlessness, but it was easily arrested by a turn or two of the
tourniquet.

On the evening of the 20th, this restlessness increased; delirium set
in, and early in the morning of the 22d he died.

The limb was examined after death, when the following appearances
presented:--

Femoral artery intact. Femoral vein wounded, with more than half its
caliber shot away. At about two inches from its origin there was a
wound of the profunda artery, on which an aneurism, nearly the size of
a pigeon’s egg, had formed, and passed upward through the wound made
by the ball. The profunda vein was intact. The injured vessels having
been removed for preservation, the bone was then cut down upon, when a
fracture, nearly transverse, and not at all comminuted, was observed
below the trochanters. No splitting of bone upward; downward its outer
plate was slightly cracked, but nothing more. The preparation is in the
museum of the Royal College of Surgeons.

Private James Ross, a lad of eighteen, was brought up from the
trenches, on the morning of the 3d inst., having had his right
leg blown off below the knee by a round shot. He had lost a very
large quantity of blood before the tourniquet was applied, and was
consequently so much collapsed that an operation was out of the
question. He was therefore dressed and the tourniquets (two had been
put on) removed. He never rallied, and died on the 12th, nine days
after the receipt of the injury. No hemorrhage ever occurred, though
all pressure had been removed from the artery.

  R. V. DE LISLE,
  _Surgeon, 4th King’s Own Regiment_.

 Camp before Sebastopol, Sept. 14, 1855.

The following is worthy of publication, as showing the successful
effects of strychnia, when carried to the extreme verge of propriety,
in injuries of the spinal cord.

Sergeant William Aldridge, 46th Regiment, aged 39 years, during a
sortie from Sebastopol, was knocked down in the trenches, and his back
formed a bridge over which Russians and English passed. The result was
serious injury to the spine, causing paralysis of the lower extremities
and bladder. The pain was excruciating, and the patient could not be
moved in bed for several weeks.

On the 4th of March, 1855, he was placed under my charge in the
military hospital at Portsmouth, when he complained of great pain
and tenderness along the spine, and incontinence of urine, together
with wandering day dreams and insomnolency at night. Solution of the
muriate of morphia ʒj was prescribed without any effect. (ʒj contains
1 gr.) The dose was gradually increased to ʒij of the solution.

15th March.--Fell out of bed during the night, trying to hide himself.
Is wandering, and fancies that he has deserted from the Crimea, and
will be shot. The narcotic has been omitted for several days. Strychnia
was now ordered, one-sixth of a grain three times a day.

20th.--Continues much the same, with slight twitchings of the face.

25th.--Has been unconscious for three days. Now complains of intense
pain in the back and violent cold perspiration.

28th.--Returning consciousness; feels easier, having slept
uninterruptedly for forty-eight hours. Expressed a desire to make his
will, and send to Dublin for his wife; both wishes were complied with.

30th.--Sensation and motion are gone from the lower extremities, and
the urine is still passed involuntarily. One-eighth of a grain of
strychnia was ordered twice a day.

31st.--Is powerfully under the influence of the remedy, with
convulsive movements of the upper and lower extremities; wild stare
and fixed jaws. The lower extremities had not moved for several months
previously. This paroxysm lasted for one hour under my own observation,
after which the muscles became relaxed, the face bedewed with a gentle
perspiration, and resumed its ordinary tranquil appearance.

April 2d.--Feels greatly relieved from pain, and is comparatively
comfortable; sleeps calmly. His appearance is entirely changed; looks
natural; features calm; is cheerful, and reads the papers. Strychnia
was omitted for some days after the last paroxysm, and replaced by the
tincture of the sesquichloride of iron with quassia, and a generous
diet.

6th.--Continues to improve. Has now and then slight twitchings in the
legs and arms. The strychnia was resumed and omitted, as the symptoms
indicated, to the end of the month.

May 1.--Is greatly improved; goes about the balcony in a chair.
Returning sensation in the right leg. Bladder still not under the
control of the will.

20th.--Sensation much improved in both legs, and motion increasing in
the right leg.

25th.--Convulsive movements all over the body, resulting from the use
of the strychnine. Lower extremities decidedly improved both in motion
and sensation.

June 1st.--Maintains his improved condition. Recommenced the strychnine
to-day, without any marked effect at the moment.

10th.--Violent tetanic spasms followed the employment of the remedy,
producing considerable increase of motion in both extremities. The
paroxysms _usually_ continue about fifteen minutes, when the muscular
system resumes its ordinary appearance.

20th.--Continues the same. Strychnia not resumed since last entry, as
occasional twitchings occur about the head and face, and he is now
affected by the smallest dose.

July 1st.--General health excellent.

10th.--Continues to improve daily in regaining the use of his limbs.
Is now able to walk on the ramparts with crutches, but is exceedingly
sensitive to every change of weather--damp always causing pain in the
spine. Continued to improve to the end of the month.

August 1st.--No change worthy of note.

14th.--Discharged to Chatham.

  T. H. BURGESS, M.D.,
  _Military Hospital, Portsmouth_.

The following case of injury of the abdomen, sent to me by Dr. Rooke,
civil surgeon with the army in the field, is very remarkable:--

Robert Cousins, aged 20, 77th Regiment, was admitted into the general
hospital, camp, June 8th, with severe injuries caused by a round shot,
which struck him when he was on duty in the advanced trenches. When
the shot struck him he was standing up, half-face toward the enemy,
his right arm extended in front of the right hip; he was in the act of
reaching his water-can, which rested against the parapet of the trench.

On admission he was in a state of semi-collapse, the integuments of
the right hand and forearm greatly lacerated, the wrist-joint laid
open, the bones of the carpus comminuted; the radius and ulna were also
fractured at the middle third. There was a lacerated wound in the right
iliac region, the size of the palm of the hand; over this space the
skin and muscles of the abdominal wall were torn away, the peritoneum
lining it was also lacerated, and at the bottom of the wound was seen
a coil of intestine in situ; there was no tendency to protrusion, nor
were its coats at all injured. The crest and body of the ilium were
much comminuted, the fracture extending downward between the anterior
superior and anterior inferior spinous processes. The anterior superior
spinous process was broken off. There was another wound just below the
great trochanter; this apophysis was also shattered. The right limb
was two inches shorter than its fellow, the foot everted, but, from
the great comminution of the pelvis and the extreme pain produced by
examination, it was not satisfactorily made out that the neck of the
femur was fractured, but the shortening of the limb and eversion of the
foot were in favor of that diagnosis. The injuries which the patient
had received were considered mortal; it was thought unnecessary cruelty
to amputate the forearm. Such pieces of the ilium as were loose were
removed; wet lint applied to the wounds; and brandy and water with
opiates were ordered. One of his comrades volunteered to watch over
him, and he was left, as all thought, to die. The next day (June 9th)
he had partially rallied from the state of collapse; had taken liquid
nourishment--beef-tea, arrow-root, etc. There was no pain or tenderness
of the abdomen; had passed his water without difficulty. The surface
of the abdominal wound was sloughy; intestine still visible; complains
of pain in the arm. It was not yet considered advisable to perform any
operation. He was ordered opium gr. j every four hours; also a dose of
morphia at night, arrow-root, beef-tea, and port wine, which he prefers
to brandy.

10th.--Has rallied completely; no pain or tenderness of the abdomen;
complains greatly of his arm, and is anxious that something should
be done. He slept well after taking the morphia; his face is
tranquil, breathing natural, pulse weak; no irritability. Deputy
Inspector-General Taylor saw the case in consultation with Dr. Mouat,
P. M. O. of the hospital. It was decided to amputate the forearm. This
was done at the upper third; chloroform was administered, and produced
no ill effects. He was ordered any fluid nourishment he might fancy,
with port wine, and an opiate at night.

11th.--No symptoms of peritonitis; suffers no pain; tongue clean
and moist; pulse quiet; passes his water regularly; the bowels have
not acted. The abdomen is quite soft and fallen, not the slightest
tenderness on pressure. To continue on the same plan. He could now give
some account of the way in which he was wounded. He stated that he
thought it must have been a round shot that struck him. It first struck
his arm, then entered the right iliac region, emerging at the lower
wound. The surface of the wound in the iliac region is in a sloughy
state from the severe bruising of the parts. The coil of intestine is
still visible at the bottom of the wound.

12th.--No symptoms of peritonitis; bowels have not acted; tenderness
down the outside of the thigh, with redness of the skin, and pitting
upon pressure. Stump dressed to-day and looking well.

13th.--No unfavorable constitutional symptoms. The outer part of the
thigh is tender and the skin red; free incisions were made; the fascia
was sloughy. He takes nourishment; has eight ounces of port wine daily,
eggs, arrow-root, and essence of beef. Bowels not acted.

21st.--He had no symptoms worthy of remark since the 13th. The bowels
have not been moved; he complained to-day of not being able to pass
his motions. Two injections of warm water were administered in the
course of the day. He passed a large quantity of hardened feces, which
relieved him greatly. The sloughs are separating from the incisions
in the thigh; the crest and ala of the ilium are exposed; healthy
granulations are springing up from the bottom of the wound. Stump
healing favorably.

July 26.--The case has progressed without a bad symptom. At first
it was thought that the greater part of the ala of the ilium would
exfoliate, but some red points appeared on the surface, and the
concavity of the bone became covered with granulations. The exfoliation
was limited to the anterior part of the crest of the ilium, which
separated on the 17th instant. At various times pieces of bone have
been removed as they became detached; there are others still left
to come away. The granulations on the upper wound are on a level
with the skin of the abdomen. The crest of the ilium is covered with
granulations; the wound is contracting, but there is a deficiency of
skin to cover the projecting portion of the ilium. The lower wound
is also open, and has been enlarged to remove pieces of bone; the
incisions in the thigh have healed. The bowels have acted regularly
without medicines until to-day, when he required a castor-oil
injection. The right thigh is more than two inches shorter than the
left; union appears to have taken place; he has no pain on motion. The
dead bone that still remains alone prevents the wounds from closing,
their surfaces being covered with healthy granulations. His general
health is good. He has taken at intervals some oleum jecoris aselli,
and, for a mild attack of bronchitis under which he suffered at the end
of June, expectorants and diaphoretics. There has not been a single
symptom of any abdominal complication. He has an opiate at night. The
stump has been healed nearly three weeks.

September 14th.--Since the last report no unfavorable symptoms have
occurred. The stump of the forearm has been healed some weeks; his
health is good; indeed, from first to last, he has not had a single
symptom denoting constitutional disturbance. All the dead bone from the
crest of the ilium has separated; the wound of the abdomen is skinned
over, with the exception of a small spot about the size of a sixpence.
This is healthy, and is gradually healing. The bowels act regularly.
There are still two sinuses on the outer side of the thigh--one above,
the other below, the great trochanter. On probing these, dead bone is
felt, which has not yet separated. The right limb is about three inches
shorter than the left, is freely movable in any direction without
pain. He can raise the knee from the pillow, but cannot lift the
heel from the bed; he can, however, turn himself over on to the left
side without assistance. The prominence of the crest of the ilium is
greatly diminished from loss of bone. The trochanter major is unusually
projecting; the natural appearance of the hip-joint is entirely
gone. The injuries to the bones have been so severe, it is difficult
to say what changes have occurred. The ilium and pubis have been
greatly comminuted, the fracture most probably extending through the
acetabulum. Immediately below Poupart’s ligament, to the outside of the
femoral artery, a hard substance is felt beneath the skin. This, when
he was admitted, was at first supposed to have been a piece of a shell,
but it is now thought to be a portion of the pubis driven downward upon
the thigh.

He may now be said to be convalescent.

       *       *       *       *       *

John Shehan, aged nineteen, 57th Regiment, was wounded in the left
thigh before the Redan, on the 18th of June. He was brought to the
general hospital, and placed under the charge of a gentleman of
considerable skill and experience. The wound presented two openings,
an anterior and a posterior; the latter offered greater facilities for
examination than the former; the finger, passed from behind, detected
several fragments, which were removed, and as a tolerably uniform
surface of bone (_vide_ specimen) was then felt, it was determined,
after consultation, to make an attempt to save the limb. The injured
extremity was accordingly bound up with a long splint in the most
careful manner, and matters promised favorably for a time. He, however,
complained of a good deal of suffering in the limb from time to time,
gradually wasted, suffered from diarrhœa, and finally sank on the 6th
of August. On examination post-mortem, I found the chief organs in a
normal condition. There was some congestion of the ilium, and the colon
presented a few points of ulceration. The condition of the parts in the
left lower extremity was very remarkable. Beneath the integuments, all
the muscular and other textures, from the seat of injury to the groin,
were converted into a soft, broken-down, black, rotten mass; and I may
here observe that this low but intense disorganizing process, extending
through the greater part of the limb, has presented itself in several
of my examinations of somewhat similar injuries, and appears to me
to be connected with _a peculiar pathological state in which all the
vital organs remain sound, but the vis vitæ is remarkably reduced below
par_. The fractured bone it is unnecessary to describe. The vertical
and cross infraction of the fragments and its almost “arborescent”
appearance are most remarkable. I look upon it as a specimen of no
ordinary value, conveying more than one most useful lesson. The bones
are in the museum of the Royal College of Surgeons.

  R. D. LYONS,
  _Pathologist to the Army in the East_.

 Camp before Sebastopol, August 30, 1855.

Private William Leah, 30th Regiment, aged twenty-one, was brought to me
on the 27th of June, while I was on duty in the trenches, with fracture
of the external condyle of the humerus of left arm, by a musket-ball,
which had entered the joint between it and head of radius, and had
made its exit over olecranon process of ulna. Artery uninjured. On
being sent to camp, the joint was excised by Mr. Dowse, surgeon of the
regiment. The patient progressed favorably, and the wound has been
healed for nearly a month. He can use all the muscles of the forearm,
except the flexor of the little finger, and is regaining the motion
possessed by the elbow-joint.

  DAVID MILROY, M.D.,
  _Assistant-Surgeon, 30th Regiment_.

 Camp, Second Division, Heights of Sebastopol, Sept. 5, 1855.

J. Maguire, 31st Regiment, aged twenty, wounded in the advanced
trenches.

July 12, five A.M.--Carried into hospital, wounded by a splinter of
shell in left elbow and on left hip. The splinter struck him in an
oblique direction, from behind, fracturing olecranon process and
internal condyle of humerus, lacerating and otherwise injuring the
joint, the ulnar nerve being also injured. The splinter continuing its
onward course, inflicted a lacerated wound on the hip, with comminuted
fracture of about the anterior fifth of the crest of the ilium, several
small pieces of bone being driven in on the peritoneum, causing pain on
the slightest motion. All the loose portions of bone were removed, and
several others separated from the muscles. Abdomen painful, and swollen
at that side. Abdomen continued painful during the day; bowels acted;
he also passed water freely.

13th.--Pain in abdomen much less; little, if any, constitutional
disturbance; elbow extremely painful; the pain accompanied with partial
paralysis of the little and ring fingers. Staff-Surgeon Dr. Gordon
having seen him, and not apprehending any danger from the wound in the
side, the operation for excision of the elbow-joint was determined
on, and performed under chloroform, by a single straight incision
passing through the original wound, including the upper and lower
fourths of the forearm and arm. There was very little hemorrhage. The
arm was then put up in an angular splint. It continued to progress
favorably, the greater part healing by the first intention. There was
some suppuration, but a free exit being given to the matter, it did not
retard recovery.

August 19th.--This patient was discharged from the regimental hospital,
to general hospital, Balaklava. The wound nearly healed; sensation
partially restored to the fingers; slight motion at the bend of the
elbow; but he has not power to raise the hand.

  THOMAS J. ATKINSON,
  _Assistant-Surgeon, 31st Reg. in Med. Charge_.

 Camp before Sebastopol, Sept. 1, 1855.

Private Anthony Murray, aged twenty-eight, 41st Regiment, a healthy
man, was struck, while on duty in the trenches before Sebastopol, on
the night of the 23d of July, 1855, by a portion of a shell, which
penetrated the left elbow-joint; the head of the radius and the outer
half of the articulating surface of the humerus were comminuted,
fragments being impacted in the cancelous structure of the humerus,
and driven in between that bone and the ulna. Excision of the joint
having been determined on, it was performed in the following manner: a
straight incision was made along the posterior surface of the joint,
the olecranon cut through, and the extremities of the several bones
removed in succession; the parts were then brought together by suture,
and the limb placed in a flexed position; about a third of the wound
healed by the first intention; no inflammation supervened. On the
3d of August the wound was granulating in a healthy manner; on the
22d, it had almost healed, and the limb was put up permanently, the
forearm at right angles to the arm; on the 31st, some union had taken
place between the bones; the man can move the thumb and three fingers;
he is free from pain; his health is very good, and he appears to be
progressing favorably in every respect.

  J. E. SCOTT, M.D., _Surgeon, 41st Regiment_.

 August 31st, 1855.

Private Jesse Lockhurst, 31st Regiment, aged twenty-six, was wounded in
the advanced trenches, 17th of August, 1855.

August 17th.--Six o’clock A.M., carried into regimental hospital,
having received an extensive lacerated wound of right cheek: very
little apparent hemorrhage, but the power of deglutition was
completely lost, and respiration impeded. On making an examination
of the wound, it was ascertained that the right superior maxillary
bone was fractured, and a portion of the hard palate with the molar
teeth driven in on the tongue; there was a large piece of shell or
shot lodged at the bottom of the wound, lying on left palate, and,
as far as could be ascertained, on the back of pharynx. Staff-Surgeon
Dr. Gordon being present, the ball, after much labor, was extracted,
and found to be a grape-shot of seventeen and a half ounces weight.
During the operation it was found necessary to dilate the wound by
dividing the lip near its external angle--the portions of bone that
were removed were the alveolar process, with all the molar teeth,
including part of the palate and a portion of the orbital plate and
nasal process of the superior maxillary bone, and all the malar bone.
There was no serious hemorrhage during the operation, nor immediately
after the extraction of the shot. The cheek was then plugged with lint
and the wound brought into apposition by sutures. The man experienced
immediate relief after the operation, sat up in bed, washed out his
mouth, and drank some water; he seemed extremely thankful, and blessed
the doctors. During the night and part of the next day there was some
oozing from the mouth. No bad symptom occurred until the 20th, when an
active hemorrhage came on from the back of the palate. The exact source
could not be ascertained. He became very weak and almost pulseless; but
the hemorrhage was eventually restrained by means of ice and plugging
the wound with lint moistened in tincture of matico. Iced drinks
occasionally.

31st.--The man is now doing extremely well, can talk, and takes a
pint of jelly daily; the external wound is not yet quite healed,
in consequence of the saliva flowing through it. The right eye is
uninjured, and sight unaffected.

September 1st.--He has just been discharged to general hospital,
Balaklava, from the regimental hospital.

  THOS. J. ATKINSON, _Assistant-Surgeon_,
  _31st Regiment, in Med. Charge_.

 Camp before Sebastopol, September 1, 1855.

On the morning of July 24th, Private Francis O’Brien, a lad of
eighteen, was brought from the trenches, with a wound from a
musket-ball in the right temple. It entered about two inches above
the orbit, passed downward, and drove out a large portion of the
supra-orbital ridge, which appeared to be imbedded in the upper eyelid,
and was cut down upon by the medical officer in the trenches, in
mistake for the ball, which it certainly very much resembled. As no
ball could be found, it was supposed to have passed out at the opening
of entrance.

The finger when passed into the wound could feel the pulsation of
the brain, yet from that day to the present no symptom of cerebral
disturbance has appeared, unless it be that since his convalescence the
muscles of the face work convulsively when he feels faint and weak from
remaining too long in the erect posture. About a month after admission,
the detached portion of the bone above the orbit was removed from the
eyelid, though with considerable difficulty, and on the following
morning the ball fell from the wound, much to the poor lad’s horror,
who thought his eye had dropped out.

Both wounds have now healed, but he is unable to raise the right
eyelid; the eye is perfect, but apparently without power of vision,
though sensible to the stimulus of light, for on turning the wounded
side to the light, the left pupil contracts. His general health is good.

  R. V. DE LISLE,
  _Surgeon, 14th King’s Own Regiment_.

 Camp, Sept. 10.

Private Joseph Bourke, 17th Regiment, admitted on 9th of September,
1855, with fracture of anterior superior angle of right parietal bone,
with depression of about one-third of an inch, for the size of a
florin. No attempt was made to elevate the depressed portion. Has not
had a bad symptom. Wound of scalp nearly healed.

  W. P. WARD,
  _Surgeon, 17th Regiment_.

Private Michael Caffrey, 88th Regiment, wounded at the attack upon the
Redan on the 8th of September, was brought to the hospital of the 38th
Regiment on the morning of the 9th. A round rifle-ball struck him at
the anterior part of the left parietal bone, and passed through the
brain in a line which brought it out at the vertex, fracturing the
parietal bone of the opposite side; the ball at its entrance split,
and one-half pushing before it a small piece of bone, both lodged at
the entrance; the other half of the ball was found lodged in the brain
at the upper and back part, having detached a circular portion of the
skull.

A director was passed along the track of the wound, and the scalp
laid open; the brain was found to protrude through the fracture. In
this condition the patient lived for eleven days, utterly unconscious
of everything passing around him, the urine and feces coming away
involuntarily. There was paralysis of the opposite side.

A post-mortem examination showed the brain to have been reduced to a
pultaceous mass only in the direction of the passage of the missile;
the remaining portion of the wounded hemisphere and that of the
opposite side were healthy.

The absence of the usual train of head symptoms, and the length of time
which so extensive an injury permitted life to remain, render this case
worthy of some remark.

  FREDERIC WALL,
  _Surgeon, 38th Regiment_.

 Camp before Sebastopol, Sept. 20, 1855.

Private William Doyle, 19th Regiment, aged nineteen years, was wounded
in the head by a rifle-ball, in the advanced trench of the right
attack, on August the 30th. The scalp and pericranium were cut about
two inches, and a portion of the cranium, a little in advance of
the posterior and superior angle of the right parietal bone, close
to the sagittal suture, about an inch in length and half an inch in
breadth, was depressed. According to statement the man was rendered
perfectly senseless and motionless, from the instant of being struck
by the bullet. On reaching camp he presented all the usual symptoms
indicating compression; pupils dilated and fixed, warm surface, total
unconsciousness, complete paralysis, etc. On examination of the
depressed portion of bone, no opening whatever could be felt; the edges
of the sunk bone and the bone adjoining were in contact, and it was
presumed to be an ordinary case of fracture with depression simply.
Some very minute portions of cerebral substance were observed to be
mixed with the clot of blood about the wound, such as might be squeezed
through a fissure. Trephining being determined on, it was performed
at once, and the depressed bone raised without difficulty. No relief
of symptoms followed. The dura mater bulged slightly upward into the
opening. On passing the finger over its surface, a little beyond the
space exposed by the trephine, a defined cut edge was felt about an
inch in advance of the depressed piece of bone, being the boundary of
an opening into the cerebral substance.

Three hours after arrival in camp the patient died. On examination
post-mortem, a wedge-like section of the ball was found to have
entered and penetrated the cerebral substance; it was discovered in
the anterior lobe on the right side, just above the orbitar plate.
It had not completely penetrated, but was lying just above the
membrane covering the lobe. The ball--a conical rifle-ball with three
cannelures--was cut smoothly from apex to base, as if by a sharp knife.
This must have been done by the edge of broken bone above the opening
made in the parietal bone, one-half of the ball flying off, the other
entering the skull. On close examination, several very small points of
lead were found to be imbedded along the margin of the bone alluded
to. The depressed portion of bone, directly after the piece of ball
entered, must have sprung up again by its own resiliency, or been
forced up by sudden pressure from within, so that no evidence of an
aperture, but merely a fissure and depression remained. The inner table
was separated, and nearly detached, for a space rather more extensive
than that of the depressed part of the outer table. The superior
longitudinal sinus was wounded by the sharp edge of the broken inner
table, and a very considerable quantity of blood extravasated upon the
surface of the brain.

The portion of bone implicated in this injury has been preserved.

  THOMAS LONGMORE,
  _Surgeon, 19th Regiment_.

 Camp before Sebastopol.


REMARKS.

Six amputations at the hip-joint (if not more) have been performed in
the Crimea, and all the sufferers have died, a loss which has not been
experienced in civil life under any circumstances, many persons having
survived the operation for years. It has been fairly attributed to
the depressing causes from which the army suffered, and for which the
government has been blamed; although the great functionaries appear
to me to have less to account for than their subordinates, as far as
regards deficiencies in the treatment of the sick and wounded.

The operation for removing the head of the femur from its connection
with the hip, leaving the limb for future use, was first recommended by
me as a substitute for amputation at the hip-joint, and has been done
in at least six instances, one only surviving. I limited the operation
to injuries of the head and neck of the bone, or with little extension
beyond these two parts, being cases which hitherto invariably died
unless amputation at the hip-joint were performed, and which it was
and is hoped the operation of excision might render unnecessary; but
it must be done under happier circumstances, and perhaps with greater
restriction. The success which has followed the removal of the head of
the humerus from the shoulder-joint even with as much as one-third of
the shaft, as low as the insertion of the deltoid muscle, has led to
the belief that as much may be done in the thigh; and in the hope that
it might be so, a considerable portion of the shaft of the femur has
been removed with the head and neck in the cases alluded to, so that an
approximation of the remainder of the shaft to the cavity of the joint
has not been possible. If the operation performed by Surgeon O’Leary,
68th Regiment, (page 564,) which at the end of seven weeks is reported
as doing well, although the pulse remained between 80 and 100, should
succeed, it is doubtful whether the limb will be of any use or better
than an artificial leg, from the extent of the bone removed, which will
prevent the formation of a firm joint or union. The sling used in this
case has been considered very advantageous by all who have seen the
man, and proves how much may be done in all cases of compound fractures
by similar appliances, but which has not yet been done. A correct
judgment cannot, however, be formed as to the value of this operation
until it has been performed on one of those cases in which a ball shall
simply lodge in the head or neck of the femur without injuring the
shaft of the bone--an accident which has been so frequently observed in
the head of the humerus, and of which I have sent two preparations to
the museum of the College of Surgeons. (See page 127.)

It has been already stated that the loss of life after amputations
performed for gunshot fractures of the upper part of the thigh has been
so great, both in the French and English armies, that such operations
have been nearly abandoned.

The Russians, at the commencement of the siege of Sebastopol, made use
of a conical rifle bullet, flat at the base, weighing nearly one ounce
and three-quarters. Latterly they have used a larger conical one, with
three grooves around the circumference of the base of the cone, which
is hollowed out to receive a cup, and shows a projection on the inside
of the hollow. This ball is near two inches long, and weighs somewhat
more than one ounce and three-quarters.

The balls formerly used by the French army were twenty to the pound,
and by the English, sixteen. The balls alluded to are nine to the
pound. When this Russian ball strikes soft parts only, such as the
thigh, it merely makes a larger hole than the common bullet, into which
the finger passes easily, and the wound heals as readily. Whenever it
strikes a bone, it would appear to break it more extensively, and to
require more certainly the amputation of the limb; although the smaller
French ball used in former days, when it struck a bone, disabled the
sufferer as effectually for all future service, yet it might not as
certainly lead to his death.

Dr. Lyons not only transmitted to me the case, related page 579, of
John Shehan, but has since sent me the broken bones, which confirm
everything I have said on this subject, page 321. The sound bone above
the fracture has become more solid; the splinters not having been
removed are lying across, and prevent the approximation or union of
the ends of the old bone, while the effort made by nature to effect
this object by the deposition of new ossific matter, adds to the evil
by fixing these splinters in so solid a manner that they cannot escape
or be removed by any other means than that of forcible abstraction,
after painful and perhaps dangerous operations, each splinter possibly
requiring a separate one. Shehan’s case was one for amputation from
the first, if he had been in a state to undergo it with a prospect of
success.

The treatment of gunshot fractures of the leg ought to have been more
successful than it has been, even when both bones were broken; the
want of success may be in part attributed to the remissness which has
taken place in supplying the necessary, nay, the essential appliances,
by means of which much suffering might have been alleviated, perhaps
prevented, even if cures could not have been effected.

In performing the operation for the excision of portions of the
extremities of bones, a chain saw is a most desirable aid on many
occasions. There was not one with the British army in the Crimea, and
when wanted, they were borrowed from the French ambulances. It was only
on the 30th of September last some were ordered to be sent out, and
they cannot yet have arrived. In a lecture I delivered on the 14th of
April last in the Theater of the College of Surgeons, as its President,
by permission of the Council, the proceeding being unusual, I drew
attention, for the express purpose, to the necessity which existed
for the Crimean army being supplied with a machine capable of being
moved from bed to bed, by means of which the unfortunate soldier could
be raised in the extended state, and after being washed, his wounds
dressed, and his bedclothes changed, he might be again laid down with
comparatively little uneasiness. Fifty of them would not cost £300, but
there are none in the Crimea, except two, one sent to the Coldstream
Guards, by Lord Strafford at his own expense, and one which the makers
placed at my disposal. I hear that _three_ have been ordered lately,
like the chain saw, when too late, for many are now no more who stood
in the greatest need of them, and without which machine they had little
chance of being saved.

On the 14th of April, 1855, I published a lecture, in which I gave a
sketch of an apparatus for slinging a broken leg, which instrument
I declared to be a _sine qua non_ in the successful treatment of a
gunshot fracture of the leg. By permission of the Duke of Newcastle,
I sent out forty-six sets complete for every part of the body, the
year preceding. They were, I am told, left at Varna; and four medical
officers, of character and knowledge, who have lately returned
from the East, assure me within the last week that no such, or any
similarly useful, apparatus was ever seen in the hospitals in front of
Sebastopol. Other instances of remissness of equal importance might
be adduced, if it were not useless to advert to them; for we delight,
I believe, in being admitted by foreigners to be a wonderful people
in the mismanagement of our affairs in the first instance, however
important or trivial. It is, I believe, an admitted maxim, that the
right men should be in the right place--the square ones in the square
holes, the round ones in the round holes; but there is another one of
equal importance, viz., that the right thing should be in the right
place at the right time, without which teaching or practicing surgery
becomes of little value.

Amputation at the knee-joint has been done, I hear, in six cases since
the taking of Sebastopol; four are dead; one is doing well under Mr.
Blenkins, of the Guards, and the other yet survives. Excision of the
knee-joint has been performed since the taking of Sebastopol in one
case by Staff-Surgeon Lakin, and is doing well.

The excisions performed on the head of the humerus, and on the bones
composing the elbow-joint, have been very successful. There is,
however, a circumstance to which I am desirous of drawing attention,
viz., that the head of the humerus should never be removed in
amputations, when it is uninjured, however close the destruction below
may have approached it. The round head of bone left in the socket
preserves the squareness of the shoulder, and renders the loss of
the arm less unseemly. It tends to prevent the inclination the body
generally has to the opposite side, and its being left adds nothing to
the difficulties of the operation. The excisions of the ankle-joint
have been numerous and more successful than might have been expected
under the depressing causes alluded to.

For the preparations of the head of the humerus and of the astragalus,
referred to at pages 110 and 128, I have since learned I am indebted
to Deputy Inspector-General Macgregor; and I am particularly so to
Assistant-Surgeon Gregg, of the 17th Regiment, for the great care he
has bestowed on several of the specimens of injury sent to me.

Wounds penetrating the cavities of the chest and abdomen have been no
less fatal than those of the lower extremities. The same want of power
has been exhibited in them; the same inability to bear the means of
cure which, under happier circumstances, have proved successful.

I hope to receive reports on wounds of arteries, on secondary
hemorrhage, and on injuries of the head, so as to enable me to remove
any doubts which may exist on these points; and I beg to assure those
officers who will favor me with their opinions and facts, that they
shall be duly reported in another “Addenda.”

I cannot conclude these remarks without expressing my sense of the
great practical ability displayed by very many of the medical officers
in the Crimea, of their devotion, of their self-denial--qualities which
ought to obtain for them the special approbation of the nation.

_October 18, 1855._



INDEX.


  Abdomen, wounds of, 488, 649.
    causing abscesses in parietes of, 489.
    penetrating wounds of, 497.
      protrusion of viscera in, 498.
        of omentum, 498.
        of intestine, 501, 509.
    effusion of blood into, 505, 510.
    treatment of hemorrhage in penetrating wounds of, 510.
    suppuration in cavity of, 511.
    and pelvis, conclusions respecting wounds of, 555.
    right arm and thigh, extensive injury to, by a round shot, 576.

  Abdominal parietes, gunshot wounds of, 489.
    lodgment of balls in, 489.
    incised wounds of, 490.
      followed by ventral rupture, 493.
      on continuous suture of, 493.
    severe contusions of, followed by rupture of the hollow or solid
      viscera, 491.

  Abernathy’s mode of tying the external iliac, 257.

  Abscess of liver, consequent to injuries of the head, 356.
    in abdominal parietes, caused by neglected injuries, 489.

  Acids, mineral, use of, in sloughing wounds, 70, 168.
      in hospital gangrene, 70, 168.

  _Addenda_, commentaries on the cases in, 586.

  Alexander, Deputy Inspector-General, on amputations, while under the
    influence of chloroform, 563.

  Amaurosis from balls passing behind the eyes, 478.

  Amputation, primary, not required in gunshot wounds of the upper
      extremity, 120.
    aphorisms on, 73.
    at the ankle-joint, Mr. Syme’s operation for, 105.
    of the arm below the tuberosities, 126.
      by the circular incision, 134.
      by Mr. Luke’s operation by two flaps, 135.
    primary, of the arm, 120.
    at the elbow-joint, 137.
    place of election for, in local mortification of a limb, 46.
    of the fingers, 139.
    of the foot, 114.
      by Roux’s plan, 108.
    of the forearm, 137.
      by the flap operation, 137.
      by the circular incision, 138.
    for gunshot wounds of the femur, 145.
    at the hip-joint, 77, 92, 562, 563, 586.
      Mr. Guthrie’s mode of operating in, 79, 83.
      Professor Langenbeck’s, 80.
      Mr. Brownrigg’s, 82.
      under chloroform, 564.
    immediate, question as to, 51.
      cases for, 150.
    of the leg, 99.
      by the circular incision, 99.
      by Mr. Luke’s flap operation, 101.
      immediately below the tuberosity of the tibia, 102.
    of the metacarpal bones, 139.
    of a metatarsal bone, 118.
    in cases of mortification from wounded arteries, 228.
    necessity for, 51.
    of the phalanges, 140.
    primary and secondary, 59.
    secondary, 59, 141.
    at the shoulder-joint, 122.
      by two flaps, 124.
      by one flap, 125.
      by Lisfranc’s operation, 125.
    at the tarsus, 112.
    of the thigh, by the circular incision, 83.
      by Mr. Luke’s flap operation, 86.
    at the wrist, 138.
    under the influence of chloroform, in the Crimea, 561.
      case of death from, 561.
      Deputy Inspector-General Taylor on, 562.
      Deputy Inspector-General Alexander on, 563.

  Ankle-joint, excision of, 103.
    Mr. Syme’s amputation at, 105.

  Aneurism of the arch of the aorta, 276.
    formation of, after wound of artery, 212.
      Hunterian theory respecting, 188.
    popliteal, operation for, 263.
    traumatic, formation of, 214.

  Aneurismal swelling after deep wound of an artery, 212.

  Anus, artificial, 525.
      operation for the formation of, in the loins, 558.
      Desault’s operation for, 527.
      Dupuytren’s forceps for, 527.
      Mr. Trant’s forceps for, 528.

  Aorta, ligature of, 250, 252, 256.
    aneurism of the arch of, 276.

  Arachnoid and dura mater, wounds of, 345.

  Arm, amputation of, below the tuberosities, 126.
      primary, 120.
      by the circular incision, 134.
      by Mr. Luke’s double flap operation, 135.
    gunshot fracture of, 121, 156.
    wounds of the arteries of, 238.
    thigh and abdomen, extensive injury to, 576.

  Arsenic, local use of, in hospital gangrene, 169.

  Arteries, wounded, the Hunterian theory inapplicable in the treatment
        of, 189.
      Mr. Guthrie’s theory respecting, 189.
      principles of surgery relative to, 191.
    punctured wounds of, 210.
      formation of aneurism after, 211.
    transverse wound of, 212.
    complete division of, 212.
    large, mode of arresting hemorrhage from, 234.
    of arm and forearm, wounds of, 238.

  Artery, structure of, 176.
    deep wound of, forming aneurismal swelling, 213.
    effects of a ligature on, 203.
    wounded, not to be operated on, unless it bleed, 215, 241.
      to be tied at the seat of injury, 191, 219.
    main, of the lower extremity, mortification caused by a wound of,
      45, 226.

  Artificial anus, 525.
      formation of, in the loins, 558.
      Desault’s operation for, 527.
      Dupuytren’s forceps for, 527.
      Mr. Trant’s forceps for, 528.
    foot, M. de Beaufoy’s, 119.

  Astragalus and calcis, Mr. T. Wakley’s operation for the removal of,
      115.
    ball lodged in the, 109, 590.
    removal of, 109.

  Auscultation, value of, in injuries of the chest, 367.

  Axillary artery, gunshot wounds of, rarely cause mortification of the
      hand or fingers, 46, 235.
    ligature of, 278.
    wounds of, 235.


  Ball, lodging in the abdominal parietes, 489.
      in the astragalus, 109, 590.
      in the bladder, 553.
        calculus formed on, 553.
          operation for removal of, 554.
      in bone, 36, 149.
      in the brain, 283.
      behind the eye, 478.
    or other foreign bodies loose in the cavity of the pleura, 448.
      inclosed in a cyst, 451.
    lodged in the head of the humerus, 128.
      in the liver, 532.
    orifices of entrance and exit, 27, 489.
    passing behind the eyes, causing amaurosis, 478.
    lodging in the pelvis, 545.
    penetrating the brain, 347.
    rolling on the diaphragm, 451.
      operation for extraction of, 455.
    separating the sutures of the skull, 349.

  Balls, relative size of those used by the Allies and by the Russians,
      588.
    on cysts inclosing foreign bodies, in gunshot wounds of the chest, 451.
    operation for empyema, 452.
    operation for gunshot fracture of the lower jaw, 480.

  Baudens, M., on excision of the head of the humerus, 133.

  Bayonet, wounds by, 37.
    wounds, delusion as to, 38.

  Bearers for the wounded, 156.

  Beaufoy’s, M. de, artificial foot, 119.

  Bedsteads for gunshot fractures of the femur, 152.

  Bell, Mr. J., on emphysema in gunshot wounds of the chest, 412.

  Bennet, Dr. Hughes, on phlebitis, 71.

  Blackadder, Mr., on hospital gangrene, 164, 169.

  Bladder, wounds of, 546.
    ball in the, 553.
    calculus formed on, 553.
      operation for extraction of, 554.

  Blood, effusion of, into the abdomen, 505, 510.

  Boggie, Dr., on hospital gangrene, 168, 169.

  Bone, lodgment of a ball in, 36, 149.
    protrusion of, after amputation, 89.
    exfoliation of, after amputation, 89.

  Bones of the face, penetrating wounds of, 479.

  Brachial artery, ligature of, 279.

  Brain, balls lodging in, 283.
    balls penetrating into, 347.
    M. Burdach’s statistics of lesions of, 306.
    compression of, 302.
      paralysis caused by, 305.
    injuries of the head affecting the, 283.
    concussion of, 287.
      causing mania, 299.
    laceration of, by contre-coup, 340.
    motions of, 303.
    suppuration of the surface of, 342.
    wounds of, 347.
      causing abscess of the liver, 356.

  Bronchophony, 372, 376.

  Brow and eyelids, wounds of, 477.

  Brownrigg’s mode of amputating at the hip-joint, 82.

  Brunner, glands of, 486.

  Buck, Dr. Gurdon, operation for excision of the knee-joint, 97.

  Burdach’s statistics of lesion of the brain, 306.


  Calcis and astragalus, operation for the removal of, 115.
    removal of, 104.

  Calculus formed on a ball in the bladder, 553.
    operation for extraction of, 554.

  Cannon-shot, hemorrhage after the carrying away a limb by, 25.
    wind of, 43.
    causes mortification of a limb, by destroying its internal textures,
      43.

  Carotid, common, ligature of, 270.
      statistics of ligature of, 241.
    external, ligature of, 272.
      the common carotid not to be tied for wounds of, 242.
    internal, ligature of, 272.
      wounds of, through the mouth, 245.
        operation for securing, 245, 248, 272.
      the primitive carotid not to be tied for wounds of, 246.
    primitive, not to be tied for wounds of external carotid, 541.
      nor for wounds of the internal carotid, 246.

  Cartilages, costal, fracture of, in gunshot wounds of the chest, 429.

  Cerebrum, fungus of, (hernia cerebri,) 352.

  Chain saw, utility of, 588.

  Chelius on suture of incised wounds of abdominal parietes, 493.

  Chest, wounds of, 364, 590.
    effusion into, 371, 378, 420.
    purulent effusion, etc. into, 378, 390, 420, 435.
      operation for, 394.
    non-penetrating wounds of, 364.
    value of auscultation in wounds of, 367.
    incised wounds of, 364, 414.
    wounds of both sides of, 417.
    large penetrating wounds of, the lung injured, 418.
      with hemorrhage into the cavity, 421.
    ecchymosis a sign of internal hemorrhage in penetrating wounds of, 424.
    conclusions respecting wounds of, 424.
    gunshot wounds of, 426.
      statistics of, 426.
      enlargement of, 427.
      fracture of the ribs in, 428.
        of the costal cartilages in, 429.
      involving the lungs, 429.
      removal of splinters, etc., 445.
      the ball loose in the cavity of the pleura, 448.
        rolling on the diaphragm, 451.
        inclosed in a cyst, 451.
      involving the lungs, effusion caused by, 435.
      formation of a dependent opening, 452.
      operation for the evacuation of the fluid, 455.
      anatomy of the parts concerned, 453.

  Chloroform, use of, 55.
    Dr. Snow on, 55.
    Mr. Syme on the treatment of approaching death from, 58.
    amputation under the influence of, in the Crimea, 561.
      case of death from, 561.
    Deputy Inspector-General Taylor on, 54, 562.
    Deputy Inspector-General Alexander on, 563.

  Circulation, collateral, 184.

  Colon, Hilton’s operation for opening into, 558.

  Commentaries on the cases in the _Addenda_, 586.

  Compound fractures, 145.
    splints for, 153.

  Compression of the brain, 302.
      convulsions caused by, 307.
      paralysis caused by, 305.
    in hemorrhage from wounds of the hand, 238.

  Conclusions respecting wounds of the chest, 424.
    abdomen and pelvis, 555.
    hospital gangrene, 173.

  Concussion of the brain, 287.
    causing mania, 299.

  Contre-coup, fracture of the skull by, 316.
    laceration of the brain by, 340.

  Contusions, severe, of abdomen, followed by rupture of the hollow or
    solid viscera, 490.

  Convulsions caused by compression of the brain, 307.

  Cooper, Sir A., mode of tying the external iliac, 258.

  Cranium, fracture of the base of, 317.

  Crepitating râle, or rhonchus, 375.


  Delpech on hospital gangrene, 165, 166, 167.

  Deposits, purulent, 61, 68.

  Depression of the skull, 329.
    of the back of the skull, with fracture, 338.

  Desault’s operation for artificial anus, 527.

  Diaphragm, ball rolling on the, 451.
    operation for the extraction of, 455.
    wounds of, 458.
      may cause internal hernia, 463.

  Dupuytren’s forceps for artificial anus, 527.

  Dura mater, incision of, 343.
    removal of blood from the surface of, 360.
    suppuration on the surface of, 342.
    wounds of, 345.


  Ecchymosis, a sign of hemorrhage into the chest, 424.

  Effusion, purulent, in penetrating wounds of the chest, 420, 435.

  Elbow-joint, amputation at, 137.
    excision of, 135, 580.

  Emphysema, 410.
    Mr. J. Bell on, in gunshot wounds of the chest, 412.

  Empyema, 390, 436.
    operation for, 394, 455.
      M. Baudens on, 452.
    necessity for depending opening in, 452.
    Mr. Quekett’s experiments on the anatomy of the parts engaged in,
      452.
    operation for, by incision, 455.

  Endocardial sound of the heart, 466.

  Epigastric artery, ligature of, 510.

  Erysipelas phlegmonodes, 40.
    improvement in the treatment of, 41.
    of the scrotum, 42.
    of the scalp, 359, 363.

  Excision of the ankle-joint, 103.
    calcis, 104.
    calcis and astragalus, 115.
    elbow-joint, 135, 580.
      with injury to left hip, 581.
    head of the femur, 90, 150, 564, 587.
      in gunshot wounds of, 150.
    of the head, neck, and great trochanter of the femur, 564.
    of the head of the humerus, 126, 571, 590.
      Langenbeck’s operation for, 130.
      M. Baudens on, 133.
    of the knee-joint, 97.
      Mr. Jones’s mode of operating, 97, 98.
      Dr. Gurdon Buck’s operation for, 97.
    metacarpal bone of thumb, 140.
    phalangeal joints, Langenbeck’s operation for, 140.

  Excito-motory system of Dr. Marshall Hall, 286.

  Exfoliation of bone after amputation, 89.

  Exocardial sound of the heart, 466.

  Expiration, 369.

  Extraction of the ball in gunshot wounds, 32.

  Extremities, upper, gunshot wounds of, 20.

  Eye, ball lodged behind, 478.
    wounds of, 477.

  Eyelids and brow, wounds of, 477.


  Face, wounds of, 476.
    penetrating wounds of the bones of, 479.

  Femoral artery, gunshot wound of, a cause of local mortification,
      45, 226.
    laceration of, 208.
    ligature of, 260.
    superficial ligature of, 262.
    and vein, injuries of, may cause gangrene, 45.

  Femur, removal of the head of, 90, 150, 564, 587.
    gunshot wounds of, 145, 579, 587.
      secondary amputation in, 145.
      of the head and neck of, 150.
      bedsteads for, 152.

  Fingers, amputation of, 139.
    mortification of, rarely caused by wound of axillary artery, 46.

  Fissure of the skull, 311.

  Foot, gunshot wounds of, 107, 112.
    amputation of, 114.
    amputation of, by Roux’s plan, 108.
      at the ankle-joint, Mr. Syme’s operation for, 105.
    artificial, M. de Beaufoy’s, 119.

  Forearm, gunshot wounds of, 137.
    amputation of, 137.
      by flap operation, 137.
      by circular incision, 138.
    wounds of arteries of, 238.

  Forehead, gunshot wounds of, causing loss of sight, 350.

  Foreign body, lodgment of in a nerve, 47.

  Fowler’s solution of arsenic, in hospital gangrene, 169.

  Fractures, compound, 145.
    splints for, 153.

  Fracture, gunshot, of the leg, 154, 588.
        Mr. Luke’s apparatus for, 154.
      of the head of the femur, 150.
      of the upper extremities, 120.
      of the shoulder-joint, 120.
      of the elbow-joint, 136.
      of the arm, 121, 156.
      of the skull, 311.
    of the skull by contre-coup, 316.
    of the base of the cranium, 317.
    of the inner table of the skull, 321, 324, 328.
    with depression at the back part of the skull, 338.
    of the superior maxillary bone, 582.
    of the ribs in gunshot wounds of the chest, 429.
    of costal cartilages, ditto, 429.

  Frontal sinuses, gunshot wound of, 350.

  Fungus, or hernia cerebri, 352.


  Gall-bladder, gunshot wounds of, 530.

  Gangrene, hospital, 163.
      Fowler’s solution of arsenic in, 169.
      mineral acids in the treatment of, 70, 168.
      sloughing or pulpous form of, 166.
      conclusions respecting, 173.
    local and dry, from wound of the main artery of the lower extremity,
      44, 226.
    traumatic, 42.

  Glands of Brunner, Grew, and Peyer, 486.
    solitary, 487.

  Gluteal artery, ligature of, 259.

  Goyraud’s operation for ligature of the internal mammary, 473.

  Grew, glands of, 486.

  Gross’s experiments on intestine, 506.

  Gunshot fractures of the upper extremities, 120.
      lower ditto, 154.
    wounds of axillary artery, rarely cause mortification of hand or
        fingers, 46, 285.
      extraction of the ball in, 32.
      of the foot, 107, 112.
        knee-joint, 94, 574.
        shoulder-joint, 120.
        arm, 121, 156.
        elbow-joint, 136.
        forearm, 137.
        hand, 139.
        femur, 145, 579, 587.
          head and neck of, 150.
        face, 479.
        leg, 154, 588.
        lower jaw, 480.
        skull, 346, 584.
        frontal sinuses, 350.
        forehead, causing loss of sight, 353.
        orbit, 350, 583.
        superior maxillary bone, etc., 582.
        chest, 426.
          statistics of, 426.
        fracture of the ribs in, 428.
          costal cartilages in, 429.
          involving the lungs, 429.
        heart, 468.
        abdominal parietes, 489.
        intestine, 515.
        liver, 528.
        gall-bladder, 530.
        stomach, 535.
        spleen, 536.
        kidney, 538.
        spermatic cord and testicle, 539.
        penis, 540.
        pelvis, 541.
        bladder, 546.
        rectum, 555.
        inflammation consequent on, 30.

  Guthrie, Mr., mode of amputating at the hip-joint, 79, 83.
    theory respecting wounded arteries, 189.


  Hall, Dr. Marshall, excito-motory system of, 286.

  Hand, gunshot wounds of, 139.
    mortification of, rarely caused by wound of the axillary artery,
      46, 235.
    compression in wounds of, 238.

  Head, injuries of, 283.
    affecting the brain, 283.
    causing abscess of the liver, 356.
      mania, 299.

  Heart, sounds of, 465.
    relative position of, 464.
    wounds of, 464.
      recovery after, 464, 468.
    insensibility of, 471.
    laceration and rupture of, 472.

  Hernia cerebri, 352.
    of the lung, 456.
    of the stomach or bowels into the chest, after wounds of the
      diaphragm, 463.

  Hevin on the swallowing of knives, 535.

  Hilton’s operation for opening into the colon, 558.

  Hip-joint, amputation at, 77, 92, 562, 563, 586.
      Mr. Guthrie’s operation for, 79, 83.
      Langenbeck’s, 80.
      Mr. Brownrigg’s, 82.
    injury to, with excision of elbow-joint, 581.

  Hemorrhage after a gunshot wound, 25.
    secondary, 208.
      from the intercostal artery, 474.
    after the carrying away a limb by cannon-shot, 25.
    from sloughing stumps, 71.
    means used by nature for the suppression of, 187, 191.
    from large arteries, mode of arresting, 234.
    from wounds in the hand, compression in, 288.
    in penetrating wounds of the chest, 421.
    in wounds of the heart, 468.
    in penetrating wounds of the abdomen, 510.

  Hospital gangrene, 163.
    Deputy Inspector-General Taylor on, 171.
    Dr. Tice on, 165.
    M. Delpech on, 165, 166, 167.
    Mr. Blackadder on, 164, 169.
    Dr. Boggie on, 168, 169.
    Dr. Walker on, 170.
    mineral acids in the treatment of, 70, 168.
    use of Fowler’s solution of arsenic in, 169.
    sloughing or pulpous form of, 166.
    conclusions respecting, 173.
    hospital returns respecting, 175.

  Hospital, statistics of operations, 158.

  Hughes, Dr., on pneumothorax, 396.

  Humerus, amputation of, below the tuberosities, 127.
    excision of the head of, 126, 571.
      by Langenbeck’s operation, 130.
      M. Baudens on, 133.
    ball lodged in the head of, 128.
    amputation of, by the circular incision, 134.
      Mr. Luke’s, by two flaps, 135.
    gunshot fracture of, 156.

  Hunter, John, on inflammation of the veins, 70.

  Hunterian theory of aneurism, 188.
    inapplicable to the treatment of wounded arteries, 189.


  Iliac, external, ligature of, 257.
    internal, ligature of, 256.

  Iliacs, common, relative situation of, 251.
    ligature of, 252.

  Immediate amputation, question as to, 51.
      cases for, 150.
    tumors of the scalp, 340.

  Incisions, use of, in erysipelas phlegmonodes, 40.

  Inflammation consequent on gunshot wound, 30.
    acute idiopathic, of the pleura, 370, 376.
      of the lungs, 373, 380.
    typhoid, of the lungs, 388.
      of the pleura, 390.

  Innominata, ligature of, 273.

  Inspiration, 368.

  Intercostal artery, wounds of, 474.

  Internal carotid, wounds of, through the mouth, 245.
      operation for, 245, 248, 272.
    mammary artery, wounds of, 473.
    strangulated hernia, after a wound of the diaphragm, 463.

  Intestine, structure of, 482.
    rupture of, 491.
    protrusion of, in penetrating wounds of abdomen, 501, 509.
    wounds of, 504, 508.
      punctured, 504, 509.
      Travers and Gross’s experiments on, 506.
    divided, treatment of, 507.
      Ramdohr on, 507.
    wounded, application of continuous suture to, 508.
    gunshot wounds of, 515.


  Jaw, lower, wounds of, 480.
      Baudens’s operation for, 480.
    upper, wounds of, 479.

  Jones’s mode of excising the knee-joint, 97, 98.


  Knee-joint, gunshot wounds of, with fracture of the bones, 94.
    excision of, 97.
      Jones’s operation for, 97, 98.
      Dr. Gurdon Buck’s operation for, 97.
    loss of, by a round shot, 574.

  Kidney, wounds of, 537.

  Knives, etc. in the stomach, 535.
    operation for their removal, 536.


  Laceration of the femoral artery, 208.
    brain by contre-coup, 340.
    and rupture of the heart, 472.

  Langenbeck’s mode of amputating at the hip-joint, 80.
    excision of the head of the humerus, 130.
      phalangeal joints, 140.
      metacarpal bone of thumb, 141.

  Larrey’s operation for opening the pericardium, 469.
    ligature of the femoral artery, prior to amputation at the
      hip-joint, 79.

  Lateral sinus, wounds of, 351.

  Larynx, wound of, 571.

  Lee, Mr. Henry, on phlebitis, 70.

  Leg, gunshot fractures of, 154, 588.
    amputation of, 99.
      by the circular incision, 99.
      by Luke’s flap operation, 101.
      immediately below the tuberosity of the tibia, 102.
    apparatus for compound fracture of, 154.
      for slinging, when broken, 589.

  Ligature on an artery, effects of, 203.
    size of, etc., 207.
    one, utterly insufficient to control hemorrhage from a wounded
      artery, 245.

  Lisfranc’s amputation at the shoulder-joint, 125.

  Liver, abscess of, consequent to injuries of the head, 356.
    wounds and injuries of, 528.
    removal of portions of, 533.
    lodgment of balls in, 532.

  Longitudinal sinus, wounds of, 351.

  Luke’s flap amputation of the thigh, 86.
      leg, 101.
      arm, 135.
    apparatus for compound fracture of the leg, 154.

  Lung, hernia of, 456.

  Lungs, acute inflammation of, 373, 380.
      morbid changes caused by, 380.
    typhoid inflammation of, 388.
    gunshot wounds of, 413.
    removal of splinters from, 445.


  Machine for raising wounded soldiers in bed, 589.

  Mammary, internal, wounds of, 473.
    Goyraud’s operation for ligature of, 473.

  Mania caused by concussion of the brain, 299.

  Maxillary bone, superior, gunshot fracture of, 582.

  Membrane, mucous, of the stomach, 485.

  Meningeal artery, middle, injury of, 314.

  Metacarpal bone of thumb, excision of, 140.
    bones, amputation of, 139.

  Metatarsal bone, amputation of, 118.

  Mineral acids, use of, in hospital gangrene, etc., 70, 168.

  Mortification, 42.
    from wind of cannon-shot, not admitted, 43.
    from extensive injuries from large shot, etc., 44.
    from gunshot wound of main artery of a limb, 45, 226.
    of hand and fingers, rarely caused by wound of the axillary
      artery, 46, 235.
    from cold, 46.

  Motions of the brain, 303.

  Mouth, wound of the internal carotid through, 245.
    operation for, 245, 248, 272.

  Mucous membrane of the stomach, 485.

  Musket-ball wounds. See _gunshot wounds_.


  Neck, wounds of, 242, 475.
    Velpeau on wounded arteries of, 246.

  Nerve, consequences of the section of, 47.
    lodgment of a foreign body in, 47.
    enlargement, of extremity of, after amputation, 89.
    consequences of incomplete section of, 47.

  Nose, wounds of, 477.


  Occiput, depression and fracture of, 338.

  Œgophony, 373.

  Ollivier on lacerations and ruptures of the heart, 472.

  Omentum, protrusion of, in penetrating wounds of abdomen, 498.

  Operations, hospital statistics of, 158.

  Orbit, wounds of, 350, 583.

  Os calcis, removal of, 104.


  Patella, compound gunshot fractures of, 95.

  Paracentesis thoracis, 394, 455.

  Paralysis, the result of compression of the brain, 305.

  Parotid gland, wounds of, 479.
    and duct, wounds of, 479.

  Pelvis, wounds of, 541.
    balls lodging in, 545.
    and abdomen, conclusions respecting wounds of, 555.

  Penis, wounds of, 540.

  Pericardium, Larrey’s operation for opening, 469.
    Skielderup’s ditto, 469.

  Peroneal artery, ligature of, 266.

  Peyer, glands of, 486.

  Phagedena gangrenosa, 163.

  Phalangeal joints, excision of, 140.

  Phalanges, amputation of, 140.

  Phlebitis, 60, 62, 63.
    Mr. Hunter on, 70.
    Mr. Henry Lee on, 70.
    Dr. Hughes Bennett on, 71.

  Plantar artery, external, ligature of, 267.

  Pleura, acute idiopathic inflammation of, 370, 376.
    typhoid ditto, 390.
    effusion into the cavity of, 371, 378, 420.
    purulent ditto, 379, 390.
      operation for, 393.
    balls or other foreign bodies loose in the cavity of, 418.

  Pneumonia, 373, 379.
    morbid changes caused by, 380.
    typhoid, 388.

  Pneumothorax, 396, 402.
    Dr. Hughes on, 396.

  Popliteal aneurism, operation for, 263.
    artery, not to be tied, unless wounded and bleeding, 265.
      wound of, 573.

  Pourriture d’hôpital, 163.

  Primary amputation, advantages of, 59.
    not required in gunshot wounds of the upper extremity, 120.

  Profunda femoris, ligature of, 261.
    wound of, 573.

  Protrusion of bone after amputation, 89.
    of the brain, 352.

  Pulpous form of hospital gangrene, 166.

  Purulent deposits, 61, 68.


  Quekett, Mr., experiments on the anatomy of the parts engaged in
      empyema, and the operation by incision, 452.
    on the structure of the agminated glands of Grew and Peyer, 486.


  Radial artery, wound of, 238.
    ligature of, 282.
    wound of, in the hand, 238.
      operation for, 282.

  Ramdohr on the treatment of divided intestine, 507.

  Ravaton on protrusion of omentum in penetrating wounds of abdomen,
    501.

  Rectum, wounds of, 555.

  Removal of the head of the femur, 90.
      and neck of, in gunshot wounds of, 150.
    os calcis, 104.
    astragalus and calcis, 115.

  Respiration, the four movements of, 285.
    distinction of sounds during, 367.

  Respiratory murmur, 367.

  Rhoncus crepitans, 370, 375.

  Ribs, fracture of, in gunshot wounds of the chest, 428.
    the cartilages of, 429.

  Roux’s amputation of the foot, 108.

  Rupture of the heart, 472.
    ventral, 488, 493.
    of intestine, by violence, 491.
    of the solid viscera, by violence, 493.


  Scalp, immediate and secondary tumors of, 341.
    wounds of, 361.
    erysipelas of, 359, 363.

  Sciatic artery, ligature of, 259.

  Scrotum, erysipelas phlegmonodes of, 42.

  Secondary amputations, 59, 141.
      in gunshot wounds of the femur, 145.
    hemorrhage, 208.
    tumors of the scalp, 341.

  Shock or constitutional alarm, 26.

  Shoulder-joint, gunshot wounds of, 120.
    amputation at, 122.

  Sight, loss of, from a musket-ball traversing the forehead, 350.

  Sinuses, frontal, gunshot injury to, 350.

  Sinuses, longitudinal and lateral, wounds of, 351.

  Skielderup’s operation for opening the pericardium, 469.

  Skull, simple fissure or fracture of, 311.
    fracture of, by contre-coup, 316.
      the inner table of, 321, 324, 328.
    depression of, 329.
      and fracture of back part of, 338.
    gunshot wounds of, 346, 584.
    balls separating the sutures of, 349.
    removal of a large portion of, 359.

  Sloughing stumps, hemorrhage from, 71.
    form of hospital gangrene, 166.
    ulcer, 164.
    wounds, use of mineral acids in, 70.

  Snow, Dr., on chloroform, 55.

  Solitary glands, 487.

  Sounds, distinction of, in respiration, 367.
    of the heart, 465.

  Spermatic cord, wounds of, 539.

  Sphacelus, dry, from wound of main artery of lower extremity, 45, 226.

  Spine, effects of strychnia in injury of, 574.

  Spleen, wounds and injuries of, 536.
    removal of, 538.

  Splints for fractures, 153.

  Splinters, removal of, from a wounded lung, 445.

  Statham’s operation for removal of astragalus, 110.

  Statistics, hospital, of operations, 158.
    Burdach’s, of lesions of the brain, 306.
    of ligature of common carotid, 241.

  Stomach, mucous membrane of, 485.
    wounds of, 533.
    gunshot wounds of, 535.
    fistulous opening in, after gunshot wounds of, 535.
    knives in, 535.
      operation for the removal of, 536.

  Structure of arteries, 176.
    of intestine, 482.

  Strychnia, effects of, in injury of the spine, 574.

  Subclavian, ligature of, 274.
    above the clavicle, 276.

  Suppuration on the surface of the dura mater and brain, 342.

  Suture, continuous, for wounded intestine, 508.
    for incised wounds in abdominal parietes, 493.

  Sutures of the skull, separated by a ball, 349.

  Syme, Mr., amputation at the ankle-joint, 105.
    on the treatment of approaching death from chloroform, 58.


  Tarsus, amputation at, 112.

  Taylor, Deputy Inspector-General, on hospital gangrene, 171.
    on amputations under chloroform, 54, 562.
    on wound of the larynx, 572.
    on the privations endured by the British soldiery in the Crimea,
      and their effects, 562.

  Testicle, removal of, after a wound, 539.

  Thigh, amputation of, by the circular incision, 83.
      by Luke’s flap operation, 86.
    arm and abdomen, extensive injury to, 576.
    gunshot fractures of, 579, 587.

  Thumb, excision of metacarpal bone of, 140.

  Tibia, amputation of the leg below the tuberosity of, 102.

  Tibial artery, anterior, ligature of, 268.
    posterior, ditto, 266.

  Tice, Dr., on hospital gangrene, 165.

  Tongue, wounds of, 481.

  Trant’s forceps for artificial anus, 528.

  Traumatic aneurism, formation of, 214.
    gangrene, 42.

  Travers’s experiments on intestine, 506.

  Trephine not applicable in simple fracture of the skull, without
      depression, 312.
    manner of applying, 358.
    use of, at different periods, 327.
    frequent application of, 359.

  Trochanter, head and neck of the femur, excision of, 564.

  Tumors, immediate and secondary, of the scalp, 341.

  Typhoid pleuritis, 390.
    pneumonia, 388.


  Ulnar artery, ligature of, 281.
    wound of, 238, 281.


  Valvulæ conniventes, 483.

  Veins, inflammation of, 60, 62.
    Mr. Hunter on, 70.
    Mr. Henry Lee on, 70.
    Dr. Hughes Bennett on, 71.

  Velpeau on wounded arteries of the neck, 246.

  Ventral rupture, 488, 493.

  Vertebral artery, wounds of, 242.
    ligature of, 248.

  Vesicular, or respiratory murmur, 367.

  Viscera, rupture of, 491.
    protrusion of, in penetrating wounds of the abdomen, 498.


  Wakley, Mr. T., removal of os calcis and astragalus, 115.

  Walker, Dr., on hospital gangrene, 170.

  Wounded, bearers for the, 156.

  Wound by a musket-ball, 25.
    shock or alarm after, 26.

  Wounds of entrance and exit, made by a musket-ball, 27, 489.
    from flattened balls, pieces of shell, etc., 28.
    gunshot, formation of sinuses in, 31.
    extraction of ball and other foreign substances, 32.
    gunshot, the bone struck or penetrated, not broken, the ball
      lodging, 36.
    of the skull, 346, 584.
    of the forehead, causing loss of sight, 350.
    of the frontal sinuses, 350.
    by a bayonet thrust, 37.
    of the neck, with hemorrhage, 242, 475.
    of the larynx, 571.
      Deputy Inspector-General Taylor on, 572.
    of the orbit, 350, 583.
    of the longitudinal or lateral sinus, 351.
    of the arm, 121, 156.
    of the forearm, 137.
    of the profunda femoris, 573.
    of the popliteal artery, 573.
    of the abdomen, 488.
      causing abscess in paries of, 489.
    gunshot ditto, 489, 515.
    incised ditto, 490.
      followed by ventral rupture, 493.
    penetrating, 497.
      followed by protrusion of viscera, 498.
        of omentum, 498.
        of intestine, 504, 508.
    punctured ditto, 504, 509.
    of the chest, 364.
      non-penetrating, 364.
      incised, 364, 414.
    of both sides of the chest, 417.
    large, penetrating, of the chest, the lung being injured, 418.
    of the chest, conclusions respecting, 424.
    gunshot of the chest, 426.
        statistics of, 426.
      fracture of the ribs in, 428.
        costal cartilages in, 429.
      of the lung, 429.
        diaphragm, 458.
        heart, 464.
        internal mammary and intercostal arteries, 473.
        face, 476.
        eyelids and brow, 477.
        eye, 477.
        nose and ear, 477.
      penetrating, of the bones of the face, 479.
      of the parotid gland and duct, 479.
        upper jaw, 479.
        lower jaw, 480.
    of the head and neck of femur, 150.
    of the knee-joint, gunshot, 94.
    of the patella, ditto, 95.
    of the leg, 154.
    of the foot, 107.
    of the tongue, 481.
    of the liver, 528.
    of the gall-bladder, 530.
    of the stomach, 533.
    of the stomach, gunshot, 535.
    of the spleen, 536.
    of the kidney, 538.
    of the spermatic cord and testicle, 539.
    of the penis, 540.
    of the pelvis, 541.
    gunshot, of the bladder, 546.
    of the rectum, 555.
    of the abdomen and pelvis, conclusions respecting, 555.

  Wrist, amputation at, 138.



INDEX OF CASES.


  A soldier, wounded in the thigh, the ball passing between the femoral
    artery and vein, 26.

  Generals Sir Lowry Cole, Sir E. Packenham, and Colonel Duckworth;
    injuries to arteries, 26.

  Colonel Sir W. Myers and General Sir R. Crawford, illustrating the
    shock of a severe wound, 26, 27.

  Colonel Ross; musket-shot wound of arm: gradual descent of the ball to
    the elbow, 36.

  Erysipelas phlegmonodes of the left arm, treated by incisions, 41.

  Local mortification of a leg struck by a cannon-shot, the internal
    textures being destroyed, 43.

  Section of the brachial plexus of nerves by a gunshot wound, causing
    paralysis, complicated by gunshot wound of the knee-joint, requiring
    secondary amputation, 47.

  Sir James Kempt; injury to a nerve, 48.

  Admiral Sir Philip Broke; wound of skull, with paralysis, 48.

  Brigade-Major Bissett; gunshot wound, injuring the left great sciatic
    nerve, perineum, and rectum, 49.

  Mr. Wrottesley, of the Engineers; right thigh shattered by a
    cannon-shot, etc., 53.

  An East Indian; severe wound of left thigh from the explosion of his
    gun; amputation, death, 53.

  A soldier of the siege train before Sebastopol; the left thigh nearly
    carried off by a cannot-shot, 54.

  Purulent deposit, after amputation, 61.

  Phlebitis, 64.

  Jane Strangemore; amputation of limb for white-swelling of the
    knee-joint; fatal phlebitis, 64.

  Endemic fever, after secondary amputation, with subacute pneumonia,
    67, 68.

  Sloughing of a spear-wound of the arm, 69.

  Captain Flack; cannon-shot wound of left thigh, 77.

  Excision of the head and neck of the femur, 94.

  Colonel Donnellan; musket-shot wound of knee-joint, 96.

  Excision of knee-joint, by Dr. Gurdon Buck, 97. by Mr. Jones of
    Jersey, 97, 98.

  Amputation of the foot, by Roux’s operation, 108.

  Ball lodged in the astragalus, 110.

  Excision of the astragalus and calcis, 115. head of the humerus, a
    musket-ball having lodged in the bone, 128, 131.

  Gunshot wounds of the shoulder-joint, 131, 132.

  Lieutenant Timbrell; gunshot fracture of both thighs; recovery without
    amputation, 149.

  Illustrative of the means used by nature for the suppression of
    hemorrhage, 194.

  Illustrative of gunshot wounds of the femoral artery, 196, 208.

  Ligature of the right common iliac artery, for supposed gluteal
    aneurism, 206.

  Punctured wounds of arteries, 210.

  Colonel Fane; wound of carotid by an arrow; formation of an aneurism,
    211.

  Scythe wound of the femoral artery, 213.

  Wound of femoral artery with a pen-knife; closure of wound; formation
    of traumatic aneurism, 215.

  Gunshot wound of the thigh; severe hemorrhage finally arrested without
    ligature of the artery, 216.

  Don Bernardino Garcia Alvarez; gunshot wound of the thigh; hemorrhage
    from a deeply-seated vessel; ligature of the common femoral; fatal
    mortification. The femoral artery quite sound, 218.

  Duckshot wound of thigh; closure of wound; aneurismal swelling
    punctured; hemorrhage; ligature of femoral high up; death, 218.

  Captain Seton; gunshot wound of upper part of thigh; hemorrhage from
    a superficial branch of the femoral; ligature of the external iliac;
    fatal peritonitis; errors in the treatment, 219.

  Dry gangrene, from injury to the main artery of the lower extremity,
    227. following an injury to the popliteal space; large incision in the
    calf, evacuating a quantity of coagulated blood; subsequent separation
    of the limb, 228.

  Gunshot wound of the posterior tibial artery; secondary hemorrhage and
    traumatic aneurism; ligature of the femoral artery, renewal of the
    hemorrhage, amputation, death, 230. of the peroneal artery, hemorrhage
    and formation of an aneurism; ligature of the wounded vessel;
    recovery, 231.

  Axillary aneurism from a bruise; ligature of the subclavian; rupture
    of the sac; death, 236.

  Shell injury; amputation of right leg and arm; secondary hemorrhage;
    ligature of the subclavian near the seat of the bleeding, 237.

  Wounds of the vertebral artery, recorded by Breschet, Chiari,
    Ramaglia, and Maisonneuve, 242.

  Wound of the external carotid during an operation; utter insufficiency
    of one ligature, 244, 245.

  Gunshot wound of head, face, and neck; injury of external carotid and
    its branches; partial slough of internal carotid; ligature of latter
    vessel; compression; recovery, 247.

  Wound of internal carotid through the mouth; successful ligature of
    the vessel, 249.

  Ligature of the common iliac artery, 252.

  Wound of the gluteal artery; ligature of that artery and of the
    internal iliac; death, 260.

  Wound of the popliteal artery by a mortising chisel; secondary
    hemorrhage; ligature of the femoral unsuccessful; cure by ligature
    of the popliteal, 265.

  Balls lodging in the brain, 284.

  Concussion in a child, 289.

  Coup-de-soleil, 293.

  Concussion of the brain, passing into excitement, etc., 294.

  Gouty inflammation, transferred to the brain, 296.

  Illustrative of the treatment of concussion, 297.

  Concussion, complicated by the symptoms of compression, 298.
    followed by mania, 300.

  Illustrative of the after-effects of concussion, 301.

  Fatal paralysis, caused by compression of the brain, 307.

  Illustrative of the different forms of paralysis following compression
    or irritation of the brain, 309.

  Fracture of the skull without depression, 311.

  Fracture of the skull, with injury to the middle meningeal artery,
    315.

  Fracture of the base of the cranium, 317.

  Fracture of the inner table of the skull, without injury to the outer
    plate of bone, 322.

  Fracture of the inner table of the skull, without injury to the outer;
    subsequent hemiplegia of the right side; operation with the trephine
    two years afterward, 323.

  Illustrative of a peculiar fracture of the inner table of the skull,
    with a cutting instrument, 325.

  Gunshot wounds of the skull and brain, the ball lodging,
    331, 343, 348.

  Injury to the head from a fall; large abstraction of blood, 334.

  Comminuted fracture of the skull, by a piece of shell, 336.

  Injury to the head, the symptoms of concussion and compression being
    combined, 338.

  Gunshot fracture of the left parietal, with suppuration on the surface
    of, and in the substance of the brain, 343.

  Gunshot wound of the skull, the breech-pin of the gun lodging in the
    brain, 348.

  Separation of the sagittal suture by a fall, consequent to a gunshot
    wound of the body, 349.

  Gunshot injury to the frontal sinuses, 350.

  Wounds of the orbit, 351.

  Fungus cerebri, 353.

  Major D.; gunshot wound of the forehead; incomplete recovery, 357.

  Loss of a large portion of the skull; reported by Dr. Drummond, 359.

  Cannon-shot wound of the head and face, 361.

  Wound of scalp and parietal bone, 362.

  Non-penetrating wounds of the chest, 365.

  Acute pneumonia and pleurisy, 383.

  Dr. Wendelstadt; empyema, 398.

  Mr. Winter; gunshot wound of the chest, followed by empyema, 399.

  Lance and musket-shot wounds of the chest, causing empyema, 399.

  Mr. Cornish; pneumothorax and phthisis, 403.

  Pistol shot wound of the chest, with pneumothorax and empyema, 404.

  Lord Beaumont, 407.

  Sword wound of the chest, with emphysema, 412.

  Wounds of both sides of the chest, 417.

  Penetrating wounds of the chest, the lung being injured, 418.

  Sword wounds of the chest, 420.

  Penetrating wounds of the chest, with internal hemorrhage, 423.

  Fracture of rib, in gunshot wound of chest, 428, 447.

  General Sir Lowry Cole; gunshot wound of the lung, 430.

  Illustrative of gunshot wounds of the lungs, 431.

  General Sir A. Barnard, 431.

  Major-General Broke, 432.

  The Duke of Richmond, 433.

  Mrs. M., 435.

  Sir C. B.; effusion, 436.

  Gunshot wounds of the lungs, with fracture of ribs, effusion, etc.,
    436.

  Lieut.-Col. Dumaresq, 440.

  A two-pound shot passing through the right side of the chest, 441.

  Post-mortem appearances in gunshot wounds of the chest, 442.

  Mr. Drummond, 443.

  Gunshot wound of the lung; extensive enlargement of the wound; removal
    of splinters and of a piece of cloth, 446.

  Gunshot wound of the lung, remaining fistulous; death from pneumonia
    seven months afterward, 447.

  Gunshot wounds of the chest, the ball or other foreign body being
    loose in the cavity of the pleura, 448.

  Major-General Sir R. Crawford, 449.

  Gunshot wounds of the chest, the ball or other foreign body being
    inclosed in a cyst, 451.

  Wounds of the diaphragm, 458.

  Captain Prevost, 458.

  The Duc de Berri, 469.

  Lance wound of the heart and diaphragm, 470.

  Latour d’Auvergne, premier grenadier de France, 472.

  General Sir G. Walker; gunshot wound of the chest; secondary
    hemorrhage from the intercostal artery, 474.

  Gunshot wound of the chest, with rapidly fatal hemorrhage from a
    wounded intercostal artery, 475.

  Gunshot wounds of the neck, 476.

  General Sir E. Packenham; twice shot through the neck, on different
    occasions, 476.

  Lieut.-General Sir A. Leith; amaurosis from a sword wound in the
    forehead, 478.

  General Sir Colin Halkett; gunshot wounds of the neck, thigh, and
  face, 479.

  Gunshot fracture of the lower jaw, 480.

  Colonel Carleton; gunshot fracture of the lower jaw, 481.

  Captain Fritz; bursting of his gun; lodgment of the iron breech in the
    forehead; its descent through the nares into the mouth, 482.

  Ventral rupture, the result of severe bruises or other injuries to the
    abdominal parietes, 488.

  Severe and extensive wound of abdominal parietes from a musket-shot;
    exposure of the peritoneum, healing by granulations, 489.

  General Sir John Elley; sabre wound of abdomen, involving the stomach,
    and followed by a small hernia, 490.

  Rupture of intestine from external injury, 491.

  Rupture of kidney and injury to the spine from a cannon-shot, 492.

  Fatal inflammation of omentum, intestines, and peritoneum, with
    effusion, from a severe bruise inflicted by a ricochet cannon-shot,
    492.

  Penetrating wound of abdomen by a ramrod, 497.

  Penetrating wounds of abdomen, with protrusion of omentum, 500.
    with protrusion of intestine, 502.

  Penetrating wound of abdomen, with formation of abscess, 505.

  Sabre wounds of the abdomen, with extensive hemorrhage, 510.

  Sabre wound of abdomen, with suppuration in the cavity, reported by
    Ravaton, 512.

  Strangulated inguinal hernia; operation; sloughing of the intestine,
    etc., 512.

  Gunshot wounds of abdomen, with protrusion or injury of intestine,
    516.

  A Russian officer, with a gunshot wound of abdomen, a tape-worm cut in
    two by the ball, causing intense suffering until it was extracted,
    524.

  Lieut.-General Sir S. Barns; gunshot wound of the liver, 529.

  Gunshot wounds of the liver and gall-bladder, 530.

  In which portions of the liver have been removed, 533.

  In which a pig’s tail was thrust up the rectum, 535.

  In which the spleen was removed, 537.

  Wounds of the kidney, 538.

  Medullary sarcoma of the right testicle, involving the lumbar glands,
    ending fatally, caused by a gunshot wound of the testis, 540.

  Gunshot wound of the penis, 540.

  Pistol-shot wound in the last dorsal or upper lumbar vertebra, causing
    complete paraplegia, 541.

  Gunshot wounds of the pelvis, 542.

  The late Colonel Wade; gunshot wound, the ball passing through the
    ilium; lodgment of the ball for thirty-five years, 542.

  The late General Sir Hercules Packenham, G.C.B.; musket-shot wound of
    the pelvis, lodgment of the ball, 542.

  Colonel Sir J. M. Wilson; three musket-shot wounds of the left hip,
    one passing upward through the ilium, and lodging against or in the
    spine, causing paralysis of the left lower extremity, etc.; lodgment
    of the ball, 543.

  Gunshot wound of the external and common iliac arteries, 544. of the
    pelvis, the ball lodging, extracted on the forty-fifth day after the
    wound; reported by La Motte, 545.

  Captain Campbell; pistol-shot wound of abdomen; injury to spine, 545.

  Gunshot wounds of the bladder, 549.

  Captain Sleigh; gunshot wound of the pelvis, the ball entering the
    left groin, over Poupart’s ligament, and traversing the bladder
    obliquely; retention of urine; urethra obstructed by pieces of bone,
    551.

  Calculus formed around the ball in the bladder, 552.

  Pistol shot wound of the bladder; retention of urine; tumor in the
    perineum containing bloody urine, punctured; the ball, portions of
    shirt, etc., extracted from the bladder; reported by Baron Percy,
    554.

  Captain Gordon, R. N.; rifle-shot wound on one side of the sacrum,
    the ball wounding the rectum, and passing out on the other side of
    the sacrum; paralysis of the bladder for a time; permanent partial
    paralysis of the lower limbs, 555.

  Gunshot wounds of the rectum, 555.


CASES IN THE ADDENDA.

  Amputation of finger; death caused by exhibition of chloroform, 561.

  Successful amputation of the arm at the shoulder-joint, and of the
    thigh in the lowest third, without chloroform, 561.

  Amputations while under the influence of chloroform, reported by
    Deputy Inspector-General Alexander, 563.

  Sir T. Trowbridge; amputation of both feet under chloroform, 563.

  Amputations at the hip-joint under chloroform, 564.

  Excision of the head, neck, and great trochanter of the femur,
    reported by Mr. O’Leary, 564.
    reported by Staff-Surgeon Crerar, 565.
    reported by Dr. Hyde, 570.

  Excision of the head of the humerus, reported by Dr. M’Andrew, 571.

  Lieut. Evans; fatal case of wound of the larynx;
    reported by Dr. Gordon, 571.

  Wounds of the profunda femoris, and of the popliteal artery,
    reported by Mr. De Lisle, 573.

  Loss of the right leg by a round shot, 574.

  The effects of strychnia in injury of the spine, etc., reported by
    Dr. Burgess, 574.

  Extensive injury by a round shot to the abdomen, right arm, and thigh,
    reported by Dr. Rooke, of the Civil Service, 576.

  Gunshot fracture of the left femur, reported by Mr. Lyons, Pathologist
    to the Army in the East, 579.

  Excision of the elbow-joint for a gunshot wound, reported by
      Dr. Milroy, 580.
    with lacerated wound of the left hip, and comminuted fracture of the
      ilium, reported by Mr. Atkinson, 581.
    for a comminuted fracture of the bones by a piece of shell, reported
      by Dr. Scott, 582.

  Grape-shot wound of the superior maxillary and malar bones, reported
    by Mr. Atkinson, 582.

  Musket-shot wound of the right temple, fracturing the supra-orbital
    ridge, reported by Mr. De Lisle, 583.

  Musket-shot fractures of the skull, reported by Mr. Ward, Mr. Wall,
    and Mr. Longmore, 584, 585.


THE END



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 physical education of children. Dr. Mitchell has made considerable
 additions to it, introducing many topics not treated of by Dr. Eberle,
 every one of which he considers entitled to a place in a work on the
 diseases of the infant race. The large addition of matter thus made to
 the work has proved to be both acceptable and useful.


Richardson’s Anatomy.

[Illustration: Veins of the head and neck.]

 Elements of Human Anatomy: General, Descriptive, and Practical. With
 over 400 illustrations. By T. G. Richardson, M.D., Demonstrator of
 Anatomy in the Medical Department of the University of Louisville, and
 one of the attending Surgeons to the Louisville Marine Hospital. One
 vol. 8vo. $3.00.

 It is an amply sufficient text-book, and the preceptor may confidently
 place it in the hands of his pupils as such. The wood-cuts are
 numerous and elegant, and serve admirably to illustrate the
 text.--_New Jersey Medical Reporter._

 Our author claims for his work the improvement of having general,
 descriptive, and practical anatomy in the same volume; the
 arrangement of the section devoted to practical anatomy so as to
 secure the greatest possible economy of material; and lastly, in the
 substitution of English for Latin terms, wherever it appeared to be
 practicable and judicious.--_N. Y. Medical Times._


Ricord on Venereal Diseases.

 A Practical Treatise on Venereal Diseases; or, Critical and
 Experimental Researches on Inoculation applied to the study of these
 affections: With a therapeutical summary and special formulary. By
 Ph. Ricord, M.D., Surgeon of the Venereal Hospital of Paris, Clinical
 Professor of Special Pathology. Translated from the French by A.
 Sidney Doane, A.M., M.D. Thirteenth edition. One vol. 8vo. $1.50.

 M. Ricord’s reputation as a lecturer and practitioner in Paris is of
 the highest order. He is distinguished for his sound and philosophical
 views upon a disease which carries terror wherever it appears, and
 whose consequences are often felt by the innocent as well as the
 guilty. The first part of the book partakes of the philosophical
 spirit of its author, while in the pages devoted to the treatment of
 syphilis, M. Ricord has spread out the results of thousands of cases
 coming under his observation.


Thomson’s Domestic Medicine.

 A Dictionary of Domestic Medicine and Household Surgery. By Spencer
 Thomson, M.D., L.B.C.S. Edinb. First American, from the last London
 edition. Revised, with additions, by Henry H. Smith, M.D., Professor
 of Surgery in the Pennsylvania University. One vol. 12mo. $1.50.

 This work has received the highest encomiums from the critical
 journals of the day. “Many a useful life,” remarks a British
 periodical, “might have been spared, and many an insidious disease
 checked in the bud, had such works as that of Dr. Thomson been earlier
 in existence. To the traveler by sea or by land, to the settler and
 the emigrant, far from medical aid, it must prove invaluable.”

 The work has been carefully adapted to the American climate and habits
 by Dr. Henry H. Smith, of Philadelphia, whose contributions to the
 volume have greatly added to its value. It is the standard book of
 domestic medicine. The arrangement of the subjects in alphabetical
 order renders it extremely convenient for prompt reference and
 consultation.


Agnew’s Practical Anatomy.

 A new arrangement of the London Dissector, with numerous modifications
 and additions; containing a concise description of the Muscles,
 Nerves, Blood-vessels, Viscera, and Ligaments of the Human Body as
 they appear on Dissection. With Illustrations. By D. Hayes Agnew,
 M.D., Lecturer on Anatomy, and Surgeon to the Philadelphia Hospital,
 (Blockley.) One vol. 12mo. $1.00.

[Illustration]

 This work has been adapted to the use of the American student by
 altering the arrangement and changing the nomenclature in many cases;
 by adding the ligamentous system; by illustrations; by erasing what
 was unnecessary, and presenting the whole as nearly as possible in
 the topographical order. The work, as now published in this American
 edition, has been prepared with a single eye to the faithful economy
 of the student’s time.


Acton on the Urinary Organs.

 A Practical Treatise on Diseases of the Urinary and Generative Organs
 in both Sexes. Part I.--Non-specific Disease. Part II.--Syphilis. By
 William Acton, late Surgeon to the Islington Dispensary, and formerly
 Externe at the Female Venereal Hospital, Paris. From the second London
 edition. With additional Illustrations and Colored Plates. One vol.
 8vo. $4.00.

 This work is intended to be used by the student as a complete
 Text-book on the subjects of which it treats; and, at the same time,
 to supply data for the surgeon desirous of learning the most modern
 treatment of the protean forms of Syphilis, as well as materially
 to assist the practitioner who, in the witness-box, is liable to be
 cross-examined on many of the most intricate questions of generation,
 absorption, or contagion.


Transcriber’s Notes:


A number of typographical errors have been corrected silently.

Archaic spellings have been retained.

Cover image is in the public domain.

“Remarks” heading added to Table of Contents.

Index, Index of Cases, and Medical Works added to the Table of Contents.

Amputation of arm index to page 156 is deduced, only “ 56” was printed.

Index references page 649 which does not exist.



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